Association between Quality of Antenatal Care and Postpartum Depression among Women in Al Anbar Governorate, Iraq: A Cross-Sectional Study

BackgroundPostpartum depression (PPD) is a leading cause of maternal morbidity, particularly in low-resource and conflict-affected regions. While high-quality antenatal care (ANC) may offer support against maternal mental distress, the association between PPD and ANC remains underexplored in conflict-affected settings. ObjectiveTo investigate the association between perceived quality of ANC and the prevalence of PPD among postpartum women in Al Anbar governorate, Iraq. MethodsIn a cross-sectional study conducted between February 2024 and February 2025, 618 women [≤]8 weeks postpartum were recruited from 23 primary health care centers (PHCCs) across Al Anbar. ANC quality was assessed using the 46-item Quality of Prenatal Care Questionnaire (QPCQ), and PPD symptoms were measured using the Edinburgh Postnatal Depression Scale (EPDS, cutoff [≥]13). Associations between ANC quality and PPD were analyzed using chi-square tests and Pearson correlations. ResultsOverall, 42.4% of women screened positive for probable PPD. While 58.1% of participants rated their ANC as "good" (QPCQ [≥]165), perceived ANC quality did not significantly correlate with total EPDS scores (r = 0.067, p = 0.094). Subscale analysis revealed that women with PPD paradoxically reported higher scores in information sharing, anticipatory guidance, and service availability. Higher ANC visit frequency and maternal education were significantly associated with higher QPCQ scores, yet these did not correspond to lower PPD prevalence. Geographic differences in ANC quality were observed but did not align with PPD incidence. ConclusionsIn conflict-affected Al Anbar, higher perceived ANC quality did not translate into reduced PPD risk. These findings highlight the need for integrated psychosocial support within ANC programs and stress the limitations of standard prenatal care in addressing maternal mental health in conflict-affected contexts.