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Background: Postpartum depression (PPD) affects more than one in ten women and is associated with adverse consequences for mother, child and family. Integrating mental health care into maternal health care platforms is proposed as a means of improving access to effective care and reducing the ‘treatment gap’ in low- and middle-income countries. This study aimed to determine the proportion of women with PPD who sought help form a health facility and the associated factors. Methods: A community based, cross-sectional survey was conducted in southern Ethiopia. A total of 3147 women who were between one and 12 months postpartum were screened for depressive symptoms in their home using a culturally validated version of the Patient Health Questionnaire (PHQ-9). Women scoring five or more (indicating potential depressive disorder) (n = 385) were interviewed regarding help-seeking behavior. Multiple logistic regression was used to identify factors associated independently with help-seeking from health services. Results: Only 4.2 % of women (n = 16) with high PPD symptoms had obtained mental health care and only 12.7 % of women (n = 49) had been in contact with any health service since the onset of their symptoms. In the multivariable analysis, urban residence, adjusted odds ratio (aOR): 4.39 (95 % confidence interval (CI) 1.23, 15.68); strong social support, aOR: 2.44 (95 % CI 1.30, 4.56); perceived physical cause, aOR: 6.61 (95 % CI 1.76, 24.80); perceived higher severity aOR: 2.28 (95 % CI 1.41, 5.47); perceived need for treatment aOR: 1.46 (95 % CI 1.57, 18.99); PHQ score, aOR: 1.14 (95 % CI 1.04, 1.25); and disability, aOR: 1.06 (95 % CI 1.01, 1.15) were associated significantly with help-seeking from health services. More than half of the women with high levels of PPD symptoms (n = 231; 60.0 %) attributed their symptoms to a psychosocial cause and 269 (69.9 %) perceived a need for treatment. Equal proportions endorsed biomedical treatment and traditional or religious healing as the appropriate intervention. Conclusion: In the absence of an accessible maternal mental health service the treatment gap was very high. There is a need to create public awareness about PPD, its causes and consequences, and the need for help seeking. However, symptom attributions and help-seeking preferences indicate potential acceptability of interventions located in maternal health care services within primary care.
Study design: a population-based cross-sectional survey. Study area: the study was carried out in Sodo district, Gurage Zone, Southern Nations, Nationalities and Peoples Region (SNNPR) of Ethiopia. Sodo is located about 100 km south of the capital city, Addis Ababa. In the most recent census, the population was estimated to be 161,952 persons (79,356 men; 82,596 women), with 88 % of the population residing in rural areas [26]. Amharic is the official language in the district, but the second language for the majority of inhabitants. Within Sodo district, there are eight primary care health centers, each linked to health posts which are staffed by community-based health extension workers. The nearest psychiatric out-patient service is located in Butajira town, 30 km away from the capital of the Sodo district. At the time of the study there were no specialist mental health professionals located within the district and no health care personnel trained in mental health care. However, 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 [27]. PRIME is a multi-country project involving five LMICs (Ethiopia, India, Nepal, South Africa and Uganda). PRIME aims to generate evidence on the best approaches for the integration of mental health care into the existing primary and maternal health care services. This study was conducted to inform possible models of intervention for maternal mental health care within the PRIME service model. As part of PRIME, a census of all households in the district was conducted. However, only 1427 infants (aged less than one year) were recorded within the census, a figure which was much lower than the estimated population from the Central Statistics Agency [28]. Second, we used the immunization report for under one year children from the district health office. Third, we checked the registry of pregnant and postpartum women which is compiled and maintained by community-based health extension workers. Finally, the data collectors identified eligible women in a house-to-house search. These combined approaches resulted in the identification of 3147 women between one and 12 months postpartum. All the identified women were screened using the Patient Health Questionnaire, 9-item depression scale (PHQ-9) [29] and women scoring five or more on the PHQ-9 formed the sample for the study presented in this paper. Postpartum depressive symptoms were measured using the PHQ-9. The PHQ-9 was developed originally to measure depression in primary care settings [30]. The PHQ-9 has been culturally validated for use in several African country settings [31–35] including in postpartum women in rural Ghana [36] and in the primary health care context in rural Ethiopia [37]. In the latter Ethiopian study of the criterion validity of the PHQ-9, a score of five or more was found to have a sensitivity of 83 % and specificity of 75 % for the detection of major depressive disorder. This was assessed using the General Help Seeking Questionnaire (GHSQ) [38]. The GHSQ is a 9-item instrument that was developed to assess future intentions to seek help from a list of culturally-relevant sources. We adapted the GHSQ to ask about actual (rather than intended) behavior and collapsed the response categories to yes/no. The sources of help included in the GHSQ are classified into two major classes: formal and informal. Formal help-seeking includes visiting health professionals (e.g., psychiatrists, psychologists, general practitioners, nurses, etc) or traditional and faith healers [38]. In a rural Ethiopian context, this was adapted to be ‘general health worker’ or ‘mental health worker’. Informal help-seeking is defined as talking about one’s symptoms with parents, friends, a partner or other relative. The woman’s explanatory model of postpartum depressive symptoms was investigated using the Short Explanatory Model Interview (SEMI) [39]. The SEMI is a semi-structured questionnaire with open ended questions to be documented verbatim and coded using a contextualized set of possible categories. A version of SEMI was adapted for Ethiopia with an expert consensus meeting involving mental health professionals and qualitative researchers with experience working in the study site. The women’s perceptions of causes, severity, treatment needs and options for symptoms of postpartum depression were assessed. Disability was measured using the World Health Organization Disability Assessment Tool (WHODAS) [40] which covers the functional domains of understanding and communicating, getting around, self-care, getting along with people, life activities, and participation in society. Each item was scored from 1 (none) to 5 (extreme or cannot do), with the total WHODAS score ranging from 36 to 180. The WHODAS has been used in Ethiopia in perinatal women in the neighboring district and found to have convergent validity and acceptability [41]. Social support was measured using the Oslo Social Support Scale (OSSS-3) [42] The OSSS-3 total score ranges between three and 14. Scores from 3 to 8 are considered to indicate poor support, scores from 9 to 11 indicate intermediate support, and a score between 12 and 14 is considered to indicate strong social support. Although these cut-off points have not been validated in the Ethiopian context, the OSSS-3 categories were used in a community study in the same Ethiopian district and showed good utility [43]. The Barriers to Access to Care Evaluation (BACE) was adapted for use in the study site [44]. Twenty-three out of 30 original items were used in this study as some of the items were not applicable for women with PPD living in a rural African context. For example items like “Concern that it might harm my chances when applying for jobs” and “Not wanting a mental health problem to be on my medical records” were excluded. The tool asks about a range of issues that have ever stopped, delayed or discouraged an individual from getting, or continuing with, professional care for a mental health problem on a scale from 0 (not at all) to 3 (a lot). The domains of potential barriers include individual perception (including stigma), infrastructure, knowledge, social support, attitude of respondents towards the available treatment and previous experiences. Women were interviewed in their homes privately by 36 trained data collectors who were trained for 9 days. The data collectors were recruited from the district and the sub-districts or, if no eligible person was available, applicants from the neighboring sub-districts were recruited. 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. The data collectors went house-to-house, explained the purpose of the research and either gave an information sheet to the woman or read the information for those who were unable to read. Women who consented to participate were interviewed at a time convenient for them within a day or two of initial contact. 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 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 help-seeking behavior of women with symptoms of PPD from a general health facility and each of the independent variables. This outcome was of interest because of the plan to integrate mental health care for women into general health services. 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.
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