Statement of Significance (SOS)

Problem or issue

Although postpartum depression (PPD) has long been recognized as a maternal health problem resulting in burdens for both mother and infant, there is still a lack of evidence regarding symptoms, consequences, and how it is managed in the Vietnamese setting.

What is already known?

Studies examining PPD in Vietnam have revealed a high prevalence, approximately 20%, of women suffering from PPD. Common symptoms of PPD were also reported previously, but not a scoping review, in Vietnamese or English, of the early recognition of symptoms, consequences, and effective management strategies.

What this paper adds

This study is the first scoping review synthesizing common symptoms, their consequences, and available management strategies for women in Vietnam. The findings indicate the importance of early detection of PPD symptoms in nursing practice. The paper offers a comprehensive evaluation of evidence in the Vietnamese context that supports the development of health education programs for the community and establishes a framework for the management of PPD.

Background

Postpartum depression (PPD), also defined as non-psychotic depression, with onset within 4–6 weeks of giving birth up to six months or even later, is a major maternal health problem [1,2,3]. The prevalence of PPD worldwide is around 15% [3,4,5], while in Asian countries the reported range is from 3.5% to 63.3% [6]. In Vietnam, the PPD rate is approximately 20% [7,8,9,10]. Untreated PPD affects not only a mother’s mental and physical health but also their child’s development [11] and family relationships, particularly mother–child bonding [4]. As such, management of PPD is essential to improving the health outcomes of both mother and child [12, 13].

Most of the recent research on PPD has focused heavily on the prevalence and risk factors of PPD [14, 15] in order to improve community awareness regarding the importance of preventing PPD. The fact that depression is often overlooked during pregnancy or the postpartum period emphasizes the need for timely screening of obstetrical and primary care symptoms [16]. More importantly, the diagnostic guidelines of PPD [2] state that some symptoms should be linked with moderate to severe intensity and distress. This generated questions for nurses about how to recognize early and manage the common symptoms of pregnant women diagnosed with PPD [17]. Despite the fact that symptoms of PPD are consistent across nations, early screening, which is influenced by the sociopolitical perceptions of mental health illness and evidence-based information [18, 19], would reduce the risk of PPD’s potentially negative effects on both the mother and the infant. In Vietnam, the National Guidelines on Reproductive Healthcare services in 2016 clearly outlined the caring instructions for healthcare workers in 1-day, 1-week and 6-week after birth but none of the emphasis on mental screening was mentioned [20], which limited the nursing practices on mental care and early screening for postpartum women. Additionally, inadequate acknowledgment and community understanding of mental health illnesses, including PPD, as well as societal stigmatization of those who suffer from them, discourage women, family members, and the community from reporting and recognizing symptoms in a timely and proper manner [21, 22]. Moreover, mental diseases are frequently disregarded and, when they do, are blamed on fate or faults the person did in a past life. Symptoms, consequences, and follow-up of PPD have also not yet been systematically summarized to provide a comprehensive view of PPD management in the context of Vietnam. Such information could be used in combination with evaluating the importance of early screening for PPD and developing an appropriate intervention strategy to target women suffering from PPD. This knowledge gap highlights an urgent need to conduct a scoping review to synthesize the current findings on symptoms and consequences of PPD, especially among Vietnamese women to understand the current state and recommend the most suitable intervention programs.

The most recent review of PPD was published in 2012, which synthesized articles from different countries regarding the specific signs and symptoms, appropriate screening methods, and proper treatment [23]. However, this covered major traits of PPD across the world instead of the Vietnamese context with considerations of its socioeconomic differences. Additionally, changes and updates in medical treatment and symptoms management during the previous decade require a timely reappraisal of evidence. This scoping review of PPD in Vietnam, therefore, provides an updated overview of this important maternal health condition. The specific aim was to analyze the findings of studies examining symptoms, consequences, and management strategies to understand the effects of PPD and how it is managed in women who were Vietnamese nationals and living in Vietnam.

Methods

Search strategies

A literature search was conducted manually to review reported studies among Vietnamese women using the following online databases: MEDLINE, CINAHL, PubMed, ScienceDirect, EBSCOHost, Google Scholar, and a networked digital library of projects, theses, and dissertations in Vietnam. Search terms in both Vietnamese and English, including “Vietnam”, “depression”, “postpartum”, “symptom/experience”, “consequence”, and “management”, were used separately and as combinations during the search. All published and unpublished projects matching these key terms were included for screening. Each published article cited other studies that were also checked for relevance. Following the search, the title and abstract of every study were filtered and reviewed before being included for critical appraisal. The review process is presented in Fig. 1.

Fig. 1
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Search process

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Inclusion and exclusion criteria

Articles were included if the reported study fulfilled each of the following criteria: (i) examined symptoms, experiences, consequences, or management strategies of PPD; (ii) was published between 2010 and 2022; and (iii) was conducted among Vietnamese participants regardless of quantitative or qualitative method. Findings from both quantitative and qualitative perspectives can provide a much broader summary of the literature to accomplish the aims.

Analysis process

Eligible articles were reviewed before the final decision of inclusion or exclusion. All titles, abstracts, and full texts were examined to ensure relevance to the research topic. Suitable papers were retained in the review list, while irrelevant ones were removed. This step was followed by a detailed process of reading and analyzing the full text of qualified publications that was performed by two researchers independently of each other to ensure impartiality and preciseness. The quality of these articles was assessed using the critical appraisal checklists of the JBI (Joanna Briggs Institution). At the completion of the analysis, the content of the finally included publications was categorized into a literature matrix. Table 1 shows the literature review matrix of 17 articles included in this scoping review.

Table 1 Literature matrix of 17 included articles
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Results

Overall, after titles were screened, abstracts were reviewed, and full texts were accessed, a total of 39 articles were included. Of these, 21 articles pointing out symptoms/experiences, consequences, and management of PPD among Vietnamese participants were kept for critical appraisal using JBI’s checklists. Four articles that did not meet quality for review after critical appraisal were excluded after reviewing; thus, 17 publications remained for further data analysis.

Study characteristics

Research findings regarding symptoms, consequences and/or management of PPD of mothers in the postnatal period were reported intermittently during previous years in Vietnam, as shown in Table 2. Research reports (n = 5) that examined mothers’ symptoms and feelings, as well as PPD management used the qualitative method, while quantitative studies (n = 11) described the percentage of each symptom in PPD. Among studies reviewed, most focused on a 1–3-month period while only two mentioned mothers’ experiences during the first 24–48 h postpartum. Research settings varied in level of size from commune, district, province, to country. Several different research methods were used to examine PPD, including semi-structured, survey and other self-report scales.

Table 2 Characteristics of articles on PPD symptoms and management in Vietnam
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PPD symptoms among Vietnamese participants

Symptoms of PPD often include a combination of: mood changes like anxiety, irritability, and a feeling of being overwhelmed; physical disorders such as sleep disturbance (beyond that associated with the care of the baby) or loss of appetite; self-criticizing or obsessive preoccupation with the baby’s health and feeding [9, 38]. This scoping review grouped symptoms reported in the included studies into three commonly found categories: (1) physical symptoms; (2) emotional symptoms; and (3) abnormal behavior changes, as shown in Table 3. Among physical symptoms, poor appetite was reported at a high percent [9, 35, 39]. Heart palpitations/Breathing difficulty/Nausea/Headaches/Constipation were also mentioned in one qualitative study as possible symptoms [24].

Table 3 PPD experiences and symptoms among Vietnamese participants
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In terms of emotional symptoms reported with a wide range of prevalence in quantitative research, those most frequently mentioned were worries, anxiety, and stress. “Feeling nervous” was pointed out in three studies at various rates [7, 9, 27], while “sadness” was also a prominently featured concerned feeling [27, 36, 39]. Moreover, feelings of isolation included “I am abusing my child”, “do not have time to interact with the child in a relaxed mood” [7, 39], the thought “they are useless and do not want to become a burden for others” [30] or even “being homesick” [32]. From another perspective, mothers who lack care from others may have feelings of “being ignored; being denied support, and being exposed to controlling behaviors” [26, 39] or of “living under pressure with the psychic force of household tensions or the weight of kinship conflicts” [25]. A significant number of mothers had more severe symptoms in which 37.9% of them “had suicidal thoughts” [8, 36, 39].

Abnormal behaviors like “wandering around outside”, “attacking someone”, and “speaking without meaning” were not common but may be observed in some mothers who experienced a moderate level of PPD [35]. Nighttime waking apart from infant care was self-reported among women at high risk of PPD [24].

Consequences and management of PPD

The consequences of PPD have an impact on both the mother and her child(ren). Mothers could face a higher risk of future common mental disorders [29], or in some severe cases, mothers suffering from PPD may have suicidal thoughts [8]. As summarized in Table 4, only two studies mentioned child stunting (the lowest extreme of child growth defined as height-for-age below − 2 standard deviations from the median of the reference population) due to the mother’s PPD which could be explained by interfering with sensitive-responsive parenting practices [28, 31].

Table 4 Management and consequences of PPD among Vietnamese mothers
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Three of the 17 articles discussed the management and follow-up of PPD in Vietnam [29, 30, 35]. Non-psychotic PPD required proper care including timing screening, early interventions, and follow-up assessment in order not to worsen to the more severe situations. However, the results of these three studies indicated insufficient mental healthcare services for mothers during this sensitive period when the postpartum required the most attention to be cared for. For women with severe depressive symptoms such as psychosis or epilepsy, long-term management was limited in Vietnam. As such, mothers having to find a strategy to help themselves tended to “seek help from traditional medicine and fortune-tellers” rather than to explore what advice was available from healthcare providers [30]. Follow-up after delivery and long-term management of PPD has been a significant maternal healthcare gap in Vietnam over the past decade.

Discussion

Seventeen articles examining symptoms of mothers and management of PPD in postnatal period studies with different timeframes were identified and included in this scoping review of depressive symptoms, consequences, and management of PPD among mothers in Vietnam. Here, publicly accessible information on the experiences and management of women suffering from PPD is not regularly updated, in contrast to the practice in some other countries [16, 40]. This important maternal health issue urges a call for future studies on PPD among Vietnamese women with a primary focus on early detection, and its barriers to and enablers of commonly reported symptoms, rather than on the prevalence of PPD.

One of the few published studies reported that women experienced high levels of depressive symptoms in the two-week postpartum period, peaking on day five [41]. During these early days following delivery, women experienced mood disturbances, including emotional lability, frequent crying, anxiety, fatigue, insomnia, anger, sadness, and irritability [41]. In this scoping review, two studies investigated symptoms 24–48 h after birth, but little was revealed about this initial period, especially after day 2 in the first week. Examination of early PPD symptoms during these very first days is needed to support interventions for high-risk women during these days of the most sensitive moods disorders [42, 43].

Herein, our review delineates the results of studies on PPD symptoms into those that are physical, those that are emotional, and abnormal behaviors. A group of emotional symptoms was identified in an earlier review [35]. Previous studies on women in other countries confirmed that this emotional phenomenon is accompanied by symptoms such as mood disturbances ranging from euphoria to sadness, high sensitivity, sudden crying, restlessness, poor concentration, and anger [44]. Additionally, a systematic review of qualitative evidence regarding new mothers’ experiences of PPD revealed four themes: inability to control feelings; ambivalence towards family members; imbalanced support between demands; and expression of hopelessness/helplessness [16]. Research from around the world found that hormonal changes after delivery, the stress to the mother of caring for her baby, or even situations surrounding labor may each lead women to experience physical symptoms, such as eating disturbances or sleeping disorders [41, 45]. One study examining the experiences of maternal and child health nurses responding to women with PPD in Australia showed agreement regarding symptoms such as lack of feeling and lack of concentration [46]. Similarly, according to DSM-IV diagnostic criteria, insomnia, changes in appetite, and suicidality were assessed as indicative of a major depressive disorder [2]. While not frequently reported in Vietnam, some abnormal behaviors like “wandering around outside”, “attacking someone”, “speaking without meaning”, and “nighttime waking” were observed in previous studies elsewhere, especially among patients with a severe mental disorder [47, 48]. Despite the categorization of PPD symptoms into three groups of physical, emotional, and behavioral symptoms, this scoping review indicates that previous studies among the Vietnamese population did not pay sufficient attention to early recognized symptoms that started after birth. This paucity of information, along with psychosocial barriers, causes difficulty for both clinical practitioners and family members to assess early and thereby prevent the occurrence of PPD symptoms.

Appropriate management and follow-up are crucial to reducing the harmful effects of PPD and may positively impact treatment outcomes. Different types of mood disorders after giving birth required various follow-up treatment. While postpartum blues is believed to disappear without treatment, the overlooked situations can result in non-psychotic PPD, which may need professional care, and even the most severe situation as postpartum psychosis will require hospitalization [3, 38, 44]. The differentiation between PPD and postpartum blues was discussed in only three studies included in our review [29, 30, 35]. The lack of concentration on PPD cases, especially severe ones, can lead to inadequate care and further treatment for these women. Although postpartum management and care for mothers and infants were not examined well in Vietnam, these issues were explored in other countries [12, 13]. Women receiving interventional support and monitoring demonstrated better maternal mental health outcomes compared to the control group. The importance of support to mothers was examined in a separate study [13], which confirmed that primary care-based screening, diagnosis, and management improved mothers’ depression outcomes at 12 months. Postpartum Vietnamese women are in urgent need of timing and comprehensive maternal healthcare services; however, to provide such support, intervention programs need to be well-informed by local research that follows mothers along a postnatal timeline.

In this scoping review of articles published on PPD in Vietnam, both mothers’ and child(ren)’s health problems are mentioned, including suicidal thoughts and further mental disorders in mothers, and stunting and slow growth in children [28, 31]. PPD was recognized as a systemic issue affecting a woman’s functioning, sense of well-being, family relationships, parenting capacity, and competency to control her daily life [41]. Further impacts should be investigated to capture more completely the consequences of PPD on Vietnamese mothers. This would provide evidence for informed decision-making on the implementation of suitable screening and management programs for this at-risk population. These programs should consider educating women and their family members to follow modern, evidence-based methods to manage PPD rather than relying on ‘fortune-teller’ advice or ‘word-of-mouth’ practices.

Several key questions regarding PPD in Vietnam remain and offer opportunities for future research. In particular, these include considering the underlying background of barriers to and enablers of early detection of symptoms of PPD and its follow-up management after screening or diagnosis. Mothers’ symptoms were reported without reference to a group of common combined symptoms or sequence of symptoms mostly in the context of a private medical examination, with limited public awareness through community engagement [21]. Community mental health stigma was studied as a significant barrier to access follow-up healthcare services [49], and was associated with lower acceptance of treatment [50]. In addition to the unique psychosocial aspects within the Vietnam context, this is challenging for healthcare workers and family members to detect early signs or symptoms of PPD and to provide in-time support for these women. Furthermore, no research on typical consequences affecting Vietnamese mothers was found. This suggests a pressing need for a follow-up study to identify possible consequences of PPD and support strategies required both for postpartum mothers in Vietnam and to increase community awareness. Similarly, a management program or follow-up plan after early detection is recommended to focus on mothers both at mild stages and during more severe periods of PPD.

Strengths and limitations

This scoping review provides a perspective of PPD symptoms, consequences, and management in Vietnam. Published articles were searched on qualified databases, filtered, and critically appraised using a validated process provided by JBI. However, little evidence has been collected in Vietnam, especially in recent years. Additionally, many unpublished studies have not been posted online or otherwise widely shared. These resources were therefore not included in the review due to their limited accessibility. This issue may narrow the scope of our current understanding of the research topic. Finally, article selection was by reading and reviewing their content using the JBI checklist, but which did not follow fully the JBI systematic review process. This led to difficulty comparing and synthesizing research findings due to a shortage of local Vietnamese databases.

Conclusion

This scoping review presents an overview of research exploring PPD in Vietnam. Highlighted symptoms mentioned are sadness, tiredness, being ignored, lack of interest in the baby, loss of appetite, and sleep disturbance. The PPD symptoms described, categorized as either physical symptoms, emotional symptoms, or abnormal behavior changes, are recommended to facilitate further research on early screening for PPD among postpartum women. This study highlights the limited information that is currently available on the consequences of PPD among Vietnamese mothers and the management of PPD in Vietnam. We therefore advocate for in-depth studies on these topics to be conducted.

Early detection of PPD and long-term follow-up play essential roles in effective treatment of this common mood disorder. A focus should be on recognizing symptoms during early postnatal days to enable community education programs to be rolled out successfully. Identification of PPD consequences on mothers is strongly recommended, as is a strategy for hospitals and healthcare services to follow up with women reporting negative feelings or sleep disturbance. These local community-based initiatives should also be culturally aware, such as acknowledging the ritual belief system of Vietnamese mothers seeking to resolve depressive feelings after giving birth.