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Background: Postpartum depression is an important but neglected public health issue in low- and middle-income countries. The aim of this study was to assess postpartum depressive (PPD) symptoms and associated factors in a rural Ethiopian setting characterized by high social adversity and reproductive health threats. We hypothesized that infant gender preference would be associated with PPD symptoms. Methods: A cross-sectional, population-based study was conducted in Sodo district, southern Ethiopia, between March and June 2014. A total of 3147 postpartum women (one to 12 months after delivery) were recruited and interviewed in their homes. The questionnaire included demographic, reproductive health and psychosocial factors in addition to a culturally validated measure of depressive symptoms, the Patient Health Questionnaire. Scores of 5 or more were indicative of high levels of PPD symptoms. Results: The prevalence of high PPD symptoms was 12.2%, with 95% confidence interval (CI) between 11.1 and 13.4. Of these, 12.0% of the study participants had suicidal ideation. Preference of the husband for a boy baby was associated with PPD symptoms in univariate analysis (crude odds ratio 1.43: 95% CI 1.04, 1.91) but became non-significant after adjusting for confounders. In the final multivariable analysis, rural residence [adjusted odds ratio (aOR) 2.56: 95% CI 2.56, 4.19], grand multiparity (aOR 2.00: 1.22, 3.26), perinatal complications (aOR: 2.55: 1.89, 3.44), a past history of abortion (aOR 1.50: 1.07, 2.11), experiencing hunger in the preceding 1 month (aOR 2.38: 1.75, 3.23), lower perceived wealth (aOR 2.11: 1.19, 3.76), poor marital relationship (aOR 2.47: 1.79, 3.42), and one or more stressful events in the preceding 6 months (aOR 2.36: 1.82, 3.06) were associated significantly with high PPD symptoms. Conclusion: PPD symptoms affected more than one in 10 women in this Ethiopian community setting. Social adversity and reproductive health threats were associated with poorer mental health. Interventions focusing on poor rural women with low access to care are necessary. This research can serve as an entry point for the adaptation of a psychosocial intervention.
The study was conducted in Sodo district, of the Gurage zone, Southern Nations, Nationalities and Peoples’ Region (SNNPR) of Ethiopia. SNNPR is one of the largest regions in Ethiopia, accounting for more than 10 percent of the country’s land area. The SNNPR is an extremely ethnically diverse region of Ethiopia. These ethnic groups are distinguished by different languages, cultures and socioeconomic organizations. The Gurage zone has 15 districts. Sodo district is the second largest in terms of population (161,952 persons; 79,356 men and 82,596 women), with 88% of the population residing in rural areas [38] and comprises 58 sub-districts. It is located about 100 km south of the capital city, Addis Ababa. In Sodo district, there are eight health centers, each linked to five health posts served by health extension workers. There is a general hospital 30 km away from the district town, Buee, which has an outpatient psychiatric service provided by a psychiatric nurse. However, at the time of the study there was no specialist mental health professional located within the district and no health care personnel trained in mental health care. As part of the Program for Improving Mental health carE (PRIME), plans were being made to integrate mental health care into primary care and maternal health care settings across the district [39]. PRIME is a multi-country implementation research project involving five LMICs (Ethiopia, India, Nepal, South Africa and Uganda) [40]. The analyses presented in this paper were from a formative study which was conducted to identify the treatment gap for women with post-partum depression and their preferred help-seeking [41] and coping strategies [42] in order to inform service development. In this paper we focus on the identification of risk factors for development of PPD. We attempted to identify and recruit all women between one and 12 months postpartum with live infants who were residing in Sodo district. A total of 3147 women were recruited from the 58 sub-districts of the study district, identified by locators in a house-to-house census triangulated with the list of infants from the PRIME census [43] and immunization reports for the whole district obtained from the district health office. Further details of the sample identification have been described previously [41]. The eligibility criteria included being a resident of the study district for 1 year or more, having a live infant, being between one and 12 months postpartum and not exhibiting overt behavioral disturbance indicative of severe mental illness. Each household containing an eligible woman was visited by a data collector who then explained the purpose of the research and gave the woman an information sheet or read the information aloud for those who were unable to read. Women who consented to participate were interviewed at a time and place that was convenient for them, but for the most part the interview took place within their homes. The interviews took approximately 1 hour to complete. PPD symptoms were measured using the Patient Health Questionnaire (PHQ-9). The PHQ-9 was developed originally to measure depression in primary care settings [44]. The PHQ-9 has been culturally validated for use in several African country settings [3, 29, 45–47] including in postpartum women in rural Ghana [48] and in the primary health care and antenatal care settings in the neighbouring district to this study [49, 50]. In the Ethiopia primary care validation, a score of 5 or more was found to have a sensitivity of 83% and specificity of 75% for the detection of major depressive disorder. In antenatal women, the validated cut-off was four and above, giving a sensitivity of 86.7% and a specificity of 80.4%. Gender preference was measured by asking the woman whether she was happy with her child’s gender (yes/no) and whether she perceived that her husband was happy with the child’s gender (yes/no). Social support was assessed using the Oslo Social Support Scale (OSSS-3). The total score as well as the individual items of the OSSS-3 may be used. A total score ranging between 3 and 8 is classified as poor social support, a score between 9 and 11 as intermediate support, and a score between 12 and 14 as strong support [51]. The OSSS-3 has been used in Ethiopia in various settings, including the community for this study [43, 52–54]. Stressful events were measured by the list of threatening experiences (LTE-12) [55]. The LTE has been found to have convergent validity in various studies in Ethiopia [43, 53, 54]. Alcohol use disorder was indicated using the Fast Alcohol Screening Test [56], a four item questionnaire that has been adapted and used in the study site previously [43]. A score of 3 or more indicates probable hazardous or harmful drinking. Perinatal complications were assessed by asking the woman “Have you had pregnancy, or birth-related difficulties? If yes, what were they?” (coded as haemorrhage, prolonged labour or high blood pressure). A total of 36 data collectors and four supervisors, who were recruited from the district by the PRIME project and had experience of data collection, were trained for 9 days. The educational levels of the data collectors ranged from tenth grade completed to first degree. They were supervised by four supervisors who were also trained and assisted by the investigators. The supervisors were diploma or degree graduates. A pre-test was conducted in three sub-districts near the study area. Data were collected between April and June 2014. Data were double entered into EpiData version 3.1 and exported to the Statistical Packages for Social Sciences, version 20 (SPSS-20) for analysis. Frequencies, percentages, and mean values were used to describe the categorical and continuous variables. Bivariate analyses were carried out to investigate the association between symptoms of PPD and several demographic, obstetric, and psychosocial variables. The hypothesis that the woman’s perception that her husband was unhappy with the gender of the baby would be associated with PPD was tested by controlling for demographic and obstetric factors in the multivariable analysis. All variables with a p-value < 0.2 were included in the multivariable model. Adjusted odds ratios with associated 95% confidence intervals were reported in the final multiple logistic regression model. Ethical approval was obtained from the Institutional Review Board of the College of Health Sciences, Addis Ababa University. Permission was also obtained from the Sodo District Health Office and administration. Women who agreed to participate gave written consent. For those who were not literate, independent witnesses were invited to sign to indicate that the information had been read out correctly. Non-literate participants then gave a finger print to indicate consent. Women who endorsed the PHQ item indicating suicidal ideation and those with higher than or equal to 10 in the PHQ were linked to the Butajira hospital psychiatric nurse-led outpatient clinic.
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