Residential Greenness and Perinatal Depression in Low- and Middle-Income Countries: A Multi-Country Population-Based...

Perinatal depression (PND) is a major public health concern in low- and middle-income countries (LMICs), yet the role of greenness remains insufficiently understood. This study examined the association between residential greenness and perinatal depression in three LMICs. We conducted a multi-country population-based cross-sectional analysis using nationally representative Demographic and Health Survey (DHS) data from Bangladesh, Mozambique and Nepal for 2022-2023, including 6,889 perinatal women. Perinatal depression was assessed using the Patient Health Questionnaire-9. Residential greenness was measured using satellite-derived Normalized Difference Vegetation Index (NDVI) and Enhanced Vegetation Index (EVI). Generalized linear mixed-effect logistic regression models were used to estimate associations, adjusting for sociodemographic, reproductive, and environmental factors. The pooled prevalence of PND was 25.95%. We found a significant protective association between residential greenness (NDVI) and PND (fully adjusted OR=0.91 (95% CI: 0.842-0.977), p<0.05), indicating that a one standard deviation increase in residential greenness (NDVI) was associated with a 10% reduced odds of PND. Ambient temperature was positively associated with PND (OR=1.44 (95%CI: 1.290-1.625), p<0.001). Stratified analyses indicated that protective associations of greenness were stronger among younger, rural, primary education, wealthier and Mozambique women. Exploratory interaction analyses suggested a descriptive pattern in which the residential greenness-PND association appeared to vary across levels of ambient temperature; however, this pattern did not reach statistical significant in formal testing. These findings highlight the importance of integrating green infrastructure into public health and urban planning strategies to improve maternal mental health.