Association between probable postnatal depression and increased infant mortality and morbidity: Findings from the DON population-based cohort study in rural Ghana

BMJ Open, Volume 5, No. 8, Year 2015

Interpretation

Objectives: To assess the impact of probable depression in the immediate postnatal period on subsequent infant mortality and morbidity. Design: Cohort study nested within 4 weekly surveillance of all women of reproductive age to identify pregnancies and collect data on births and deaths. Setting: Rural/periurban communities within the Kintampo Health Research Centre study area of the Brong-Ahafo Region of Ghana. Participants: 16 560 mothers who had a live singleton birth reported between 24 March 2008 and 11 July 2009, who were screened for probable postnatal depression (pPND) between 4 and 12 weeks post partum (some of whom had also had depression assessed at pregnancy), and whose infants survived to this point. Primary/secondary outcome measures: All-cause early infant mortality expressed per 1000 infant-months of follow-up from the time of postnatal assessment to 6 months of age. The secondary outcomes were (1) all-cause infant mortality from the time of postnatal assessment to 12 months of age and (2) reported infant morbidity from the time of the postnatal assessment to 12 months of age. Results: 130 infant deaths were recorded and singletons were followed for 67 457.4 infant-months from the time of their mothers’ postnatal depression assessment. pPND was associated with an almost threefold increased risk of mortality up to 6 months (adjusted rate ratio (RR), 2.86 (1.58 to 5.19); p=0.001). The RR up to 12 months was 1.88 (1.09 to 3.24; p=0.023). pPND was also associated with increased risk of infant morbidity. Conclusions: There is new evidence for the association between maternal pPND and infant mortality in low-income and middle-income countries. Implementation of the WHO’s Mental Health Gap Action Programme (mhGAP) to scale up packages of care integrated with maternal health is encouraged as an important adjunct to child survival efforts. DON is a cohort study of perinatal Depression nested within the ObaapaVitA12 and Newhints13 cluster randomised controlled trials conducted in seven contiguous districts in the Brong-Ahafo Region of Ghana. The ObaapaVitA trial evaluated the effect of weekly vitamin A supplementation in women of reproductive age on maternal mortality, and the Newhints trial assessed the impact of home visits by lay community health volunteers on neonatal mortality. These trials were supported by 4 weekly home surveillance of women of reproductive age to identify pregnancies, births, infant and maternal deaths and morbidity information. DON was carried out from late January 2008 to early August 2009, and comprised depression assessments in the 4 weekly surveillance visits following identification of pregnancy and in the visits following reporting of a delivery. Both trials were registered with clinicaltrials.gov: ObaapaVitA, number {“type”:”clinical-trial”,”attrs”:{“text”:”NCT00211341″,”term_id”:”NCT00211341″}}NCT00211341; Newhints, number {“type”:”clinical-trial”,”attrs”:{“text”:”NCT00623337″,”term_id”:”NCT00623337″}}NCT00623337. The study area covers a population of about 700 00014 with more than 120 000 women of reproductive age,13 and more than 15 000 births a year. The infant mortality rate (IMR) is 63/1000 child-years and the neonatal mortality rate is 31/1000 live births.12 The area is predominantly rural, but has four medium-sized towns (populations of at least 40 000). Routine identification and treatment for antenatal/postnatal depression in primary care does not exist. Access to orthodox mental health services is limited, and help for mental ill health is generally provided by traditional healers and spiritual/healing churches.15 Participants were mothers who had a live birth reported between 24 March 2008 and 11 July 2009, who were screened for probable postnatal depression between 4 and 12 weeks post partum (some of whom had also had depression assessed at pregnancy), and whose infants survived to this point. Data were collected through the surveillance system supporting the ObaapaVitA and Newhints trials, in which all women of reproductive age were visited every 4 weeks by resident fieldworkers, who collected data on pregnancies, births and deaths. The sociodemographic, socioeconomic, pregnancy and obstetric history data were collected when a pregnancy was identified, and a pregnancy depression assessment was conducted at the next 4 weekly visit. Information about the pregnancy, delivery, the baby (or babies) and the newborn care practices was collected at the first visit after the birth. A postnatal assessment was carried out at the following 4 weekly visit. Subsequent 4 weekly visits were made to collect data on the infant until their first birthday. The assessments of antenatal and postnatal depression were made by administering the Twi (widely spoken language in Ghana and the study area) version of the nine-item Patient Health Questionnaire (PHQ-9). The PHQ-9 is a structured questionnaire that enquires after the nine symptom-based criteria for a probable diagnosis of Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV)16 depression, duration and severity of the symptoms. Symptoms reported as present for at least half the time in the previous 2 weeks are rated positively. Either depression or anhedonia (loss of interest or pleasure) must be rated, with a total of five or more symptoms for major depression and two to four symptoms for minor depression. In contrast with symptom-based scale scores, these criteria therefore identify individuals with persistent and pervasive symptoms, characteristic of a clinically significant depressive episode. In its initial review, it recorded sensitivity and specificity of 0.88 at a cut-off of 10,16 and high positive predictive value.17 The PHQ-9 has been previously validated among women who recently delivered within the same study population and showed superior psychometric properties when compared with the Edinburgh Postnatal Depression Scale18—it recorded a sensitivity of 0.94 and specificity of 0.75 at a cut-off of 5. As part of the cross-cultural adaptation of the PHQ-9 to the study setting referred to above, qualitative accounts supported the construct of depression that existed in this setting, as mothers referred to the experience as a ‘worrying’ or ‘thinking’ sickness. Outcomes were assessed every 4 weeks by resident fieldworkers until 1 year after birth and, in one of these visits, a postnatal depression assessment was also completed. The primary outcome was all-cause early infant mortality expressed per 1000 infant-months of follow-up from the time of postnatal assessment to 6 months of age. The secondary outcomes were (1) all-cause infant mortality from the time of postnatal assessment to 12 months of age and (2) reported infant morbidity from the time of the postnatal DON assessment to 12 months of age. Morbidity indicators were: any ill health on the day of visit; any serious illness in the past month requiring care-seeking outside the home; and occurrence in the past 24 h of diarrhoea, vomiting, cough, fever and frequent crying. A priori potential confounders were: maternal characteristics (age, marital status, education status, occupation, ethnicity, religion and rural or urban residence); pregnancy and obstetric variables (parity, preterm delivery and mode of delivery); and infant characteristics (sex and perceived size of baby as a proxy for birth weight). In addition, an overall socioeconomic ‘score’ for each woman was generated using factor analysis techniques after the methods described by Vyas and Kumaranayake.19 Briefly, this score is based on household possession/absence of a set of assets grouped under several themes including ownership of land, animals, presence of electricity and/or electrical goods, water source, type of latrine, number of residents per room and materials used in construction of housing. Principal component analysis (using the correlation matrix to ensure that all included variables had equal weight) was then performed to assign each asset a factor score based on the strength of its correlation to the first principle component (which is assumed to be the optimal measure of economic status). Individual asset factor scores were summed for each woman to provide a measure of her overall socioeconomic score, where the higher the score, the higher the assumed economic status of the household. Women were ranked according to these socioeconomic scores into wealth quintile groups. Intervention status was not included as prevalence of postnatal depression was comparable in the intervention and control arms of the Newhints trial. Multiple births were excluded from all analyses given the high risk associated with infant mortality, particularly in Africa,20 and the possible association with probable postnatal depression.21 Poisson regression was used to examine the association between probable postnatal depression and infant mortality, adjusting for the a priori potential confounders listed above. In addition, we tested for the moderating effect of relevant covariates by fitting appropriate interaction terms in the model. In order to account for the possible influence of reverse causality from illness that culminated in the deaths that occurred close to ascertainment of probable postnatal depression status, we conducted sensitivity analyses excluding those deaths that occurred, first within 1 week and second within 30 days after postnatal depression assessment. Only those babies whose deaths were ascertained within the period of follow-up were included in the analyses. Additional analyses compared infant mortality between: women not depressed at either antenatal or postnatal assessments, women depressed only at antenatal assessment, women depressed only at postnatal assessment and those depressed at both. Kaplan-Meier survivor function was used to plot cumulative infant survival graphs for the four groups from birth until 12 months of age, excluding any deaths that occurred before the postnatal depression assessment. For the association between probable postnatal depression and infant morbidity, we used mixed-effects repeated measures logistic regression models with random intercept at the infant level, including the same potential confounders aforementioned, plus month of visit. The delta method was applied to predict risk/rate ratios (RR) with 95% CIs for individuals with zero random effect using the marginal standardisation technique.22 We also estimated the attributable risk per cent (percentage of early infant deaths among women with probable postnatal depression, ie, attributed to exposure to probable postnatal depression) and the population attributable fraction (percentage of early infant deaths that would be prevented if the effect of probable postnatal depression is removed). All analyses were conducted using STATA V.11.23 Informed consent (by signature or thumbprint) was obtained for each woman.

AI Digest

Study Justification:

The study aimed to assess the impact of probable postnatal depression (pPND) on infant mortality and morbidity in rural Ghana. This study is important because there is limited evidence on the association between maternal pPND and infant mortality in low-income and middle-income countries. Understanding this association can help inform interventions and policies to improve child survival efforts.

Highlights:

– The study found that pPND was associated with a nearly threefold increased risk of infant mortality up to 6 months and a 1.88-fold increased risk up to 12 months.
– pPND was also associated with increased risk of infant morbidity.
– These findings provide new evidence for the association between maternal pPND and infant mortality in low-income and middle-income countries.
– The study highlights the importance of implementing the WHO’s Mental Health Gap Action Programme (mhGAP) to scale up packages of care integrated with maternal health as an important adjunct to child survival efforts.

Recommendations:

– Implement the WHO’s Mental Health Gap Action Programme (mhGAP) to scale up packages of care integrated with maternal health.
– Develop and implement interventions to identify and treat pPND in low-income and middle-income countries.
– Improve access to mental health services and support for mothers experiencing pPND.
– Strengthen maternal health programs to address the mental health needs of mothers during the postnatal period.

Key Role Players:

– Health policymakers and government officials responsible for maternal and child health programs.
– Healthcare providers, including doctors, nurses, and midwives, who can screen and provide support for mothers with pPND.
– Community health workers and volunteers who can assist in identifying and supporting mothers with pPND.
– Mental health professionals who can provide specialized care for mothers with pPND.
– Non-governmental organizations (NGOs) and international agencies working in maternal and child health who can provide resources and support for interventions targeting pPND.

Cost Items for Planning Recommendations:

– Training and capacity building for healthcare providers on screening and managing pPND.
– Development and implementation of screening tools and protocols for identifying pPND.
– Integration of mental health services into existing maternal health programs.
– Awareness campaigns and community education on pPND and available support services.
– Provision of mental health services and support for mothers with pPND.
– Monitoring and evaluation of interventions to assess their effectiveness and impact on infant mortality and morbidity.

Strength of Evidence

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong, as it is based on a large cohort study with a significant number of participants. The study design is nested within other trials, which adds to its credibility. The results show a clear association between probable postnatal depression and increased infant mortality and morbidity. However, to improve the evidence, it would be beneficial to include more details about the methodology, such as the specific criteria used to assess postnatal depression and the statistical analysis methods employed. Additionally, providing information on potential limitations of the study would further strengthen the evidence.

Abstract

DON is a cohort study of perinatal Depression nested within the ObaapaVitA12 and Newhints13 cluster randomised controlled trials conducted in seven contiguous districts in the Brong-Ahafo Region of Ghana. The ObaapaVitA trial evaluated the effect of weekly vitamin A supplementation in women of reproductive age on maternal mortality, and the Newhints trial assessed the impact of home visits by lay community health volunteers on neonatal mortality. These trials were supported by 4 weekly home surveillance of women of reproductive age to identify pregnancies, births, infant and maternal deaths and morbidity information. DON was carried out from late January 2008 to early August 2009, and comprised depression assessments in the 4 weekly surveillance visits following identification of pregnancy and in the visits following reporting of a delivery. Both trials were registered with clinicaltrials.gov: ObaapaVitA, number {“type”:”clinical-trial”,”attrs”:{“text”:”NCT00211341″,”term_id”:”NCT00211341″}}NCT00211341; Newhints, number {“type”:”clinical-trial”,”attrs”:{“text”:”NCT00623337″,”term_id”:”NCT00623337″}}NCT00623337. The study area covers a population of about 700 00014 with more than 120 000 women of reproductive age,13 and more than 15 000 births a year. The infant mortality rate (IMR) is 63/1000 child-years and the neonatal mortality rate is 31/1000 live births.12 The area is predominantly rural, but has four medium-sized towns (populations of at least 40 000). Routine identification and treatment for antenatal/postnatal depression in primary care does not exist. Access to orthodox mental health services is limited, and help for mental ill health is generally provided by traditional healers and spiritual/healing churches.15 Participants were mothers who had a live birth reported between 24 March 2008 and 11 July 2009, who were screened for probable postnatal depression between 4 and 12 weeks post partum (some of whom had also had depression assessed at pregnancy), and whose infants survived to this point. Data were collected through the surveillance system supporting the ObaapaVitA and Newhints trials, in which all women of reproductive age were visited every 4 weeks by resident fieldworkers, who collected data on pregnancies, births and deaths. The sociodemographic, socioeconomic, pregnancy and obstetric history data were collected when a pregnancy was identified, and a pregnancy depression assessment was conducted at the next 4 weekly visit. Information about the pregnancy, delivery, the baby (or babies) and the newborn care practices was collected at the first visit after the birth. A postnatal assessment was carried out at the following 4 weekly visit. Subsequent 4 weekly visits were made to collect data on the infant until their first birthday. The assessments of antenatal and postnatal depression were made by administering the Twi (widely spoken language in Ghana and the study area) version of the nine-item Patient Health Questionnaire (PHQ-9). The PHQ-9 is a structured questionnaire that enquires after the nine symptom-based criteria for a probable diagnosis of Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV)16 depression, duration and severity of the symptoms. Symptoms reported as present for at least half the time in the previous 2 weeks are rated positively. Either depression or anhedonia (loss of interest or pleasure) must be rated, with a total of five or more symptoms for major depression and two to four symptoms for minor depression. In contrast with symptom-based scale scores, these criteria therefore identify individuals with persistent and pervasive symptoms, characteristic of a clinically significant depressive episode. In its initial review, it recorded sensitivity and specificity of 0.88 at a cut-off of 10,16 and high positive predictive value.17 The PHQ-9 has been previously validated among women who recently delivered within the same study population and showed superior psychometric properties when compared with the Edinburgh Postnatal Depression Scale18—it recorded a sensitivity of 0.94 and specificity of 0.75 at a cut-off of 5. As part of the cross-cultural adaptation of the PHQ-9 to the study setting referred to above, qualitative accounts supported the construct of depression that existed in this setting, as mothers referred to the experience as a ‘worrying’ or ‘thinking’ sickness. Outcomes were assessed every 4 weeks by resident fieldworkers until 1 year after birth and, in one of these visits, a postnatal depression assessment was also completed. The primary outcome was all-cause early infant mortality expressed per 1000 infant-months of follow-up from the time of postnatal assessment to 6 months of age. The secondary outcomes were (1) all-cause infant mortality from the time of postnatal assessment to 12 months of age and (2) reported infant morbidity from the time of the postnatal DON assessment to 12 months of age. Morbidity indicators were: any ill health on the day of visit; any serious illness in the past month requiring care-seeking outside the home; and occurrence in the past 24 h of diarrhoea, vomiting, cough, fever and frequent crying. A priori potential confounders were: maternal characteristics (age, marital status, education status, occupation, ethnicity, religion and rural or urban residence); pregnancy and obstetric variables (parity, preterm delivery and mode of delivery); and infant characteristics (sex and perceived size of baby as a proxy for birth weight). In addition, an overall socioeconomic ‘score’ for each woman was generated using factor analysis techniques after the methods described by Vyas and Kumaranayake.19 Briefly, this score is based on household possession/absence of a set of assets grouped under several themes including ownership of land, animals, presence of electricity and/or electrical goods, water source, type of latrine, number of residents per room and materials used in construction of housing. Principal component analysis (using the correlation matrix to ensure that all included variables had equal weight) was then performed to assign each asset a factor score based on the strength of its correlation to the first principle component (which is assumed to be the optimal measure of economic status). Individual asset factor scores were summed for each woman to provide a measure of her overall socioeconomic score, where the higher the score, the higher the assumed economic status of the household. Women were ranked according to these socioeconomic scores into wealth quintile groups. Intervention status was not included as prevalence of postnatal depression was comparable in the intervention and control arms of the Newhints trial. Multiple births were excluded from all analyses given the high risk associated with infant mortality, particularly in Africa,20 and the possible association with probable postnatal depression.21 Poisson regression was used to examine the association between probable postnatal depression and infant mortality, adjusting for the a priori potential confounders listed above. In addition, we tested for the moderating effect of relevant covariates by fitting appropriate interaction terms in the model. In order to account for the possible influence of reverse causality from illness that culminated in the deaths that occurred close to ascertainment of probable postnatal depression status, we conducted sensitivity analyses excluding those deaths that occurred, first within 1 week and second within 30 days after postnatal depression assessment. Only those babies whose deaths were ascertained within the period of follow-up were included in the analyses. Additional analyses compared infant mortality between: women not depressed at either antenatal or postnatal assessments, women depressed only at antenatal assessment, women depressed only at postnatal assessment and those depressed at both. Kaplan-Meier survivor function was used to plot cumulative infant survival graphs for the four groups from birth until 12 months of age, excluding any deaths that occurred before the postnatal depression assessment. For the association between probable postnatal depression and infant morbidity, we used mixed-effects repeated measures logistic regression models with random intercept at the infant level, including the same potential confounders aforementioned, plus month of visit. The delta method was applied to predict risk/rate ratios (RR) with 95% CIs for individuals with zero random effect using the marginal standardisation technique.22 We also estimated the attributable risk per cent (percentage of early infant deaths among women with probable postnatal depression, ie, attributed to exposure to probable postnatal depression) and the population attributable fraction (percentage of early infant deaths that would be prevented if the effect of probable postnatal depression is removed). All analyses were conducted using STATA V.11.23 Informed consent (by signature or thumbprint) was obtained for each woman.

Materials

N/A

Innovations

Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Telemedicine: Implementing telemedicine services can provide remote access to healthcare professionals, allowing pregnant women to receive prenatal and postnatal care without having to travel long distances.

2. Mobile health (mHealth) applications: Developing mobile applications that provide educational resources, appointment reminders, and access to healthcare professionals can empower pregnant women to take control of their own health and access necessary information and support.

3. Community health worker programs: Expanding community health worker programs can help bridge the gap between healthcare facilities and remote communities. Trained community health workers can provide basic prenatal and postnatal care, as well as education and support to pregnant women in their own communities.

4. Integrated care models: Integrating mental health services into maternal health programs can help identify and address postnatal depression, which has been shown to have a significant impact on infant mortality and morbidity. This can be done by training healthcare providers to screen for and manage postnatal depression, as well as providing access to counseling and support services.

5. Public-private partnerships: Collaborating with private sector organizations, such as pharmaceutical companies or technology companies, can help leverage resources and expertise to improve access to maternal health services. This can include providing funding for infrastructure development, technology solutions, or capacity building initiatives.

6. Task-shifting and training: Training and empowering non-specialist healthcare providers, such as nurses or midwives, to provide comprehensive maternal health services can help alleviate the burden on limited healthcare resources. This can include training in prenatal and postnatal care, as well as mental health screening and support.

7. Health education and awareness campaigns: Implementing targeted health education and awareness campaigns can help raise awareness about the importance of prenatal and postnatal care, as well as mental health, among pregnant women and their communities. This can include community workshops, radio programs, or social media campaigns.

It is important to note that these recommendations are based on the information provided and may need to be tailored to the specific context and resources available in Ghana.

AI Innovations Description

Based on the information provided, the recommendation to improve access to maternal health and address the association between probable postnatal depression and increased infant mortality and morbidity in rural Ghana is to implement the WHO’s Mental Health Gap Action Programme (mhGAP) integrated with maternal health care.

The mhGAP is a program developed by the World Health Organization (WHO) to scale up packages of care for mental health in low-income and middle-income countries. By integrating mental health care with maternal health services, women who are at risk of or experiencing postnatal depression can receive timely and appropriate support and treatment.

This recommendation is based on the findings of the DON population-based cohort study, which showed a significant association between probable postnatal depression and increased risk of infant mortality and morbidity. By implementing the mhGAP program, healthcare providers can be trained to identify and manage postnatal depression, ensuring that women receive the necessary support and treatment to improve their mental health and well-being.

By integrating mental health care with maternal health services, access to treatment for postnatal depression can be improved, reducing the negative impact on infant mortality and morbidity. This recommendation aligns with the goal of improving child survival efforts and addressing the mental health needs of women in low-income and middle-income countries.

It is important to note that this recommendation should be implemented in collaboration with relevant stakeholders, including healthcare providers, policymakers, and community organizations. Adequate resources and training should be provided to ensure the successful integration of mental health care into maternal health services.

AI Innovations Methodology

Based on the information provided, here are some potential recommendations to improve access to maternal health:

1. Implement routine identification and treatment for antenatal/postnatal depression in primary care: This would involve training healthcare providers to screen for and diagnose depression during pregnancy and the postnatal period. It would also involve providing appropriate treatment options, such as counseling or medication, to women who are identified as having depression.

2. Scale up packages of care integrated with maternal health: This recommendation suggests integrating mental health services into existing maternal health programs. This could involve training healthcare providers to address mental health issues alongside physical health issues during antenatal and postnatal visits. It could also involve providing resources and support for women experiencing mental health challenges.

3. Increase access to orthodox mental health services: This recommendation highlights the need to improve access to mental health services, particularly in low-income and middle-income countries. This could involve increasing the number of mental health professionals, improving infrastructure and resources for mental health services, and reducing barriers to accessing care, such as cost or stigma.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define the indicators: Identify specific indicators that will be used to measure the impact of the recommendations. For example, indicators could include the number of women screened for depression during pregnancy and the postnatal period, the number of women receiving treatment for depression, and the reduction in maternal mortality and morbidity rates.

2. Collect baseline data: Gather data on the current state of access to maternal health services, including rates of depression screening, treatment availability, and maternal health outcomes.

3. Develop a simulation model: Create a simulation model that incorporates the baseline data and simulates the impact of the recommendations on access to maternal health. This model could take into account factors such as population size, healthcare infrastructure, and resource availability.

4. Run simulations: Use the simulation model to run various scenarios that represent the implementation of the recommendations. This could involve adjusting variables such as the number of healthcare providers trained in depression screening, the availability of mental health services, and the level of integration between mental health and maternal health programs.

5. Analyze results: Evaluate the results of the simulations to determine the potential impact of the recommendations on access to maternal health. This could involve comparing indicators such as the number of women screened for depression, the number of women receiving treatment, and the changes in maternal mortality and morbidity rates.

6. Refine and iterate: Based on the analysis of the simulation results, refine the recommendations and simulation model as needed. Repeat the simulation process to further explore the potential impact of the refined recommendations.

It’s important to note that developing a simulation methodology requires careful consideration of various factors, including data availability, model assumptions, and limitations. Consulting with experts in the field and conducting further research may be necessary to ensure the accuracy and reliability of the simulation results.

Author

Dima Health

Statistics:

Citations: 31

Identifiers:

DOI: 10.1136/bmjopen-2014-006509

Research Areas:

Community Interventions, Disparities, Environmental, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Mental Health, Quality of Care, Sexual and Reproductive Health, Social Determinants

Study Countries:

Ghana

Study Design:

Cohort Study, Cross Sectional Study, randomised-control-trial

Study Approach:

Mixed-methods, Qualitative, Quantitative

Participants Gender:

Female