Postpartum depression (PPD) is a significant maternal mental health condition that can develop following childbirth and adversely affect women's emotional well-being, daily functioning, and ability to adapt to the demands of motherhood. The postpartum period involves substantial physiological, hormonal, psychological, and social changes, which may increase vulnerability to depressive symptoms in susceptible women. Common manifestations include persistent sadness, loss of interest or pleasure, feelings of guilt or worthlessness, impaired concentration, anxiety, and difficulties with sleep beyond those attributable to infant care. Although transient mood changes, commonly described as postpartum blues, are relatively frequent after childbirth, persistent or severe depressive symptoms require clinical assessment. Postpartum depression should therefore be recognized as an important component of comprehensive maternal healthcare rather than an inevitable consequence of motherhood [1,2].

The consequences of untreated postpartum depression may extend beyond maternal psychological distress. Depressive symptoms can interfere with maternal self-care, breastfeeding, mother–infant bonding, and the establishment of responsive caregiving practices. Evidence from systematic reviews and meta-analyses suggests that maternal perinatal depression is associated with adverse child developmental outcomes, including difficulties involving cognitive, emotional, and social development [3,4]. The severity of these effects may depend on symptom duration, the availability of family support, and access to appropriate treatment. Early identification and timely intervention are consequently important for improving maternal well-being and supporting healthy infant development.

The occurrence of postpartum depression varies across populations because of differences in socioeconomic conditions, cultural contexts, healthcare access, assessment instruments, and study methodologies. International evidence indicates that depressive disorders during the perinatal period represent an important public health concern, particularly in low- and middle-income countries where mental health services may be limited [1,5]. A systematic review and meta-analysis by Shorey et al. documented substantial variation in postpartum depression estimates across studies, emphasizing the influence of population characteristics and assessment methods [6]. Such variation demonstrates the need for locally generated evidence to guide screening policies and ensure that maternal mental health services respond to the needs of specific populations.

Pakistan faces considerable challenges in the recognition and management of perinatal mental health conditions. Atif et al., in a systematic review and meta-analysis involving 43 studies and 17,544 women, reported a pooled prevalence of 30% for postnatal depression and 37% for antenatal depression [7]. A subsequent systematic review and meta-analysis by Padhani et al. included 61 studies and further highlighted the substantial burden of perinatal depression among Pakistani mothers, alongside associations with previous psychiatric illness, socioeconomic disadvantage, relationship difficulties, and other psychosocial factors [8]. However, reported estimates differ according to the postpartum assessment period, participant selection, screening thresholds, and diagnostic methods. These findings reinforce the importance of conducting hospital-based assessments to understand the burden of depressive symptoms within specific clinical populations.

Women attending obstetrics outpatient departments provide an important population for postpartum mental health assessment because these visits offer opportunities to evaluate maternal recovery and identify psychological difficulties. Nevertheless, postpartum consultations may prioritize physical complications, breastfeeding, contraception, and infant care, while emotional concerns remain unrecognized. Stigma, limited awareness, fear of judgment, and reluctance to disclose depressive symptoms may further discourage women from seeking help. Integrating standardized screening into routine maternal healthcare can facilitate the identification of women who require further assessment, provided that screening is linked to appropriate clinical evaluation, referral, and follow-up [9,10].

The Edinburgh Postnatal Depression Scale (EPDS), developed by Cox, Holden, and Sagovsky, is a widely used screening instrument designed to identify women who may be experiencing postnatal depressive symptoms [11]. It comprises 10 self-reported items addressing emotional experiences during the preceding seven days, with each item scored from 0 to 3 and a total score ranging from 0 to 30. Its brief format makes it suitable for use in obstetric outpatient settings. However, the EPDS is a screening instrument rather than a diagnostic test, and its performance depends on the selected cutoff and the characteristics of the population being assessed. In an individual-participant-data meta-analysis, Levis et al. found that a threshold of 11 or above maximized the combined sensitivity and specificity for detecting major depression, whereas a threshold of 13 or above was less sensitive but more specific [12]. Consequently, the selected threshold should reflect the study objectives and clinical context.

Evidence regarding the EPDS in Pakistan also highlights the importance of linguistic and cultural appropriateness. Husain et al. evaluated depression screening instruments among Pakistani mothers and reported that the EPDS had acceptable validity for identifying women requiring further assessment [13]. Dosani et al. examined the psychometric properties of the Urdu-language EPDS among Pakistani pregnant women and reported acceptable reliability for the overall scale, while identifying areas requiring further investigation [14]. These findings support the use of culturally appropriate screening approaches while recognizing that evidence from pregnant women may not fully establish performance among postpartum women. The World Health Organization also emphasizes integrating perinatal mental health identification and support into maternal and child healthcare services [1]. Effective screening should therefore include appropriate referral pathways and safeguards for women experiencing severe symptoms or possible self-harm [15].

Despite growing recognition of maternal mental health, further local evidence is needed regarding postpartum depressive symptoms among women attending tertiary care facilities in Khyber Pakhtunkhwa. Assessing EPDS scores and examining their relationships with selected sociodemographic and obstetric characteristics may help identify women who require additional evaluation and support. Therefore, the present study aims to assess postpartum depressive symptoms among women attending the Department of Gynaecology and Obstetrics, PAF Hospital Mushaf, Pakistan, using the EPDS. Specifically, it aims to determine the frequency of positive screening at an EPDS score of 13 or above and examine associations with selected maternal characteristics. The findings may inform local screening practices and support the integration of maternal mental health assessment into routine postnatal care.

A hospital-based descriptive cross-sectional study was conducted in the Department of Gynaecology and Obstetrics, PAF Hospital Mushaf, Pakistan, over a period of six months. The study included 100 postpartum women who attended the outpatient department within six weeks after delivery. Participants were recruited using a non-probability consecutive sampling technique. Women aged 18 years or older who were within six weeks postpartum and willing to participate were included after providing written informed consent. Women who were clinically unstable, unable to complete the assessment, unable to provide informed consent, or had a severe psychiatric condition that substantially impaired their ability to participate were excluded. A structured questionnaire was used to collect sociodemographic and obstetric information, including maternal age, residence, educational status, employment, marital status, family structure, parity, mode of delivery, pregnancy intention, previous history of depression, and perceived social support. Postpartum depressive symptoms were assessed using the Edinburgh Postnatal Depression Scale (EPDS), a standardized 10-item self-report screening instrument designed to identify women who might require further assessment for depression. Each item was scored from 0 to 3, producing a total score ranging from 0 to 30, with higher scores indicating greater depressive symptom severity. The questionnaire was administered in a language understood by the participants, using an appropriate version of the scale. An EPDS score of 13 or above was considered a positive screening result for possible postpartum depression, whereas a score below 13 was classified as a negative screening result. The EPDS was used for screening purposes and not as a substitute for a formal psychiatric diagnosis. Participants with positive screening results were considered for further clinical assessment and referral according to the available clinical procedures. Responses indicating possible self-harm required prompt clinical evaluation regardless of the total EPDS score. The collected data were coded, entered, and analyzed using IBM SPSS Statistics, version 27. Categorical variables were summarized as frequencies and percentages, while continuous variables were presented as means and standard deviations or medians and interquartile ranges, depending on their distributions. The frequency of positive EPDS screening was calculated as the proportion of participants with scores of 13 or above, with a 95% confidence interval where appropriate. Associations between positive screening status and selected sociodemographic and obstetric characteristics were assessed using the chi-square test or Fisher's exact test, as appropriate. Independent-samples t-tests or Mann–Whitney U tests were used for comparisons involving continuous variables, depending on the distribution of the data. A two-sided p-value of less than 0.05 was considered statistically significant. Institutional ethical approval was obtained, and confidentiality was maintained through the use of study identification codes and secure data handling.

A total of 100 postpartum women attending the Department of Gynaecology and Obstetrics, PAF Hospital Mushaf, Pakistan, were included in the study. The participants were assessed using the Edinburgh Postnatal Depression Scale (EPDS), and a score of 13 or above was considered a positive screening result for possible postpartum depression. The results were analyzed to describe the participants' sociodemographic and obstetric characteristics, distribution of EPDS scores, frequency of positive screening, and associations between screening outcomes and selected maternal characteristics.

Table 1 presents the sociodemographic characteristics of the participants. The largest proportion of women belonged to the 25–34-year age group (52.0%), followed by those aged 18–24 years (28.0%). Regarding residence, 58.0% of participants lived in urban areas, while 42.0% resided in rural areas. Nearly half of the women had primary or secondary education (47.0%), and 35.0% had higher education. Most participants were not employed (78.0%), and 61.0% belonged to joint or extended families.

Table 1. Sociodemographic characteristics of the study participants (n = 100)

Table 2. Obstetric and clinical characteristics of the study participants (n = 100)

Table 2 summarizes the obstetric and clinical characteristics of the participants. Multiparous women constituted 58.0% of the study population, whereas 42.0% were primiparous. Vaginal delivery was reported in 55.0% of participants, while 45.0% had undergone cesarean section. Most women reported a planned pregnancy (62.0%). A previous history of depression was reported by 12.0% of participants, and 30.0% reported limited social support.

Table 3. Distribution of EPDS scores and frequency of positive screening (n = 100)

The distribution of EPDS scores is presented in Table 3. A total of 24 participants (24.0%) scored 13 or above and were classified as having a positive screen for possible postpartum depression. The remaining 76 participants (76.0%) scored below the predefined threshold. Of these, 48 women (48.0%) had scores between 0 and 9, while 28 women (28.0%) scored between 10 and 12.

Figure 1. Frequency of positive and negative EPDS screening

Figure 1 shows the distribution of screening outcomes. Positive screening was observed in 24.0% of participants, whereas 76.0% had scores below the predefined threshold.

Figure 2. Distribution of participants by EPDS score category

Figure 2 presents the distribution of participants across the predefined EPDS score categories. The largest proportion of participants scored between 0 and 9, followed by those scoring 10–12 and those scoring 13 or above.

Table 4. Association between selected characteristics and positive EPDS screening

Table 4 presents the association between selected maternal characteristics and EPDS screening outcomes. Positive screening was more frequent among women with no formal education (44.4%) than among those with higher education (11.4%). Women reporting limited social support had a higher frequency of positive screening (46.7%) than those reporting adequate support (14.3%). Similarly, positive screening was more frequent among women with a previous history of depression (58.3%) than among those without such a history (19.3%). These associations were statistically significant for educational status (p=0.027), perceived social support (p=0.001), and previous history of depression (p=0.009). No statistically significant association was observed between maternal age and positive screening (p=0.755).

Postpartum depression is an important maternal mental health concern that may affect maternal functioning, emotional well-being, and mother–infant relationships. The present study assessed postpartum depressive symptoms among 100 women attending the Department of Gynaecology and Obstetrics, PAF Hospital Mushaf, Pakistan, using the Edinburgh Postnatal Depression Scale (EPDS), with a score of 13 or above classified as a positive screen. The findings indicated that 24 women (24.0%) screened positive for possible postpartum depression. This finding suggests that a considerable proportion of women attending postpartum outpatient services may require further mental health assessment. However, the EPDS identifies women at risk of depression rather than establishing a definitive psychiatric diagnosis, and the observed screening frequency should be interpreted within the context of the study design and recruitment setting. The frequency of positive screening in the present study was comparable in magnitude to findings reported in some Pakistani hospital-based studies, although estimates varied across settings. Dawar et al. conducted a cross-sectional study at Khyber Teaching Hospital, Peshawar, and reported a substantial burden of postnatal depressive symptoms among women assessed using the EPDS [16]. Similarly, a study conducted among women attending obstetric clinics in Pakistan reported that 29.5% screened positive using an EPDS threshold of 13 or above [17]. A separate study involving 400 postpartum women from hospitals in Punjab reported a lower frequency of 12.5% [18]. The difference between these estimates and the 24.0% observed in the present study may reflect variation in participant characteristics, timing of postpartum assessment, recruitment procedures, psychosocial circumstances, and study populations. Differences in screening implementation and the characteristics of the healthcare facilities may also contribute to the observed variation. Therefore, direct comparisons should be made cautiously rather than interpreted as evidence of differences in the underlying prevalence of clinically diagnosed depression. The use of the EPDS was an important component of the present study because it provided a standardized method for assessing postpartum depressive symptoms. The instrument was specifically developed for identifying women who may require further evaluation and has been widely used in maternal healthcare research. Levis et al., in a systematic review and individual-participant-data meta-analysis, demonstrated that the diagnostic accuracy of the EPDS varied according to the selected cutoff score [12]. A threshold of 11 or above provided a favorable balance between sensitivity and specificity, whereas a threshold of 13 or above increased specificity but reduced sensitivity. The threshold selected in the present study was therefore useful for identifying women with higher symptom scores, but some women experiencing clinically important depressive symptoms may have scored below 13. This supports the importance of considering clinical symptoms and individual risk factors alongside the total EPDS score. The association between educational status and positive EPDS screening was statistically significant in the present study. Women without formal education had a higher proportion of positive screening results than women with higher education. This relationship may reflect differences in health literacy, socioeconomic circumstances, access to healthcare, and awareness of psychological symptoms. However, educational attainment should not be considered an independent cause of postpartum depression without further investigation. A recent umbrella review by Xu et al. identified multiple interacting risk factors for postpartum depression, including psychosocial adversity, previous depression, unintended pregnancy, and inadequate social support, while emphasizing that the certainty of evidence varied across factors [19]. The findings support further examination of educational and socioeconomic circumstances when planning maternal mental health services. Perceived social support was another important factor associated with positive screening. In the present study, 46.7% of women reporting limited social support screened positive, compared with 14.3% of women reporting adequate support. This difference suggests that emotional and practical support from partners and family members may be relevant to maternal psychological well-being during the early postpartum period. Women recovering from childbirth may experience sleep disruption, physical discomfort, breastfeeding difficulties, and increased caregiving responsibilities. Inadequate assistance with these demands may contribute to psychological distress. The importance of social support is consistent with the findings of Xu et al., whose umbrella review identified poor social support as one of the factors most strongly associated with postpartum depression [19]. Nevertheless, the cross-sectional design of the present study did not establish a causal relationship between social support and depressive symptoms. A previous history of depression was also associated with positive EPDS screening. Women reporting such a history had a higher proportion of positive screening results than those without a previous history. This finding is consistent with evidence that previous depressive illness increases vulnerability to postpartum mental health problems. Husain et al. investigated the prevalence and psychosocial correlates of perinatal depression in urban Pakistan and demonstrated the importance of considering psychological and social circumstances when assessing maternal depression [20]. Similarly, the umbrella review by Xu et al. identified a history of depression as an important risk factor for postpartum depression [19]. These findings support obtaining a relevant mental health history during antenatal and postnatal consultations and arranging closer follow-up for women who may be at increased risk. Maternal age was not significantly associated with positive EPDS screening in the present study. Although differences in screening frequency were observed across age categories, these differences did not reach statistical significance. This finding suggests that maternal age alone may not be sufficient to identify women at risk of postpartum depressive symptoms. Psychological vulnerability, family circumstances, previous mental health problems, and social support may be more informative when considered together. However, the sample size of 100 participants may have limited the statistical power to detect associations, particularly within smaller age groups. Larger studies would help clarify the contribution of maternal age and other demographic characteristics. The Pakistani context further emphasizes the importance of culturally appropriate screening. Husain et al. evaluated the EPDS and the Self-Reporting Questionnaire against a structured clinical assessment among mothers in a low-income setting and found that both instruments could be useful for screening maternal depression [13]. Their findings also highlighted the importance of considering the comprehensibility and acceptability of screening tools. In clinical settings where women have different educational backgrounds and language preferences, standardized administration and the use of an appropriate validated language version are essential. The EPDS should be administered privately, and assistance should be provided without influencing participants' responses. These measures may improve the quality of information obtained during routine postpartum assessment. The findings also have implications for the organization of postpartum healthcare. The World Health Organization recommends that screening for postpartum depression and anxiety using a validated instrument should be accompanied by diagnostic and management services for women who screen positive [21]. Similarly, the American College of Obstetricians and Gynecologists recommends standardized screening for perinatal mental health conditions within systems that provide timely assessment, treatment, and follow-up [15]. At PAF Hospital, incorporating the EPDS into routine postpartum visits could provide an opportunity to identify women who require further evaluation. Screening alone, however, is insufficient without clear referral pathways, trained healthcare professionals, and access to appropriate psychological or psychiatric care. Several limitations should be considered when interpreting the findings. The cross-sectional design did not permit the determination of temporal relationships or causality between the identified characteristics and positive EPDS screening. Consecutive non-probability sampling at a single tertiary care hospital may have limited the generalizability of the findings to other healthcare settings and the wider population. The relatively small sample size may also have reduced the ability to detect some associations. In addition, the EPDS relied on self-reported symptoms and did not establish a formal psychiatric diagnosis. The selected threshold of 13 or above may also have missed some women with clinically significant depressive symptoms, because the sensitivity of the EPDS varies according to the cutoff selected [12]. Future multicentre studies with larger samples, culturally appropriate screening procedures, and confirmatory clinical assessments are warranted. In conclusion, the study highlighted the potential value of routine postpartum depression screening in the Obstetrics Outpatient Department. The frequency of positive EPDS screening and its associations with educational status, perceived social support, and previous depression support further investigation of maternal mental health within local healthcare services. Integrating standardized screening with clinical assessment, appropriate referral, and follow-up may strengthen the identification and management of postpartum depressive symptoms.

Postpartum depression is an important maternal mental health concern that warrants timely recognition and appropriate clinical management. In the present study, 24% of postpartum women screened positive for depressive symptoms using the Edinburgh Postnatal Depression Scale (EPDS) at a cutoff score of ≥13. Positive screening was associated with lower educational attainment, limited social support, and a history of depression, whereas maternal age was not significantly associated with EPDS screening status. These findings highlight the importance of considering both psychosocial circumstances and previous mental health history when assessing postpartum women. However, a positive EPDS result indicates the need for further clinical assessment rather than confirming a diagnosis of depression. As the study was conducted at a single tertiary care hospital with a relatively small sample, the findings should be interpreted cautiously and should not be generalized to all postpartum women without further research.

Recommendations

Routine postpartum depression screening should be integrated into obstetric outpatient services using a validated instrument such as the EPDS, with appropriate clinical assessment and referral pathways for women who screen positive. Particular attention should be given to women with a previous history of depression, limited social support, or lower educational attainment. Healthcare professionals should provide clear information about postpartum depression, encourage family involvement where appropriate, and ensure that women can access psychological support and mental health services without stigma. Any response indicating thoughts of self-harm should prompt timely clinical evaluation and appropriate safety measures. Further multicentre studies involving larger and more diverse populations are recommended to estimate the burden of postpartum depressive symptoms more reliably and to investigate associated sociodemographic, obstetric, and psychosocial factors. Longitudinal research could also help clarify the course of depressive symptoms and evaluate the effectiveness of routine screening and referral interventions.

Authors’ Contributions

Dr. Shehnaz Sheeba contributed to the conceptualization and design of the study, supervised patient recruitment and clinical assessment, guided the interpretation of the findings, and critically revised the manuscript for important intellectual content. Naila Mahboob contributed to patient recruitment, data collection, administration of the EPDS, data entry and analysis, literature review, and drafting of the manuscript. Both authors read and approved the final manuscript and agreed to be accountable for all aspects of the work.