The point prevalence of post-partum perinatal mental health disorders and associated psychosocial characteristics in Malta: a study protocol


  • Rachel Buhagiar Department of Psychology, University of Malta, Msida, Malta
  • Kristina Bettenzana Department of Psychology, University of Malta, Msida, Malta



Perinatal mental health disorders, Perinatal psychopathology, Postpartum, Prevalence


Background: Perinatal mental health disorders are considered to be a major public health concern, affecting approximately 20% of pregnant and postnatal women. Left untreated, maternal psychopathology can extent to the rest of the family unit, including the child. Thus, a better understanding of the overall burden of these disorders is fundamental to inform policy makers and produce practice change.  To-date, the exact prevalence of these disorders  in Malta, an island in the center of the Mediterranean Sea, remains unknown. The primary objective of this cross-sectional study will be to address this gap in knowledge and define the local prevalence of perinatal psychopathology.

Methods: A representative sample of approximately 250 postnatal women from birth up to one year after childbirth, resident in Malta, will be recruited through a stratified random technique. Participation will involve two phases.  In the first stage, selected participants will be asked to self-complete the Edinburgh Postnatal Depression Scale (EPDS), the Generalised Anxiety Disorder-7 item (GAD-7), the Yale Brown Obsessive Compulsive Scale (YBoCS), the Post-Traumatic Stress Disorder Checklist for DSM-V (PCL-5), and the Difficulties in Emotional Regulation Scale (DERS) questionnaires.  In the second stage, those women who score equal or above the cut-off values in any of these questionnaires, will be assessed using the diagnostic Mini-International Neuropsychiatric Interview (MINI) to confirm or refute a diagnosis of a mental health disorder. Basic demographic details and psychosocial characteristics will be recorded.

Conclusions: This study will help determine the point prevalence of postnatal perinatal psychopathology and associated psychosocial determinants in Malta.


O’Hara MW, Wisner KL, Asher A. Perinatal mental illness: definition, description and aetiology. Best Pract Res Clin Obstet Gynaecol. 2014;28:3-12.

NHS England. Perinatal, 2019. Available at: Accessed on 4 May 2021.

Myors KA, Schmied V, Johnson M, Cleary M. Therapeutic interventions in perinatal and infant mental health services: a mixed methods inquiry. Issues Ment Health Nurs. 2014;35:372-85.

Nuffield department of Population Health (NPEU). Confidential enquiry into maternal death, 2017. Available at: on-deaths. Accessed 25 April 2021.

Bauer A, Parsonage M, Knapp M, Iemmi V, Adelaja B. The costs of perinatal mental health problems, 2014. Available at: https://www.nwcscnsenate. Accessed on 25 April 2021.

Leadsom A, Field F, Burstow P, Lucas C. The 1001 critical days. The importance of the conception to age two period, 2019. Available at: uploads/2018/02/The_1001_Critical_Days_Manifesto.pdf. Accessed on 5 May 2021.

Government of South Australia. South Australian perinatal practice guideline. Assessing parent infant relationship, 2018. Available at: https://www. Accessed on 10 May 2021.

Howard LM, Khalifeh H. Perinatal mental health: a review of progress and challenges. World Psychiatry. 2020;19:313-27.

Chmielewska B, Barratt I, Townsend R, Kalafat E, van der Meulen J, Gurol-Urganci I et al. Effects of the COVID-19 pandemic on maternal and perinatal outcomes: a systematic review and meta-analysis. The Lancet. 2021; 9(6):e759-72.

Racine, N, Hetherington E, McArthur BA, McDonald S, Edwards S, Tough S et al. Maternal depressive and anxiety symptoms before and during the COVID-19 pandemic in Canada: a longitudinal analysis. The Lancet 2021;8(5):405-15.

Shorey S, Chee CYI, Ng ED, Chan YH, Tam WWS, Chong YS. Prevalence and incidence of postpartum depression among healthy mothers: a systematic review and meta-analysis. J Psychiatr Res. 2018;104:235-48.

Dennis C-L, Falah-Hassani K, Shiri R. Prevalence of antenatal and postnatal anxiety: systematic review and meta-analysis. Br J Psych. 2017;210:315-23.

National Statistics Office, Malta. Regional Statistics Malta-2020 Edition, 2020. Available from Accessed on 10 June 2021.

Felice E, Saliba J, Grech V, Cox J. Prevalence rates and psychosocial characteristics associated with depression in pregnancy and postpartum in Maltese women. J Affect Disord. 2004;82:297-301.

Gatt M, Zahra C. National Obstetrics Information System, Directorate for Health Information and Research. NOIS Annual Report, 2019. Available at: Accessed on 25 April 2021.

The Royal College of Psychiatrists. Framework for routine outcome measures in perinatal psychiatry, 2018. Available at: docs/default-source/improving-care/better-mh-policy/college-reports/college-report-cr216.pdf? sfvrsn=12b1e81c_2. Accessed on 10 June 2021.

Harrison S, Henderson J, Alderdice F, Quigley MA. Methods to increase response rates to a population-based maternity survey: a comparison of two pilot studies. BMC Med Res Methodol 2019;19:1-8.

Toepoel V, Schonlau M. Dealing with nonresponse: strategies to increase participation and methods for postsurvey adjustments. Mathl Popul Stud 2017;24:79-83.

Levis B, Negeri Z, Sun Y, Benedetti A, Thombs BD. Accuracy of the Edinburgh Postnatal Depression Scale (EPDS) for screening to detect major depression among pregnant and postpartum women: a systematic review and meta-analysis of individual participant data. BMJ. 2020:1-11.

Centre of Perinatal Excellence (COPE). Australian Perinatal Mental Health Guideline Evidence Review. Technical report part B. Psychosocial assessment and screening for depression or anxiety, 2017. Available from health-professionals-3/review-of-new-perinatal-mental-health-guidelines/. Accessed on 5 May 2021.

Storch EA, De Nadai A, Conceicao do Rosario M, Shavitt RG, Torres AR, Ferrao YA et al. Defining clinical severity in adults with obsessive-compulsive disorder. Compr Psychiatry, 2015;63:30-35.

Connell J, Barkham M, Stiles WB, Twigg E, Singleton N, Evans O, Miles J. Distribution of CORE-OM scores in a general population, clinical cut-off points and comparison with the CIS-R. BJPsych. 2007;190:69-74.

Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E et al. The Mini-International Neuropsychiatric Interview (M.I.N.I): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry. 1998;20:22-33.

Ressing M, Blettner M, Klug SJ. Data analysis of epidemiological studies. Dtsch Arztebl Int. 2010;107:187092.

Woody CA, Ferrari AJ, Siskind DJ, Whiteford HA, Harris MG. A systematic review and meta-regression of the prevalence and incidence of perinatal depression. J Affect Disord. 2017;219:86-92.

Felice E, Saliba J, Grech V, Cox J. Validation of the Maltese version of the Edinburgh Postnaatl Depression Scale. Arch Women Ment Health. 2006;9:75-80.

Buhagiar R, Dimech C, Felice E. Validation of the Post-Traumatic Stress Disorder Checklist for DSM-5 in the Maltese Perinatal Population. MMJ. 2021.