Assessing factors associated with poor maternal mental health among mothers of children born small and sick at 24–47 months in rural Rwanda

Background: Global investments in neonatal survival have resulted in a growing number of children with morbidities surviving and requiring ongoing care. Little is known about the caregivers of these children in low- and middle-income countries, including maternal mental health which can further negatively impact child health and development outcomes. We aimed to assess the prevalence and factors associated with poor maternal mental health in mothers of children born preterm, low birthweight (LBW), and with hypoxic ischemic encephalopathy (HIE) at 24–47 months of age in rural Rwanda. Methods: Cross-sectional study of children 24–47 months born preterm, LBW, or with HIE, and their mothers discharged from the Neonatal Care Unit (NCU) at Kirehe Hospital between May 2015–April 2016 or discharged and enrolled in a NCU follow-up program from May 2016–November 2017. Households were interviewed between October 2018 and June 2019. Mothers reported on their mental health and their child’s development; children’s anthropometrics were measured directly. Backwards stepwise procedures were used to assess factors associated with poor maternal mental health using logistic regression. Results: Of 287 total children, 189 (65.9%) were born preterm/LBW and 34.1% had HIE and 213 (74.2%) screened positive for potential caregiver-reported disability. Half (n = 148, 51.6%) of mothers reported poor mental health. In the final model, poor maternal mental health was significantly associated with use of violent discipline (Odds Ratio [OR] 2.29, 95% Confidence Interval [CI] 1.17,4.45) and having a child with caregiver-reported disability (OR 2.96, 95% CI 1.55, 5.67). Greater household food security (OR 0.80, 95% CI 0.70–0.92) and being married (OR = 0.12, 95% CI 0.04–0.36) or living together as if married (OR = 0.13, 95% CI 0.05, 0.37) reduced the odds of poor mental health. Conclusions: Half of mothers of children born preterm, LBW and with HIE had poor mental health indicating a need for interventions to identify and address maternal mental health in this population. Mother’s poor mental health was also associated with negative parenting practices. Specific interventions targeting mothers of children with disabilities, single mothers, and food insecure households could be additionally beneficial given their strong association with poor maternal mental health. This study was conducted in Kirehe District in the Eastern Province of Rwanda. Kirehe District is served by Kirehe District Hospital (KDH), which is operated by the Rwanda Ministry of Health (MOH) and serves a catchment of over 400,000 people [35] plus a refugee camp of 60,000 people [36]. Kirehe District Hospital has been supported by Partners In Health/Inshuti Mu Buzima since 2008. The hospital has provided specialized inpatient neonatal care for preterm and LBW newborns, as well as newborns with HIE and other medical conditions since 2012. In May 2016, a Pediatric Development Clinic (PDC) was established at Kirehe District Hospital through the collaboration of Partners In Health/Inshuti Mu Buzima and the MOH to provide clinical, nutritional, and developmental follow-up to children discharged from the Kirehe District Hospital neonatol care unit (NCU). Detailed information on PDC can be found elsewhere [37]. This was a cross-sectional study that included children aged 24–47 months born with prematurity, LBW, or HIE, and discharged from the NCU at Kirehe District Hospital between May 2015 and April 2016 or enrolled in the PDC from May 2016 to November 2017. Primary caregivers of these children were included in this study if they were the biological mothers and if data on their mental health status was collected. Data were collected between October 2018 and June 2019 by a trained team of Partners In Health/Inshuti Mu Buzima data collectors. Data collectors conducted household interviews in Kinyarwanda with primary caregivers of eligible children, and measured anthropometrics and developmental indicators for children. Due to limitations in literacy, the data collector conducted the consent process and interview verbally and written confirmation of consent was provided by participants with a signature or fingerprint. The collected data included caregiver-reported child’s developmental status, child’s caregiver-reported disability status, child feeding, caregiver mental health, household socio-economic status, child discipline practices, and early stimulation activities. The child’s nutritional status was measured directly. Maternal mental health was measured using the Hopkins Symptom Checklist, which has been validated in Rwanda. It is a 25 item measure of symptoms of anxiety and depression with the total score being a mean of all items; a score > 1.75 is considered high level of anxiety and depression symptoms [38]. The full questionnaire is available in Supplementary File 1. Stunting (low height-for-age), wasting (low weight-for-height), and underweight (low weight-for-age) were measured using standard anthropometric procedures to capture weight and height (or length) and compared to the WHO Child Growth Standards [39]. The cutoff point for severe malnutrition was a z-score less than − 3 standard deviations and moderate malnutrition is a z-score less than − 2 standard deviations using the WHO Child Growth Standards. Home environment was assessed using UNICEF’s Family Care Indicators [40], which measure early learning activities, availability of play materials, and exposure to inadequate care. Inadequate care is when caregivers reported that the child was left alone, or the child was cared for by another child less than 10 years of age, for 1 hour or more in the past week. The UNICEF Multiple Indicator Cluster Survey measure of violent discipline [41] was also used. Exposure to violent discipline was defined as caregiver-reported use of any psychological aggression (i.e., yelling, name calling) or physical punishment (i.e., hitting, spanking) to the child in the past month. Household socioeconomic status was measured using an asset index which was analyzed using principal component analysis for a measure of relative wealth in our sample; households were grouped into tertiles representing the poorest, the middle, and the wealthiest groups. In addition, the Rwandan “Ubudehe” categorization was collected, which is a Rwandan community-based ranking of wealth status. Households are categorized in to 4 groups with the first category being the extremely poor and qualifying for government social services including free health insurance, and the fourth being the wealthiest category. Child disability was measured using the Ten Questions Questionnaire [42], which is a caregiver-reported screening tool for detecting impairments in physical development, hearing, vision, and communication. Children whose mother responded to yes on any one impairment were considered at risk for moderate to severe disability. Child development was measured using the Ages and Stages Questionnaire (ASQ-3) [43]. The ASQ-3 asks 30 age-specific questions across communication, gross motor, fine motor, personal social, and problem solving domains. Children are screened as “at risk for developmental delay” if they fall below the standard Western-normed cut-point in any one of the five domains. Social support was measured using the Inventory of Socially Supportive Behaviors which had been previously adapted to Rwanda and is scored as a mean score of all items with 1 being the minimum score (low social support) and 5 being the maximum [44, 45]. Months of Adequate Household Food Provisioning is a way to measure self-reported household food access over the past year [46]. We described socio-economic and demographic characteristics, child nutrition and development, home environment and maternal mental health using frequencies and percentages for categorical variables and mean and standard deviation (SD) or median and interquartile range (IQR) for continuous variables. Bivariate associations between maternal mental health status and each covariate was assessed using Fisher’s exact (categorical) and t-test (continuous) or Wilcoxon rank sum test if continuous measures were not normally distributed (social support, months of adequate household food provisioning). Backwards stepwise techniques were used to build a multivariable logistic regression model to investigate factors associated with poor maternal mental health. We included in the full model all variables associated with maternal mental health at α = 0.20 in the bivariate analysis. Manual removal of variables was completed following backwards stepwise procedures and the final model included only variables significant at α = 0.05.