The findings mentioned above point to a considerably high prevalence of PPD among Georgian females. Additionally, significantly higher rates of PPD were identified in primiparas compared to multiparas, and major predictors of PPD among first-time mothers were highlighted. Specifically, advanced maternal age, physiologic delivery mode, high economic status, and strong family support were among the most consistent predictors of depressive symptoms.

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Except for a few contrasting and rather unexpected results, most of the findings in this cross-sectional analysis support previous studies. It should be highlighted that this pilot study only explores the individuals based on their responses to an online questionnaire. In contrast, the majority of studies to which the results of the current study are compared are longitudinal designs, mostly cohort, involving clinical interviews and prolonged observational periods. The contrasting findings could be attributed to the latter.

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The overall prevalence of PPD (49.6%) among study subjects turned out to be significantly higher compared to the prevalence in numerous other countries. In the Western world, rates of PPD range from 10-15%.12,21 Studies that were conducted in Delhi and adjacent states of northern India, Egypt, and Uganda showed that the prevalence was 15.8%,21 17.9%,22 and 16.3%,23 respectively. Similar studies were done in Lebanon, Cameroon, and Nigeria, establishing that the prevalence was 21%,24 23.4%,25 and 23%,26 respectively. However, numerous epidemiological studies have confirmed that PPD is becoming increasingly common than previously thought, and the prevalence varies significantly between nations.27 The reported prevalence of PPD is established to be significantly high in Guyana, Costa Rica, Italy, Chile, South Africa, Korea, and Taiwan, ranging from 34-57.0%.28

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A systematic review of all papers reporting PPD prevalence using the Edinburgh Postnatal Depression Scale28 has established that the prevalence is lower in developed countries12 compared to relatively low- and middle-income countries.13 Given that Georgia is a developing country, this could be one of the reasons why the prevalence in the present study was so high. Since the current study was conducted as an online survey, using a questionnaire posted on the social network, there is a possibility that females who experienced symptoms of PPD were more engaged with this issue and responded to the questionnaire more actively. 

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The current study also sought to demonstrate that first-time mothers are at higher risk of developing postpartum depression compared to multipara females since they struggle more to adjust to the role of mother, have lower maternal confidence, and, as a result, experience more anxiety and depression after giving birth. As the results showed, the rates of PPD were significantly higher among first-time mothers compared to multigravida females. The prevalence was 54.9% in first-time mothers and 16.9% in multiparas. A similar difference was identified in the prospective cohort study conducted in 2020 among Japanese women, which established that prevalence was 15.2% and 6.7% in primiparas and multiparas, respectively.18

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Determining the correlation of potential risk factors to postpartum depression among first-time mothers was another purpose of the present study. The results showed that four of the eight characteristics, including age, delivery mode, economic and living conditions, and family support, were linked to PPD in primiparas. Increased age was significantly associated with elevated EPDS scores, consistent with a substantial number of data suggesting that women giving birth at an advanced age have a higher risk of developing depression.29-31 According to a cross-sectional study conducted in Canada in 2007-2008, the prevalence of depression in females who had recently delivered was significantly higher in women aged 40 to 44 years compared to those aged 30 to 35 years.32 This increased risk has been linked to several reasons, such as the idea that older women experience more difficulty adjusting to the role of mother.33

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Furthermore, they are more likely to develop obstetric complications, which could be another contributing factor to a higher risk of PPD.34 The current study showed a positive association between the physiologic mode of delivery and increasing risks of PPD. This finding is consistent with a cohort study conducted in Uppsala, Sweden, which established that Caesarean section, compared to physiologic delivery, was associated with fewer depressive symptoms at 6 six weeks postpartum.17 A possible interpretation of this phenomenon is that females who deliver via C-sections may receive more significant support from their immediate environment and, therefore, are less likely to develop depressive symptoms.17 However, a prospective observational study conducted in Pittsburgh, Pennsylvania, did not find a relationship between delivery mode and PPD scores.35 Thus, the evidence presented in the literature contradicts this finding. The current study showed a positive association between the level of economic and living conditions and depression as well, implying that better conditions are associated with an increased risk of PPD. This was an unexpected result since the study anticipated revealing that low economic status and poor living conditions are associated with increased depressive symptoms. Numerous studies have established that low income is associated with an increased risk of depression in postpartum females.36 For instance, results of a descriptive study conducted in Northern California showed that low socioeconomic status was associated with increased depressive symptoms in late pregnancy at 2 and 3 months postpartum.37 A possible explanation for the unexpected finding of the current study could be the limited access to the questionnaire for those with significantly poor conditions. Since the study was conducted as an online survey and required access to the internet, cell phones, computers, etc., which might not have been available to females with very low economic status, the questionnaire was probably less accessible to them. In the present study, increased family support was statistically associated with a reduced risk of PPD. Although a prospective cohort study conducted in Iran in 2016 did not find this association,15 there is evidence that postpartum care, particularly peer support, could be beneficial for women who are at high risk for PPD, leading to a statistically significant drop in their EPDS scores.38 A prospective cohort study further strengthened this conclusion carried out in China, which established that a lack of postnatal family support, especially from the husband, is a significant risk factor for PPD.39

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The results of the current study did not reveal a connection between the level of education and PPD, which is consistent with findings from several other surveys.24,40 However, some other studies established a lower education level as one of the contributing factors to PPD.41-43 It should be noted that the education level of the participants in the current study has only been determined based on their responses to a questionnaire that asked if they had completed high school or university. The educational activities increase the likelihood that their responses were not truly indicative of their level of education. This study failed to find an association between newborn health problems and an increased risk of PPD as well.

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In contrast, an institution-based cross-sectional study conducted in Ethiopia in 2018 revealed that having a hospitalized child postpartum was associated with PPD. Females who had a current hospitalized child were nearly three times more likely to experience depression compared to women with healthy newborns.44 Another study found that newborn health problems, such as colic, jaundice, and feeding problems, were moderate predictors of PPD.17 The results of the present study could be attributed to the fact that, in the latter, women were asked whether their newborns had any general health concerns without specifying whether the baby had been hospitalized. Therefore, there is a possibility that their newborns' health problems were minimal, not having an impact on their mental health. The current study found no association between employment and postpartum depression either, contrary to prospective cohort studies carried out in Switzerland and Japan, which revealed that pregnant employed women had a lower risk of PPD compared to pregnant who were unemployed.45,46 Unemployment may lead to lowered self-esteem, financial instability, and decreased social standing, all of which are potential sources of mental stress;47 however, there are numerous factors, such as family support, that could have improved the mental health of the unemployed participants of the current study, producing contrasting results.

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In contrast to the other studies that suggested a positive relationship between labor pain and postpartum depression,48-50 in the current study, obstetric pain was not associated with an increased risk of PPD. The fact that women in the present study were not directly observed while giving birth may have contributed to this result since their pain level was only evaluated based on the questionnaire responses they provided. Hence, there is a possibility that their answers did not accurately reflect their actual level of pain.

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The primary strength of the study is a large sample size of 648 participants, which is a significantly high number in proportion to the Georgian population of fewer than four million. Conducting the study as an online survey is highly time-consuming and cost-effective. It is also minimally time-consuming for the study participants since filling out the questionnaire takes 5-10 minutes. Additionally, this gives the study another advantage of anonymity, which yields more truthful responses and produces more accurate data for the current study. However, conducting research through online questionnaires poses a high risk of bias, as subjects were not observed while filling out the questionnaires, increasing the potential for more subjective and inadequate answers. Another limitation is that the mental health status of the females with previous psychiatric illnesses, the primary exclusion criteria of the study, was not verified directly using official documents; the participants were marked as having a history of psychiatric disease solely based on their responses. Another weakness of this design that could significantly increase the risk of bias is that the females who gave birth several years ago could have had altered versions of their past mental health recollections and trouble documenting their actual experiences of the postpartum period.

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Furthermore, the current study findings cannot be generalized to the entire population since the subjects included only a specific group of females who were members of specific Facebook groups. The most efficient way to reduce the risk of bias from the online survey design would be to conduct a clinical study with face-to-face interviews and long-term monitoring. Gathering more information through clinical interviews would ultimately lead to more valuable data in correlation with the current study and result in a better understanding of this issue. Still, it would not be an absolute solution for eliminating the subjectivity of the respondents as there is no ultimate strategy to measure honesty levels in study participants.

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To the authors' best knowledge, the data regarding PPD is limited in the Georgian population. Hence, this study offers valuable insight into this critical mental health condition that needs serious attention and treatment. It will help increase awareness among society and healthcare providers who work directly on this condition. The findings of this research have important implications for providing care and support for Georgian females by helping identify the areas that require improvement. Furthermore, it could inform future studies in this area.