The term "postpartum depression" refers to a severe depressive episode with a peripartum start, meaning that the most recent episode occurred both during pregnancy and in the four weeks immediately following birth [1]. PPD symptoms are similar to other depression disorders, however, PPD can be distinguished from other forms of depression by its onset and duration. Loss of appetite, sleeplessness, extreme irritability, rage, exhaustion, lack of joy in life, extreme mood swings, and the most concerning symptom hearing thoughts of harming oneself or a baby are all signs of PPD, all of these signs could indicate that the mother might neglect her child [2]. According to a study, one out of every seven moms had this condition [3]. According to a significant meta-analysis carried out in 2021; the prevalence rate of postpartum depression worldwide is 17.22% [4]. A study in 2023 at a tertiary care hospital, in Saudi Arabia reported that the prevalence of PPD was 50.3%, which is greater than any previous studies in Saudi Arabia. risk factors were sleep difficulties (p = 0.005), lack of interest in daily activities (p = 0.031), mood swings (p = 0.021), frequent episodes of depression (p 0.0001), and annoyance or concern (p 0.0001) also found to significantly increase the risk of PPD [5]. Research in southwest of Saudi Arabia showed that Postpartum depression was seen in 43.4% of women. The main indicators of developing PPD were found to be family conflict and a lack of support from spouse and family during pregnancy. Women who reported family conflict were six times more likely to develop PPD than those who did not report family conflict (aOR = 6.5, 95% CI = 2.3-18.4). Women who reported a lack of marital support during pregnancy had a 2.3-fold greater risk of PPD (aOR = 2.3, 95% CI = 1.0-4.8), while women who did not get family support during pregnancy were more than three times more likely to suffer PPD (aOR = 3.5, 95% CI 1.6-7.7) [6]. A study in the women of Hail, Saudi Arabia reported data was obtained from 316 women between the ages of 20 and 45 who are mothers of one or more children and have not been diagnosed with any psychiatric disorder. The demographic data is as follows. The study included 316 individuals, with 38.61% aged between 31 and 40 years old, followed by 41-45 years old (34.49%), and 20-30 years old (26.90%). The majority (76.58%) had a university education, with secondary school (15.51%) [7].   The number of studies related to our topic is limited, particularly in the Middle East and the Arab world, and many existing studies suffer from methodological weaknesses, such as small sample sizes and inconsistent findings. Recent research conducted in Syria found that nearly one in three women experience postpartum depression. The burden of mental health challenges extends beyond the individual, significantly affecting children and families as well. These findings highlight the urgent need for more rigorous and comprehensive research in this area.   Objectives The aim of this study was to measure the knowledge level among Saudi population about postpartum depression after multiple pregnancies.

Study Design This study was a cross-sectional study Conducted between Aug 2023 – May 2025 in Saudi Arabia, based on a structured validated questionnaire. Participants in the research included postpartum women over age of 18 whose gave birth to various infants in Saudi Arabia.   Inclusion and Exclusion Criteria Women in Saudi Arabia with a history of multiple pregnancies who agreed to participate in the study were included. Men and women who declined to participate were excluded.   Sample Size By using the Qualtrics calculator and a 95% degree of confidence, the size of the sample was estimated, So the minimum sample size was 384. The Sample size was estimated by using this formula:   n= P (1-P) * Zα 2 / d 2   with a confidence level of 95% n: Calculated sample size Z: The z-value for the selected level of confidence (1- a) = 1.96. P: An estimated knowledge Q: (1 – 0.50) = 50%, i.e., 0.50 D: The maximum acceptable error = 0.05.   So, the calculated minimum sample size was:   n = (1.96)2 X 0.50 X 0.50/(0.05) 2 = 384   Data Collection and Study Tool Data for this study were collected through a structured, self-administered electronic questionnaire distributed to multiparous women across various regions in Saudi Arabia, with a predominance of participants from the Makkah region. The data collection period spanned four weeks during 2023. The survey was designed to assess participants’ knowledge, awareness, and perceptions regarding postpartum depression (PPD) after multiple pregnancies, with specific attention to cultural, social, and healthcare-related factors relevant to the Saudi context.   The questionnaire consisted of both closed-ended and multiple-choice questions, divided into sections covering sociodemographic information, familiarity with PPD, personal and observed experiences, recognition of symptoms, sources of information, perceived risk factors, cultural influences, barriers to seeking help, and views on available support services. Responses were collected anonymously using a secure online platform to ensure participant confidentiality and encourage honest reporting. The tool was reviewed for content relevance and clarity prior to distribution, ensuring alignment with the study’s objectives.   Pilot Test The questionnaire was distributed to 20 individuals who were asked to complete it. This pilot test aimed to evaluate the simplicity of the questionnaire and the feasibility of the study. Data collected during the pilot study were excluded from the final analysis of the study.   Analysis and Entry Method By using the "Microsoft Office Excel Software" program (2016) for Windows, the collected data was entered into the computer. In order to perform statistical analysis, data was subsequently transferred to the Statistical Package of Social Science Software (SPSS) program, version 20 (IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.).

Table 1 displays various demographic parameters of the participants with a total number of (106). Majority of the respondents were in the age group of 25-34years (32.1%); those aged 35-44 years were 21.7% and those 45-54 years were 20.8%. Women aged between 18 and 24, 17.9% of the participants, was followed by older population 55 years and over, which constituted 7.5% of a total sample. Only female participants were involved in the study, which made up 100% of the sample. Geographically, the Makkah region contributed the highest percentage of respondents (74.5%) indicating regional bias within the sample.   As shown in Figure 1, A small slice of the population, representing 18.9% (n=20) indicated high level of familiarity with postpartum depression. Somewhat familiar, a substantial majority (72.6%, n=77) reported. On the other hand, only 8.5% of respondents, 9 people, indicated that they lacked familiarity with the topic.   Table 1: Sociodemographic characteristics of participants (n=106) Parameter No. Percent Age 18 to 24 19 17.9 25 to 34 34 32.1 35 to 44 23 21.7 45 to 54 22 20.8 55 or more 8 7.5 Gender Female 106 100.0 Region Al-Baha Region 1 0.9 Assir Region 1 0.9 Hail region 3 2.8 Jazan Region 2 1.9 Madinah Region 7 6.6 Qassim Region 2 1.9 Riyadh Region 5 4.7 Tabuk Region 2 1.9 Eastern Region 3 2.8 Jeddah 1 0.9 Makkah 79 74.5     Figure 1: Level of personal knowledge regarding postpartum depression after multiple pregnancies in the Saudi culture among participants (n = 106)   Table 2 sheds light on the awareness and familiarity of participants with postpartum depression (PPD) specifically concerning multiple pregnancies. Most of the participants reported (97.2%) that they had heard of PPD before, but a significant part of them (20.8%) did not even know that multiple pregnancy can result in PPD. Notably, experiences were cut nearly in half as approximately 49.1% of the participants either reported personal or acquaintance-level exposure to PPD after multiple pregnancies. However, the level of familiarity with the PPD based on the Saudi cultural group differed, with most of the group describing themselves as “somewhat familiar” (72.6%), and those who considered themselves “very familiar” were a minority (18.9%). Some of the specific risk factors mentioned by participants were lack of extended family support (72.6%) and cultural expectations /pressures (62.3%). Awareness of the signs and symptoms of PPD generally matched the overall knowledge of the disorder. About 22.6% are not sure as to the importance of PPD, the majority considering it a significant issue. 55.7% of participants recognized social media as a major source of information, while only 30.2% believed healthcare professionals adequately manage PPD after several pregnancies. About 46.2% were unsure about this aspect, implying potential lapses in their awareness level or faith in medical facilities.   Table 2: Parameters related to knowledge and familiarity regarding postpartum knowledge (n=106). Parameter No. (%) Have you heard of postpartum depression (PPD) before? No 3 2.8 Yes 103 97.2 Do you know that postpartum depression can occur after multiple pregnancies? No 22 20.8 Yes 84 79.2 Have you or someone you know, experienced, postpartum depression after multiple pregnancies? No 54 50.9 Yes 52 49.1 How much do you know about postpartum depression after multiple pregnancies within Saudi cultural context? Very familiar 20 18.9 Somewhat familiar 77 72.6 Not familiar at all 9 8.5 What do you think are the specific risk factors for developing postpartum depression after multiple pregnancies in Saudi Arabia?* Lack of extended family support 77 72.6 Culture expectations, and pressures 66 62.3 Limited social networks for your mothers 27 25.5 Financial constraints specific to Saudi culture 21 19.8 How familiar are you with specific signs and symptoms of postpartum depression after multiple pregnancies in Saudi Arabia? Very familiar 19 17.9 Somewhat familiar 73 68.9 Not familiar at all 14 13.2 Do you think that postpartum depression after multiple pregnancies Is a significant Issue within the Saudi cultural context? No 11 10.4 Yes 71 67.0 Not sure 24 22.6 What sources of specific information have you come across regarding postpartum depression after multiple pregnancies in Saudi Arabia?* Healthcare professionals in Saudi Arabia 39 36.8 Saudi Arabian online articles or websites 43 40.6 Social media accounts specific to Saudi culture 59 55.7 Books or magazines written by Saudi authors 13 12.3 Others 5 4.7 Do you believe that healthcare providers in Saudi Arabia adequately address postpartum depression after multiple pregnancies within Saudi cultural context? No 25 23.6 Yes 32 30.2 Not sure 49 46.2 *Results may overlap       Figure 2: Effect of personal experience among Saudi women who experienced postpartum depression after multiple pregnancies among participants (n = 106)   As shown in Figure 2, According to the survey, 42.5% of respondents believe that Saudi women who experience PPD after multiple pregnancies are more informed about it. On the other hand, there are 28.3% (n=30) who are not aware of this belief. A significant 29.2% (n=31) of people were unconfident when responding.   Table 3 gives significant details about awareness, knowledge, and barriers identified to postpartum depression (PPD) after multiple pregnancies among Saudi Arabian women. The respondents reported that traditional practices had affected postpartum care for 62.3% of the participants thus, showing the importance of culturally sensitive intervention. Many (79.2%) participants reported as their key reason for attending the session that they found the need to discuss PPD to be meaningful, but 77.4% have never discussed it with their healthcare provider, and 83% remain lacking in knowledge of support services that are available. This gap indicates that there is an urgent need for an improved dialogue and more available resources. While more than 70% indicated willingness to discuss PPD, cultural stigma (33.9%) and the inability to access culturally appropriate help (76.4%) continued to be significant barriers to obtaining help. From these findings, it is apparent that education and training will need to address PPD in Saudi Arabia as culturally sensitive (48.1%), healthcare providers will need to have culturally effective support skills (66.0%), and support groups ought to be developed with family involvement in mind (53.8%).   Table 3: participants’ knowledge and awareness of postpartum knowledge (n=106) Parameter No. (%) Are there any specific factors in Saudi Arabia that might influence the recognition and acknowledgement of postpartum depression after multiple pregnancies? * Cultural attitude towards mental health in Saudi Arabia 42 39.6 Influence religious beliefs on seeking help for mental health issues 30 28.3 Role of extended family support in Saudi culture 55 51.9 Influence of traditional practices and customers on postpartum care 66 62.3 In your opinion, what specific steps can be taken to improve knowledge and awareness of postpartum depression after multiple pregnancies in Saudi Arabia? * Incorporation Saudi cultural value and norms in education and awareness campaigns 51 48.1 Training healthcare professionals to provide culturally sensitive support to women with postpartum depression in Saudi Arabia 70 66.0 Establishing specialized support groups for Saudi women with multiple pregnancies 57 53.8 Involving family members particularly female relatives, in the support process 60 56.6 Others 2 1.9 Are there Any specific Barriers that prevent Saudi women for seeking help or support for postpartum depression after multiple pregnancies? * Lack of awareness about culturally appropriate resources 81 76.4 Cultural stigma surrounding mental health in Saudi Arabia 36 33.9 Limited access to healthcare services specific to Saudi culture 39 36.8 Language barriers specific to Saudi culture 19 17.9 Others 3 2.8 Do you believe That Saudi women who experienced postpartum depression after multiple pregnancies are more knowledgeable about the condition within Saudi culture context? No 30 28.3 Yes 45 42.5 Not sure 31 29.2 How important do you think is to address Postpartum depression after multiple pregnancies within Saudi culture context? Very important 84 79.2 Somewhat important 20 18.9 Not important 2 1.9 Have you ever discussed postpartum depression after multiple pregnancies with your healthcare provider? No 82 77.4 Yes 24 22.6 Are You aware of any support services or resources specifically designed for Saudi women experiencing postpartum depression after multiple pregnancies? No 88 83.0 Yes 18 17.0 Would You Feel comfortable discussing postpartum depression after multiple pregnancies openly with your family or friends? Yes, I would feel comfortable discussing it openly 74 69.8 No, I would not feel comfortable discussing it openly 6 5.7 It depends on the situation 26 24.5 *Results may overlap   Table 4 shows that previous knowledge of postpartum depression has statistically significant relation to level of personal knowledge regarding postpartum depression after multiple pregnancies in the Saudi culture (P value=0.001). It also shows statistically insignificant relation to familiarity with signs and symptoms of postpartum depression, age group, previous experience of postpartum depression, knowing that postpartum depression is related to multiple pregnancies, if postpartum depression is significant in Saudi population and the effect of healthcare providers in addressing postpartum depression.   Table 4: Relation between previous knowledge of postpartum depression and sociodemographic and familiarity regarding postpartum depression Parameters Previous knowledge of postpartum depression Total (N=106) P value* Yes no How familiar are you with the specific signs and symptoms of postpartum depression after multiple pregnancies in Saudi Arabia? Very familiar 19 0 19 0.472 18.4% 0.0% 17.9% Somewhat familiar 71 2 73 68.9% 66.7% 68.9% Not familiar at all 13 1 14 12.6% 33.3% 13.2% Which age group do you belong to? 18 to 24 18 1 19 0.350 17.5% 33.3% 17.9% 25 to 34 33 1 34 32.0% 33.3% 32.1% 35 to 44 23 0 23 22.3% 0.0% 21.7% 45 to 54 22 0 22 21.4% 0.0% 20.8% 55 or more 7 1 8 6.8% 33.3% 7.5% How much do you know about postpartum depression after multiple pregnancies within the Saudi cultural context? Very familiar 20 0 20 0.001 19.4% 0.0% 18.9% Somewhat familiar 76 1 77 73.8% 33.3% 72.6% Not familiar at all 7 2 9 6.8% 66.7% 8.5% Have you or someone you know experienced postpartum depression after multiple pregnancies? Yes 52 0 52 0.085 50.5% 0.0% 49.1% No 51 3 54 49.5% 100.0% 50.9% Do you know that postpartum depression can occur after multiple pregnancies? No 22 0 22 0.369 21.4% 0.0% 20.8% Yes 81 3 84 78.6% 100.0% 79.2% Do you think that postpartum depression after multiple pregnancies is a significant issue within the Saudi cultural context? Yes 69 2 71 0.788 67.0% 66.7% 67.0% No 11 0 11 10.7% 0.0% 10.4% Not sure 23 1 24 22.3% 33.3% 22.6% Do you believe that healthcare providers in Saudi Arabia adequately address postpartum depression after multiple pregnancies within the Saudi cultural context? Yes 31 1 32 0.601 30.1% 33.3% 30.2% No 25 0 25 24.3% 0.0% 23.6% Not sure 47 2 49 45.6% 66.7% 46.2% *P value was considered significant if ≤0.05   Table 5 shows awareness of support services for postpartum depression has statistically significant relation to the effect of healthcare providers in addressing postpartum depression in Saudi Arabia (P value=0.002). It also shows statistically insignificant relation to familiarity with signs and symptoms of postpartum depression, age group, previous experience of postpartum depression, knowing that postpartum depression is related to multiple pregnancies, if postpartum depression is significant in Saudi population and previous knowledge of postpartum depression.   Table 5: Awareness of support services for postpartum depression in association with sociodemographic and familiarity regarding postpartum depression Parameters Awareness of support services for postpartum depression Total (N = 106) P value* No Yes How familiar are you with the specific signs and symptoms of postpartum depression after multiple pregnancies in Saudi Arabia? Very familiar 14 5 19 0.341 15.9% 27.8% 17.9% Somewhat familiar 61 12 73 69.3% 66.7% 68.9% Not familiar at all 13 1 14 14.8% 5.6% 13.2% Which age group do you belong to? 18 to 24 14 5 19 0.120 15.9% 27.8% 17.9% 25 to 34 26 8 34 29.5% 44.4% 32.1% 35 to 44 20 3 23 22.7% 16.7% 21.7% 45 to 54 22 0 22 25.0% 0.0% 20.8% 55 or more 6 2 8 6.8% 11.1% 7.5% How much do you know about postpartum depression after multiple pregnancies within the Saudi cultural context? Very familiar 15 5 20 0.252 17.0% 27.8% 18.9% Somewhat familiar 64 13 77 72.7% 72.2% 72.6% Not familiar at all 9 0 9 10.2% 0.0% 8.5% Have you or someone you know experienced postpartum depression after multiple pregnancies? Yes 44 8 52 0.667 50.0% 44.4% 49.1% No 44 10 54 50.0% 55.6% 50.9% Do you know that postpartum depression can occur after multiple pregnancies? No 20 2 22 0.268 22.7% 11.1% 20.8% Yes 68 16 84 77.3% 88.9% 79.2% Do you think that postpartum depression after multiple pregnancies is a significant issue within the Saudi cultural context? Yes 57 14 71 0.436 64.8% 77.8% 67.0% No 9 2 11 10.2% 11.1% 10.4% Not sure 22 2 24 25.0% 11.1% 22.6% Do you believe that healthcare providers in Saudi Arabia adequately address postpartum depression after multiple pregnancies within the Saudi cultural context? Yes 21 11 32 0.002 23.9% 61.1% 30.2% No 25 0 25 28.4% 0.0% 23.6% Not sure 42 7 49 47.7% 38.9% 46.2% Have you heard of postpartum depression (PPD) before? Yes 85 18 103 0.427 96.6% 100.0% 97.2% No 3 0 3 3.4% 0.0% 2.8%

There is now increasing recognition of postpartum depression (PPD) as a key mental health problem in various communities, including Saudi Arabia, which has paid much attention to this concern. Recognizing distinctive problems and lack of knowledge in multiparous women, this study aimed to estimate awareness of PPD among this population in the context of Saudi Arabia. A comparison of our study’s findings with existing research will enable us to determine how these levels of knowledge affect the management and prevention of PPD, placing our results in a regional and global context.   A large majority of our participants were already aware of PPD (97.2%), but only 20.8% knew that the condition may be more common after giving birth more than once. Such a result reflects the findings in previous studies. For instance, Koura and Alasoom reported that women in the Eastern Province of Saudi Arabia also showed a similar level of understanding of PPD symptoms. However, their investigation showed that postpartum women, and especially those with multiple pregnancies, tend to have significant misunderstandings regarding the timing and persistence of depressive symptoms [9]. These results indicate a serious concern: even with the general knowledge of PPD, lack of understanding of the intricacies of PPD may fail to create timely awareness and intervention in women affected by PPD.   Moreover, our results on cultural factors that inhibit help-seeking are consistent with demographic trends in comparable studies in Saudi Arabia. Our participants, who accounted for 62.3% of the group, identified cultural and social pressures as major reasons for the high reluctance to discuss mental health openly. This finding is consistent with the study of Alsaleem et al. [10], who indicate the existence of stigma concerning mental illness and its effect on the help-seeking behaviors of postpartum women. The finding that 77.4% of our participants have never sought medical advice on PPD is a clear gap between the awareness of the condition and the use of available mental health resources. The disparity between awareness and service utilization is a critical issue in the existing health care system as evidenced by the recommendations of Alshowkan and Shdaifat on improved provider-woman communication [11].   Furthermore, the fact that social media are perceived as the primary source of information about PPD (55.7%) represents a considerable transformation in the way health information gets to the public. Although these networks can be used to increase awareness, they can also cause misinformation if the information is not medical based. In line with other research, this demonstrates how postpartum mental health information often reaches the public through informal networks, thereby reducing the integrity of the information [12]. Our results show that social media is one of the main reasons why the participants have a rather poor understanding of PPD symptoms, as only 17.9% of them said they were very familiar with them. It suggests a basic need to use these platforms to deliver more organized and reliable health information.   These problems are aggravated by the lack of support mechanisms, as it is evident from the fact that 83% of our participants were unaware of the available resources. Findings indicate that postpartum women are frequently confronted with significant barriers to access to specialized mental health services because both structural and societal factors play a role in this problem. Postpartum women have continuous low use of mental health resources, and the healthcare protocols often fail to offer support during a vulnerable period [10]. It is supported by 76.4% of our participants that there is a great lack of cultural specificity in mental health services, which is a significant weakness of the existing healthcare system. Also, the relationship between existing knowledge about PPD and wider awareness of the condition suggests a reason to create educational programs that can be used by patients and medical professionals. Statistical analysis of our data revealed a strong correlation between these factors, suggesting that increased familiarity is related to prior knowledge and supporting the possible advantage of targeted educational efforts. O’Connor et al. [13] suggest that wide screening and education are important strategies for enhanced diagnosis and treatment of postpartum depression. Developing culturally appropriate educational materials can satisfy two needs at once: Increasing awareness at the same time also helps to lessen stigma about seeking support.   Although these findings are useful, we also need to keep in mind the limitations that exist in our study. The cross-sectional nature of this study’s methodology, which captures a snapshot of knowledge at a certain point, fails to explain variations in awareness and attitudes towards PPD among multiparous women. The present diversity of participants is praiseworthy, but a larger sample would improve our understanding of the topic in future studies. Additionally, self-reporting may introduce biases thus potentially skewing the findings in terms of the extent to which the participants comprehend and relate to PPD.

This study contributes to the emerging discourse surrounding postpartum depression by exposing critical knowledge gaps among multiparous women in Saudi Arabia. Despite high levels of general awareness, the findings suggest a pressing need for targeted educational initiatives that address specific misconceptions and barriers to care. By enhancing understanding and reducing stigma, healthcare providers can foster an environment where postpartum women feel empowered to seek assistance, ultimately leading to improved mental health outcomes for mothers and their families. Efforts to integrate culturally sensitive approaches, bolstered by the engagement of social media and community resources, can create a robust framework for supporting maternal mental health in the complex landscape surrounding postpartum depression.   Ethical Statement Informed consent was obtained from each participant after explaining the study in full and clarifying that participation was voluntary. Data collected was securely saved and used for research purposes only.