Background Pregnancy is a time of major psychological changes making pregnant women more susceptible to depression and anxiety. Prevalence is higher among women living in Bangladesh, India and Pakistan, compared to high-income countries, due to poor understanding and lack of mental health integration within antenatal care. Antenatal depression/anxiety is associated with adverse outcomes including postnatal depression, low birth weight and impaired fetal development. Existing systematic reviews provided only limited information, including a lack of meta-analysis, on the social determinants of antenatal depression or anxiety in these South Asian countries. This review aimed to identify, synthesise and appraise the evidence on the social determinants associated with antenatal depression and anxiety in women living in Bangladesh, India and Pakistan.

Methods We searched five databases (MEDLINE, Embase, PsycINFO, Scopus, Web of Science) and PROSPERO using keywords and MeSH headings. Two investigators screened all search results independently. Supplementary searches included hand searching reference lists and citation searches using Google Scholar. Observational studies published between 1st January 2000 and 4th January 2021 were included if they were in the English language, used validated tools for measuring depression/anxiety in pregnant women and reported statistical associations or raw numbers. Quality of included studies were assessed using the Newcastle-Ottawa scale. Summary estimates were obtained using random-effects model. Heterogeneity and publication bias was measured using the I² statistic and Egger’s test, respectively. The review was registered on PROSPERO (reference: CRD42020167903).

Results The searches identified 3,372 studies; following deduplication, 1,987 studies remained for screening. Following screening and supplementary searches, a total of 34 studies were included in this review (with 27,379 women). Meta-analysis of Adjusted Odds Ratios (AOR) found that Intimate partner violence (AOR 2.48, 95% CI 1.41–4.33), unplanned pregnancy (AOR 1.53, 95% CI 1.28–1.83), male gender preference (AOR 3.06, 95% CI 1.40–6.72) and poor relationship with in-laws (AOR 2.69, 95% CI 1.25–5.80) were significantly associated with antenatal depression.

Conclusion Screening tools to identify pregnant women at high risk of antenatal depression should be integrated within antenatal care to prevent adverse outcomes. Knowledge of social determinants will inform the development of such screening tools and interventions. One limitation of this review is the language restriction; however, international journals largely publish in English. Future research involving qualitative studies to understand the mechanisms within the associations are needed.