Antenatal depressive symptoms and utilisation of delivery and postnatal care: A prospective study in rural Ethiopia

Background: Uptake of delivery and postnatal care remains low in Low and Middle-Income Countries (LMICs), where 99% of global maternal deaths take place. However, the potential impact of antenatal depression on use of institutional delivery and postnatal care has seldom been examined. This study aimed to examine whether antenatal depressive symptoms are associated with use of maternal health care services. Methods: A population-based prospective study was conducted in Sodo District, Southern Ethiopia. Depressive symptoms were assessed during pregnancy with a locally validated, Amharic version of the Patient Health Questionnaire (PHQ-9). A cut off score of five or more indicated possible depression. A total of 1251 women were interviewed at a median of 8 weeks (4-12 weeks) after delivery. Postnatal outcome variables were: institutional delivery care utilization, type of delivery, i.e. spontaneous or assisted, and postnatal care utilization. Multivariate logistic regression was used to examine the association between antenatal depressive symptoms and the outcome variables. Results: High levels of antenatal depressive symptoms (PHQ score 5 or higher) were found in 28.7% of participating women. Nearly two-thirds, 783 women (62.6%), delivered in healthcare institutions. After adjusting for potential confounders, women with antenatal depressive symptoms had increased odds of reporting institutional birth [adjusted Odds Ratio (aOR) =1.42, 95% Confidence Interval (CI): 1.06, 1.92] and increased odds of reporting having had an assisted delivery (aOR = 1.72, 95% CI: 1.10, 2.69) as compared to women without these symptoms. However, the increased odds of institutional delivery among women with antenatal depressive symptoms was associated with unplanned delivery care use mainly due to emergency reasons (aOR = 1.62, 95% CI: 1.09, 2.42) rather than planning to deliver in healthcare institutions. Conclusion: Improved detection and treatment of antenatal depression has the potential to increase planned institutional delivery and reduce perinatal complications, thus contributing to a reduction in maternal morbidity and mortality.

A population-based, prospective study was conducted in Sodo District, located in the Southern Nations, Nationalities and People’s Region (SNNPR) of Ethiopia. The district has 54 rural and four urban sub-districts (“kebeles”), the smallest administrative unit in Ethiopia. The official language of the region and the district is Amharic. An estimate of about 161,000 people (79,000 men; 82,000 women) resided in Sodo in 2007. The majority of the inhabitants belong to the Sodo Gurage ethnic group (85%), with the remaining population being mostly Oromo and Amhara in ethnicity [52]. Agriculture is the main economic activity within the region. The cohort was formed by recruiting all consenting pregnant women in the district in their second and third trimester of pregnancy, between early September and end of November 2014. In the current Ethiopian healthcare system, community based health workers (Health Extension Workers, HEWs) are tasked with community health prevention and promotion activities. They are also tasked with identification and monitoring of pregnant women and to keep accurate and up-to-date maternal records in health posts (frontline primary healthcare facility staffed by HEWs). In support of these activities, HEWs coordinate with the health development army, a community-based network of health education volunteers, each of whom covers five families. The members of the health development armies are required to notify HEWs of all pregnant women in their respective areas. In this study, HEWs, members of health development armies, kebele chairmen and pregnant women themselves acted as key informants to identify all pregnant women in their respective sub-districts. Through home to home visits of identified women, the data collectors obtained informed consent from potential participants and conducted the baseline interviews. A minimum of three visits were carried out before considering participants ‘unavailable’ or ‘unidentifiable’. Eligibility criteria for participation in the study included: (1) being in the second or third trimester of pregnancy; (2) continuously resident in the area for a minimum of 6 months; (3) no hearing or cognitive impairment that would affect their capacity to communicate adequately; (4) giving informed consent. Sample size was estimated using EpiInfo version 7 [55] assuming a statistical power of 80% with a two tailed 5% margin of error; 11.7% of institutional delivery utilization among women without antenatal depression [52]; a 10% difference between women with and without antenatal depressive symptoms, which was assumed to be clinically significant. A three to one ratio for women with and without antenatal depressive symptoms was used based on the rates of antenatal depression cited in the literature for LMICs settings [17–19, 23–25]. On this basis, the target sample size was 1174 pregnant women (294 with antenatal depressive symptoms and 880 women without antenatal depressive symptoms). However, all 1311 antenatal baseline participants (356 with antenatal depressive symptoms and 955 without antenatal depressive symptoms) formed the cohort for this study [56]. Data collection was conducted by trained interviewers using an Amharic version of the questionnaires. Forty experienced data collectors and four supervisors were trained for 2 days by the main coordinator of the study (TB) on administration of the instruments, objectives of the study and ethical issues. Training methods included lectures, demonstrations and role-plays. TB closely monitored and supervised the conduct of the study through weekly meetings with the data collectors and supervisors. Completed questionnaires were checked carefully for consistency, adherence to instructions and missing data, first by the supervisors and then by the coordinator and data entry clerks. The data were double entered using EpiData version 3.1 [55] while data collection was proceeding. Completed questionnaires deemed missing or inconsistent were returned back to data collectors for investigation and correction. Data reporting was made in adherence to a STROBE statement checklist [57] to maintain standard of reporting for cohort data. Main outcomes were whether delivery occurred in a healthcare institution or at home without skilled birth attendatnt; (2) whether delivery in a healthcare setting was planned or unplanned and (3) whether postnatal care was utilized. The outcome variables were prospectively assessed at a median of 8 weeks postpartum (interquartile range of 6–11 weeks postpartum) using the lay interviewer-administered questionnaires. The delivery setting was dichotomized into home delivery vs. institutional delivery. The method of delivery was dichotomised as spontaneous vaginal delivery (SVD) or assisted delivery (instrumental vaginal delivery or Caesarean Section). Women who delivered in health care institutions were also asked whether this had been planned, or had arisen “due to prolonged labour”, and or “due to referral linked to complications” (the latter two responses were subsequently coded as ‘unplanned’). Postnatal care utilization was rated positive if there was at least one visit to a health care professional within 4 weeks of delivery. The primary exposure was the occurrence of depressive symptoms antenatally. A locally validated Amharic version of the Patient Health Questionnaire (PHQ-9) [58] was used to screen for antenatal depressive symptoms at baseline, during the second and third trimesters of pregnancy. In studies from high-income countries, the cut-off scores indicating possible major depressive disorder cluster around 10 points [59], however, validation studies of the PHQ-9 in rural areas of low-income countries of sub-Saharan Africa, have found a lower optimal cut-off point. In Ethiopia, the PHQ-9 has been validated in antenatal women and in primary care settings in the neighbouring district of the current study, with the optimal cut-off point indicating probable depression identified as 5 or more in primary care attendees [60]. In a community sample of postnatal women in Ghana, the optimal cut-off to indicate probable depression was also 5 or more [22]. Therefore, in this study, a PHQ score of 5 or more was taken to indicate probable antenatal depression. Potential confounding variables were reviewed from the literature and assessed at baseline, during the second and third trimesters of pregnancy. A five item scale, the Women’s Abuse Screening Test (WAST) [61, 62] was used to assess intimate partner violence (IPV). WAST was chosen for its brevity and the acceptability of the wording. A score of one or more on WAST indicates women who have experienced IPV [61, 62]. A three item scale, the Oslo Social Support scale (OSS-3) [63], was used to assess social support. The OSS-3 scale has been used in a community based study in the same setting [64]. Questions from the 2011 Ethiopian Demographic Health Survey (EDHS) were used to collect information on previous stillbirth, spontaneous abortion, neonatal and infant mortality, and comorbid medical conditions, including HIV, tuberculosis, renal or cardiac diseases, hypertension, anaemia or gastritis. Pregnancy intention was coded as ‘intended’ if the woman intended the pregnancy to happen; ‘mistimed’ if the woman would have preferred the pregnancy to have happened at a future date and ‘unwanted’ if the woman did not want to be pregnant at all. The number of antenatal care (ANC) visits was also asked and it was adjusted to gestational age by dividing the number of actual ANC visits by expected number of ANC contacts for a given gestation [one, two, three and four ANC contacts were expected for women at 16th, 28th, 32nd and 40th weeks of gestation respectively based on WHO recommendations [41]]. Birth preparedness was also assessed using items taken from EDHS and other similar studies that asked mothers whether they had planned the means of transport, prepared a delivery kit, identified a health facility and obtained the money required for expenses during delivery [50, 52, 65]. A seven-item scale was used to assess the accessibility of health care facilities for women. This tool assessed the level of difficulty, distance to reach the nearest health facility, and travel time taken as well as affordability and availability of health facilities [66]. Pregnancy complications were assessed using a list of key danger signs during pregnancy as obtained from the EDHS [52]. Close-ended questions were used to assess socio-demographic and socio-economic variables, including residence, marital status, estimated monthly income and educational level of participants. Stata version 13.1 (Stat Corp, 2013) was used to analyse the data. Monthly income was divided into tertiles and labelled as “high”, “medium”, and “low” income categories. The profile of exposures and outcomes was described using simple descriptive summary values. The number of women lost to follow up was 4.6% including missing data in outcome variables of seven women (Fig. ​(Fig.1).1). Thus, complete case analysis was used as it was suggested that less than 5% lost to follow up was of little concern [67, 68]. A diagram of sample recruitment procedure Binary logistic regression was used to examine the association between antenatal depressive symptoms and the outcome variables. Bayesian Information Criterion (BIC) test was used to test model goodness of fit as a result of which ‘number of ANC visits’ was removed from two models. Socio-demographic and socioeconomic variables, interpersonal and life adversities (IPV, lack of social support), obstetric and medical conditions (experience of adverse perinatal outcomes, pregnancy complications, comorbid medical conditions, pregnancy intention, experience of institutional delivery and birth preparedness) were included in all analyses as potential confounders. Ethical approval (ref. number: 024/14/psy dated 23/03/14) was obtained from the Institutional Review Board of the College of Health Sciences, Addis Ababa University. Women with a very high level of depressive symptoms (PHQ-9 ≥ 15) and those with suicidal ideation, as assessed by a particular item in the PHQ-9, were referred to health centres to access free primary care-based mental health services. Women with a PHQ-9 score above the validated cut off were not referred to health care facilities to avoid causing unnecessary concern among women with false positive symptoms, as the PHQ-9, as a screening tool, has low positive predictive validity [58, 69, 70].

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• bitew, tesera
• hanlon, charlotte
• kebede, eskinder
• honikman, simone
• onah, michael n.
• fekadu, abebaw