Impact of perinatal and repeated maternal common mental disorders on educational outcomes of primary school children in rural Ethiopia: Population-based cohort study

BJPsych Open, Volume 5, No. 6, Year 2019

Interprétation

Background There have been no studies from low- or middle-income countries to investigate the long-term impact of perinatal common mental disorders (CMD) on child educational outcomes.Aims To test the hypothesis that exposure to antenatal and postnatal maternal CMD would be associated independently with adverse child educational outcomes in a rural Ethiopian.Method A population-based birth cohort was established in 2005/2006. Inclusion criteria were: age between 15 and 49 years, ability to speak Amharic, in the third trimester of pregnancy and resident of the health demographic surveillance site. One antenatal and nine postnatal maternal CMD assessments were conducted using a self-reporting questionnaire, validated for the local use. Child educational outcomes were obtained from the mother at T1 (2013/2014 academic year; mean age 8.5 years) and from school records at T2 (2014/2015 academic year; mean age 9.3 years).Results Antenatal CMD (risk ratio (RR) = 1.06, 95% CI 1.05-1.07) and postnatal CMD (RR = 1.07, 95% CI 1.06-1.09) were significantly associated with child absenteeism at T2. Exposure to repeatedly high maternal CMD scores in the preschool period was not associated with absenteeism after adjusting for antenatal and postnatal CMD. Non-enrolment at T1 (odds ratio 0.75, 95% CI 0.62-0.92) was significantly but inversely associated with postnatal maternal CMD. There was no association between maternal CMD and child academic achievement or drop-out.Conclusions Our findings support the hypothesis of a critical period for exposure to maternal CMD for adverse child outcomes and indicate that programmes to enhance regular school attendance in low-income countries need to address perinatal maternal CMD.Declaration of interest None. The study was an extension of a population-based birth cohort, the Child outcomes in relation to Maternal Mental Illness in Ethiopia (C-MaMiE) study. A total of 1065 pregnant women were recruited in 2005–2006 and have been followed up, together with the index child, to date. In the current study, we examined the exposure of maternal CMD measured repeatedly since the inception of the cohort in relation to the birth date of the child. Educational outcomes of children were measured at two time points: T1 (2013/2014 academic year, child mean age of 8.5 years (s.d. = 0.3) and T2 (2014/2015 academic year, mean age of 9.3 years, s.d. = 0.3). The C-MaMiE cohort was established within the Health and Demographic Surveillance Site (HDSS)14 in Butajira, Gurage Zone, Southern Nations Nationalities and Peoples’ Region of Ethiopia. Butajira is located 135 km south of the capital Addis Ababa, is predominantly rural and is notable for the diversity of ethnicities and languages in the population. The HDSS has nine subdistricts with different ecological zones (low and highlands) and one urban administration in Butajira town. Butajira is densely populated and livelihoods are based on mixed farming of staples, such as maize and false banana, and cash crops, such as khat and chilli peppers. Ethiopia is striving for complete primary education coverage, although national figures from the 2015/2016 academic year indicate that only 85.5% have enrolled currently, with 10.1% drop-out and 6.7% grade repetition.15 The official age for school enrolment is 7 years. Primary education lasts for 8 years (age group 7–14 years) with two cycles: basic (grades 1–4) and general education (grades 5–8). Families are expected to cover the costs of school uniforms, food and exercise books; otherwise, education is free for all Ethiopians.16 Except for one regional examination at the completion of grade 8, the academic performance of students is assessed by the class teacher using non-standardised tests. In the first cycle of primary education, children are taught and evaluated by a single teacher following the ‘self-contained class’ concept.16 At the inception of the C-MaMiE cohort, a population-based sample of 1065 women was recruited out of 1234 eligible women (86.3%) meeting inclusion criteria of age between 15 and 49 years, ability to communicate in Amharic, a resident of the HDSS and in the third trimester of pregnancy. The women and the child born from the index pregnancy have been assessed repeatedly over time. Ten time-point assessments were conducted starting in pregnancy and at 2, 12, 30, 36, 42, 48, 60, 78 and 102 months of age of the child in the postnatal period, see supplementary Fig. 1 available at https://doi.org/10.1192/bjo.2019.69. The primary educational outcomes for this study (school enrolment, absenteeism, drop-out and academic performance) were selected based on their contextual relevance, given that (a) key bottlenecks to academic success occur at the stages of school enrolment (although working towards 100% coverage, the most recent estimates of school enrolment in Ethiopia are 85.5%), regular attendance and retention in school in this setting, and (b) that regular school attendance has been shown to have important socialisation benefits, regardless of the impact on academic achievement.17,18 All outcomes were measured in relation to academic years rather than the birth date of the children as shown in supplementary Fig. 1. They were measured as follows. This was measured using the World Health Organization 20-item version of the Self-Reporting Questionnaire (SRQ-20) in pregnancy and at all nine postnatal time points until the child was on average 8.5 years.19 The SRQ-20 items ask about the presence or absence of depressive, anxiety and somatic symptoms in the preceding 1 month (answered ‘yes’ or ‘no’). The SRQ-20 has been validated for perinatal women in this rural Ethiopian population.20 Repeated high maternal CMD scores were generated as the count of time points after the 2-month postnatal time point when the woman scored ≥6. Measures of potential confounding factors were used from the following time points depending on the hypothesis: (a) model 1 (exposure of antenatal CMD): pregnancy time point, (b) model 2 (exposure of postnatal CMD): postnatal 2-month time point, and (c) model 3 (exposure of repeated high maternal CMD scores): 60 months postnatal time point. An adapted version of the 12 item List of Threatening Experiences21 scale was used to measure stressful life events over the pregnancy (antenatal time point) and preceding 6 months for the postnatal assessments. Self-report of the following proxy indicators of socioeconomic status were measured: current roof material, the experience of hunger in the preceding month because of lack of food or money, and the existence of emergency resources in times of crisis. A report of the frequency of paternal alcohol and/or khat use was obtained from the woman. Literacy level of both parents, age of the mother, marital status, birth order and gender of the child were obtained from self-report of the woman. Height measures were carried out by trained project data collectors using a stadiometer with a movable headpiece. Using the World Health Organization reference population,22 height-for-age z-scores were calculated using World Health Organization Anthro software.23 To ensure privacy, confidentiality and her preference, all interviews with the women were carried out in the woman’s home or surrounding area. The project data collectors had all completed high-school education, and were experienced in conducting interviews and in the use of the study measures. At each time point, they received an additional 3 days of refresher training on the use of newly added instruments. The questionnaires were piloted before commencing data collection and discrepancies in ratings were discussed to ensure that the data collectors had a common understanding. Supervisors and a field coordinator monitored the data-collection process and performed quality checks on a random sample of evaluations. Data-entry clerks double entered data with EpiData version 3.124 on the day of data collection, where possible. Any identifiable information about the respondent was kept securely and separately from the assessment data and a code number was used to ensure confidentiality. A hypothesis-driven analysis was conducted using Stata version 1225 to examine the association of maternal CMD in model 1 antenatally, and model 2 at 2 months postnatal using SRQ-20 total score, and in model 3 repeated high maternal CMD scores (as previously defined) with educational outcomes. First, we conducted unadjusted logistic regression for school non-enrolment and drop-out (binary outcomes), zero-inflated Poisson regression for absenteeism (count data, with excess zeroes) and linear regression for academic achievement (continuous, normally distributed). We then carried out two stages of multivariable analysis; first a model containing each primary exposure adjusted for all potential confounders identified a priori, and finally we ran a model containing antenatal, postnatal and repeated high CMD scores and all potential confounders at the 60-month time point in the same model. Estimates of associations were presented with their corresponding 95% confidence intervals. The study has been reported according to the STROBE reporting checklist. The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. All procedures involving human participants were approved by the Institutional Review Board of the College of Health Sciences, Addis Ababa University, Ethiopia (reference number 082/13/psy) and the Research Ethics Committee of King’s College London, UK (reference number PNM/13/14-92). Written or verbal informed consent was obtained from each woman for her own and her child’s participation in the study as well and to access school records of the child. Verbal consent was witnessed and formally recorded. For the anthropometric assessment assent was obtained from the child. Any woman who presented with high CMD symptoms and suicidal ideation was supported to seek care at the psychiatric unit at Butajira Hospital, with the project covering treatment and transportation costs.

Résumé de l’IA

Study Justification:

– The study aimed to investigate the long-term impact of perinatal common mental disorders (CMD) on child educational outcomes in rural Ethiopia.
– This study is important because there have been no previous studies from low- or middle-income countries that have examined this relationship.
– Understanding the impact of maternal CMD on child educational outcomes can inform the development of programs and interventions to support children’s education in low-income countries.

Study Highlights:

– The study used a population-based birth cohort established in 2005/2006, following 1065 pregnant women and their children.
– Maternal CMD was assessed using a self-reporting questionnaire, and child educational outcomes were obtained from mothers and school records.
– The study found that antenatal and postnatal maternal CMD were significantly associated with child absenteeism.
– Non-enrollment at school was significantly associated with postnatal maternal CMD.
– There was no association between maternal CMD and child academic achievement or drop-out.

Study Recommendations:

– The findings suggest that exposure to maternal CMD during the perinatal period can have a negative impact on child educational outcomes.
– Programs to enhance regular school attendance in low-income countries should address perinatal maternal CMD.
– Further research is needed to explore the mechanisms through which maternal CMD affects child educational outcomes and to develop effective interventions.

Key Role Players:

– Researchers and academics in the field of maternal and child health
– Policy makers and government officials responsible for education and mental health
– Health professionals, including psychiatrists and psychologists
– Teachers and school administrators
– Community leaders and organizations

Cost Items for Planning Recommendations:

– Development and implementation of educational programs to address perinatal maternal CMD
– Training and capacity building for health professionals, teachers, and community leaders
– Mental health services and support for women with CMD
– Monitoring and evaluation of program effectiveness
– Research funding for further studies and interventions in this area

Force de la preuve

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong, but there are some areas for improvement. The study design is a population-based cohort study, which is generally considered to be a robust design. The study includes a large sample size of 1065 pregnant women and follows them up over time. The outcomes are measured at two time points, which allows for longitudinal analysis. The study also adjusts for potential confounding factors. However, the abstract does not provide information on the statistical methods used for analysis, which could affect the strength of the evidence. Additionally, the abstract does not mention any limitations of the study, which is important for assessing the quality of the evidence. To improve the evidence, the authors could provide more details on the statistical methods used and discuss the limitations of the study.

Abstrait

The study was an extension of a population-based birth cohort, the Child outcomes in relation to Maternal Mental Illness in Ethiopia (C-MaMiE) study. A total of 1065 pregnant women were recruited in 2005–2006 and have been followed up, together with the index child, to date. In the current study, we examined the exposure of maternal CMD measured repeatedly since the inception of the cohort in relation to the birth date of the child. Educational outcomes of children were measured at two time points: T1 (2013/2014 academic year, child mean age of 8.5 years (s.d. = 0.3) and T2 (2014/2015 academic year, mean age of 9.3 years, s.d. = 0.3). The C-MaMiE cohort was established within the Health and Demographic Surveillance Site (HDSS)14 in Butajira, Gurage Zone, Southern Nations Nationalities and Peoples’ Region of Ethiopia. Butajira is located 135 km south of the capital Addis Ababa, is predominantly rural and is notable for the diversity of ethnicities and languages in the population. The HDSS has nine subdistricts with different ecological zones (low and highlands) and one urban administration in Butajira town. Butajira is densely populated and livelihoods are based on mixed farming of staples, such as maize and false banana, and cash crops, such as khat and chilli peppers. Ethiopia is striving for complete primary education coverage, although national figures from the 2015/2016 academic year indicate that only 85.5% have enrolled currently, with 10.1% drop-out and 6.7% grade repetition.15 The official age for school enrolment is 7 years. Primary education lasts for 8 years (age group 7–14 years) with two cycles: basic (grades 1–4) and general education (grades 5–8). Families are expected to cover the costs of school uniforms, food and exercise books; otherwise, education is free for all Ethiopians.16 Except for one regional examination at the completion of grade 8, the academic performance of students is assessed by the class teacher using non-standardised tests. In the first cycle of primary education, children are taught and evaluated by a single teacher following the ‘self-contained class’ concept.16 At the inception of the C-MaMiE cohort, a population-based sample of 1065 women was recruited out of 1234 eligible women (86.3%) meeting inclusion criteria of age between 15 and 49 years, ability to communicate in Amharic, a resident of the HDSS and in the third trimester of pregnancy. The women and the child born from the index pregnancy have been assessed repeatedly over time. Ten time-point assessments were conducted starting in pregnancy and at 2, 12, 30, 36, 42, 48, 60, 78 and 102 months of age of the child in the postnatal period, see supplementary Fig. 1 available at https://doi.org/10.1192/bjo.2019.69. The primary educational outcomes for this study (school enrolment, absenteeism, drop-out and academic performance) were selected based on their contextual relevance, given that (a) key bottlenecks to academic success occur at the stages of school enrolment (although working towards 100% coverage, the most recent estimates of school enrolment in Ethiopia are 85.5%), regular attendance and retention in school in this setting, and (b) that regular school attendance has been shown to have important socialisation benefits, regardless of the impact on academic achievement.17,18 All outcomes were measured in relation to academic years rather than the birth date of the children as shown in supplementary Fig. 1. They were measured as follows. This was measured using the World Health Organization 20-item version of the Self-Reporting Questionnaire (SRQ-20) in pregnancy and at all nine postnatal time points until the child was on average 8.5 years.19 The SRQ-20 items ask about the presence or absence of depressive, anxiety and somatic symptoms in the preceding 1 month (answered ‘yes’ or ‘no’). The SRQ-20 has been validated for perinatal women in this rural Ethiopian population.20 Repeated high maternal CMD scores were generated as the count of time points after the 2-month postnatal time point when the woman scored ≥6. Measures of potential confounding factors were used from the following time points depending on the hypothesis: (a) model 1 (exposure of antenatal CMD): pregnancy time point, (b) model 2 (exposure of postnatal CMD): postnatal 2-month time point, and (c) model 3 (exposure of repeated high maternal CMD scores): 60 months postnatal time point. An adapted version of the 12 item List of Threatening Experiences21 scale was used to measure stressful life events over the pregnancy (antenatal time point) and preceding 6 months for the postnatal assessments. Self-report of the following proxy indicators of socioeconomic status were measured: current roof material, the experience of hunger in the preceding month because of lack of food or money, and the existence of emergency resources in times of crisis. A report of the frequency of paternal alcohol and/or khat use was obtained from the woman. Literacy level of both parents, age of the mother, marital status, birth order and gender of the child were obtained from self-report of the woman. Height measures were carried out by trained project data collectors using a stadiometer with a movable headpiece. Using the World Health Organization reference population,22 height-for-age z-scores were calculated using World Health Organization Anthro software.23 To ensure privacy, confidentiality and her preference, all interviews with the women were carried out in the woman’s home or surrounding area. The project data collectors had all completed high-school education, and were experienced in conducting interviews and in the use of the study measures. At each time point, they received an additional 3 days of refresher training on the use of newly added instruments. The questionnaires were piloted before commencing data collection and discrepancies in ratings were discussed to ensure that the data collectors had a common understanding. Supervisors and a field coordinator monitored the data-collection process and performed quality checks on a random sample of evaluations. Data-entry clerks double entered data with EpiData version 3.124 on the day of data collection, where possible. Any identifiable information about the respondent was kept securely and separately from the assessment data and a code number was used to ensure confidentiality. A hypothesis-driven analysis was conducted using Stata version 1225 to examine the association of maternal CMD in model 1 antenatally, and model 2 at 2 months postnatal using SRQ-20 total score, and in model 3 repeated high maternal CMD scores (as previously defined) with educational outcomes. First, we conducted unadjusted logistic regression for school non-enrolment and drop-out (binary outcomes), zero-inflated Poisson regression for absenteeism (count data, with excess zeroes) and linear regression for academic achievement (continuous, normally distributed). We then carried out two stages of multivariable analysis; first a model containing each primary exposure adjusted for all potential confounders identified a priori, and finally we ran a model containing antenatal, postnatal and repeated high CMD scores and all potential confounders at the 60-month time point in the same model. Estimates of associations were presented with their corresponding 95% confidence intervals. The study has been reported according to the STROBE reporting checklist. The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. All procedures involving human participants were approved by the Institutional Review Board of the College of Health Sciences, Addis Ababa University, Ethiopia (reference number 082/13/psy) and the Research Ethics Committee of King’s College London, UK (reference number PNM/13/14-92). Written or verbal informed consent was obtained from each woman for her own and her child’s participation in the study as well and to access school records of the child. Verbal consent was witnessed and formally recorded. For the anthropometric assessment assent was obtained from the child. Any woman who presented with high CMD symptoms and suicidal ideation was supported to seek care at the psychiatric unit at Butajira Hospital, with the project covering treatment and transportation costs.

Matériaux

https://efashare.b-cdn.net/materials/bb5800e82e2e5319bb7a4f91fa4823749fed1b9b63e035d09472e3ba1a58189e/S2056472419000693sup001.docx

Innovations

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

1. Telemedicine: Implementing telemedicine services can provide remote access to healthcare professionals for pregnant women in rural areas. This allows them to receive prenatal care, mental health support, and guidance without the need for physical travel.

2. Mobile health (mHealth) applications: Developing mobile applications that provide educational resources, appointment reminders, and personalized health information can empower pregnant women to take control of their own health. These apps can also include features for monitoring mental health and connecting with support networks.

3. Community health workers: Training and deploying community health workers in rural areas can help bridge the gap between healthcare facilities and pregnant women. These workers can provide basic prenatal care, mental health screenings, and referrals to appropriate healthcare providers.

4. Mobile clinics: Establishing mobile clinics that travel to remote areas can bring essential healthcare services, including prenatal care and mental health support, directly to pregnant women who may not have easy access to healthcare facilities.

5. Public awareness campaigns: Launching public awareness campaigns to educate communities about the importance of maternal health and the available resources can help reduce stigma and encourage pregnant women to seek care. These campaigns can be conducted through various mediums, such as radio, television, and community gatherings.

6. Collaborations with local organizations: Partnering with local organizations, such as women’s groups, community centers, and religious institutions, can help reach pregnant women in rural areas and provide them with information, support, and resources for maternal health.

7. Financial incentives: Implementing financial incentives, such as subsidies or cash transfers, can help alleviate the financial burden of seeking maternal healthcare for women in low-income settings. This can encourage more pregnant women to access necessary care.

It’s important to note that the specific context and needs of the community should be considered when implementing these innovations to ensure their effectiveness and sustainability.

AI Innovations Description

The study titled “Impact of perinatal and repeated maternal common mental disorders on educational outcomes of primary school children in rural Ethiopia: Population-based cohort study” aimed to investigate the long-term impact of perinatal common mental disorders (CMD) on child educational outcomes in a rural Ethiopian setting.

The study used a population-based birth cohort established in 2005/2006, consisting of 1065 pregnant women. Maternal CMD was assessed using a self-reporting questionnaire, and child educational outcomes were obtained from the mother and school records at two time points: T1 (2013/2014 academic year, mean age 8.5 years) and T2 (2014/2015 academic year, mean age 9.3 years).

The findings of the study revealed that antenatal and postnatal maternal CMD were significantly associated with child absenteeism at T2. However, exposure to repeatedly high maternal CMD scores in the preschool period did not have a significant association with absenteeism after adjusting for antenatal and postnatal CMD. Postnatal maternal CMD was inversely associated with non-enrollment at T1. There was no association between maternal CMD and child academic achievement or drop-out.

Based on these findings, the study suggests that programs aimed at improving regular school attendance in low-income countries should address perinatal maternal CMD. This recommendation highlights the importance of addressing maternal mental health during pregnancy and postnatal periods to improve access to maternal health and subsequently enhance child educational outcomes.

It is important to note that the study was conducted in a specific rural Ethiopian setting, and further research is needed to determine the generalizability of these findings to other contexts.

AI Innovations Methodology

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

1. Increase awareness and education: Implement programs to educate pregnant women and their families about the importance of maternal mental health and its impact on child outcomes. This can be done through community health workers, antenatal clinics, and educational campaigns.

2. Strengthen antenatal and postnatal care: Ensure that antenatal and postnatal care services include screening and support for maternal mental health. This can involve training healthcare providers to identify and address common mental disorders during pregnancy and after childbirth.

3. Integrate mental health services into primary healthcare: Improve access to mental health services by integrating them into primary healthcare settings. This can involve training primary healthcare providers to diagnose and manage common mental disorders, as well as providing referral pathways for more specialized care when needed.

4. Provide psychosocial support: Establish support groups or counseling services for pregnant women and new mothers to address their mental health needs. This can include peer support programs, group therapy sessions, or individual counseling.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could involve the following steps:

1. Define the indicators: Identify specific indicators that reflect improved access to maternal health, such as increased utilization of antenatal and postnatal care services, reduced rates of maternal mental disorders, improved child educational outcomes, and increased awareness and knowledge about maternal mental health.

2. Collect baseline data: Gather data on the current status of these indicators in the target population. This can involve surveys, interviews, or analysis of existing data sources.

3. Implement interventions: Implement the recommended interventions in the target population. This can be done through pilot projects, community-based programs, or policy changes.

4. Monitor and evaluate: Continuously monitor and evaluate the impact of the interventions on the defined indicators. This can involve collecting data at regular intervals, conducting surveys or interviews, and analyzing the data to assess changes over time.

5. Analyze the data: Use statistical analysis techniques to analyze the collected data and determine the impact of the interventions on the defined indicators. This can involve comparing pre- and post-intervention data, conducting regression analyses, or using other appropriate statistical methods.

6. Interpret the results: Interpret the results of the analysis to understand the effectiveness of the interventions in improving access to maternal health. This can involve identifying trends, patterns, and associations in the data, and drawing conclusions based on the findings.

7. Adjust and refine: Based on the results and findings, make any necessary adjustments or refinements to the interventions to further improve their effectiveness. This can involve modifying the interventions, scaling them up to reach a larger population, or addressing any identified gaps or challenges.

By following this methodology, it would be possible to simulate the impact of the recommended interventions on improving access to maternal health and assess their effectiveness in achieving the desired outcomes.

Auteur

Dima Health

Statistics:

Citations: 1

Identifiers:

DOI: 10.1192/bjo.2019.69

Research Areas:

Disparities, Food Security, Health System and Policy, Maternal Access, Maternal and Child Health, Mental Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Substance Abuse

Study Countries:

Ethiopia

Study Design:

Case-Control Study, Cohort Study, Cross Sectional Study, Grounded Theory

Study Approach:

Quantitative

Participants Gender:

Female

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