Menu
Menu
Menu
Menu
The high prevalence of antenatal common mental disorders in sub-Saharan Africa compared to high-income countries is poorly understood. This qualitative study explored the sociocultural context of antenatal mental distress in a rural Ethiopian community. Five focus group discussions and 25 in-depth interviews were conducted with purposively sampled community stakeholders. Inductive analysis was used to develop final themes. Worry about forthcoming delivery and fears for the woman’s survival were prominent concerns of all participants, but only rarely perceived to be pathological in intensity. Sociocultural practices such as continuing physical labour, dietary restriction, prayer and rituals to protect against supernatural attack were geared towards safe delivery and managing vulnerability. Despite strong cultural norms to celebrate pregnancy, participants emphasised that many pregnancies were unwanted and an additional burden on top of pre-existing economic and marital difficulties. Short birth interval and pregnancy out of wedlock were both seen as shameful and potent sources of mental distress. The notion that pregnancy in traditional societies is uniformly a time of joy and happiness is misplaced. Although antenatal mental distress may be self-limiting for many women, in those with enduring life difficulties, including poverty and abusive relationships, poor maternal mental health may persist. © 2010 The Author(s).
The design was a qualitative study. Data were collected from September to November 2004. Ethical approval was obtained from the research ethics committees of the Ethiopian Science and Technology Agency and the Institute of Psychiatry, King’s College London. The study was conducted in and around the demographic surveillance site (DSS) at the Butajira Rural Health Programme (BRHP), Ethiopia (Berhane et al. 1999), located 130 km south of the capital city Addis Ababa. Since 1987, all households in a defined geographical area have been visited every 3 months in order to document births, deaths and migration and thus define the base population to support epidemiological study. The Butajira DSS is typical of a rural Ethiopian setting, with health indicators approximating those found in national surveys (CSA 2006). A governmental hospital, which opened in 2001, has expanded access to obstetric care, but few women choose to deliver in this setting in keeping with other rural Ethiopian areas. In Butajira, maternal mortality rates are estimated at 400–850/100,000 births (Berhane et al. 2000). Nationally, only an estimated 28% of women attend for antenatal care and fewer than 10% of women deliver in a health facility (CSA 2006). We initially identified a key informant woman who had lived in the area all her life and worked for the BRHP for some years. She was able to make use of her good standing and diverse contacts in the various sub-districts to identify potential participants and to introduce us into the community. Purposive sample was undertaken to identify community stakeholders with diverse perspectives on the experiences of women during pregnancy, childbirth and the postnatal period. We also used the sampling technique of snowballing, asking participants whether they knew of a woman who had experienced problematic perinatal mental distress. In-depth interviews were conducted with pregnant (n = 2) and postnatal (n = 4) women, a community leader, an Ethiopian Orthodox Christian priest, a Muslim traditional healer (kalicha), leaders of women’s religious groups (Christian and Muslim; n = 3), the gender officer from a local women’s advocacy organisation, the head of Women’s Affairs in the local government, two members of a women’s microfinance organisation, a trained and untrained traditional birth attendant, a midwife, a community health agent, two BRHP workers and three women identified through the snowballing process as having perinatal distress states (n = 3). Five focus group disocussions (FGDs) were conducted with the following groups: (1) postnatal women, (2) pregnant women, (3) traditional birth attendants (TBAs) with experience ranging from 2 to 30 years, (4) grandmothers and (5) fathers. All participants were required to give informed consent. The sociodemographic characteristics of participants are summarised in Table 1. Characteristics of participants for in-depth interviews and focus group discussions (FGDs) All in-depth interviews and FGDs were conducted in Amharic, the official language of Ethiopia. The in-depth interviews were all conducted by an Ethiopian midwife (AH) with previous experience in qualitative data collection. The FGDs followed recommended methodology (Krueger and Casey 2009). AH conducted two of the FGDs and assisted in the other three FGDs. The FGDs with pregnant and postnatal women were conducted by female Ethiopian doctors. The FGD of fathers was conducted by a male researcher with masters in public health, trained in qualitative methods and familiar with researching in Butajira. The reason for using different facilitators for the FGDs was partly pragmatic, as two moderators were required per group, and partly in an attempt to encourage more active participation, i.e. choosing a male facilitator for the FGD with fathers. Interviews and FGDs were tape-recorded, with a note-taker present dring the FGDs to document non-verbal communication. Recordings were transcribed in Amharic and translated into English prior to coding. Interviews and FGDs were conducted in a range of settings, including primary health care facilities, the project office, other office facilities or people’s own homes. At all times, privacy was assured. Non-professional participants received remuneration for transport costs. Interviews and FGDs were loosely structured around pregnancy, birth and the postnatal period. Open questions were used to enquire about the kinds of traditions and restrictions a pregnant woman might be subject to, the types of difficulties pregnant women can face and the sources of support they could expect to rely upon. Planned probes included direct questionning about previously identified common attributions for mental illness in Ethiopia (Alem et al. 1999), namely evil eye, bewitchment, ancestral troubles, spiritual problems and mental (‘nervous’) problems in the perinatal period, with follow-up questions aiming to elicit specific examples known to the participant. The interviewer took care to be sensitive to topics initiated by the participant and to allow the interview to proceed in as naturalistic a manner as possible. The topic guide developed iteratively as the study progressed. Initial analysis proceeded in tandem with data collection, with discussion of emerging themes between CH and AH. To improve rigour of analysis, following completion of data collection, CH and DW independently coded four transcripts using descriptive codes. Coding schemes were compared and rationalised, with discussion about points of disagreement. CH and DW then applied these codes to two further transcripts as a cross-check. CH recoded the remaining transcripts, drawing upon additional codes where the data required. Prior to drafting the paper, the authors were aware of findings from a large population study of antenatal common mental disorders in Butajira investigating cross-sectionally associated variables and the impact on perinatal outcomes (Hanlon et al. 2008, 2009a). Computer software was used to facilitate data management (Muhr 1997). In accordance with the tenets of inductive analysis (Glaser and Strauss 1967), care was taken to allow codes to emerge from the data. Higher order themes were formed which were tested back against the data and discussed. Illustrative quotes were selected with agreement from all authors.
N/A
