Determinants of postnatal depression in Sudanese women at 3 months postpartum: A cross-sectional study

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Study Justification:
– Maternal mental health is a neglected issue in Sudanese healthcare.
– This study aims to explore the factors associated with postnatal depression (PND) in Sudanese women at 3 months postpartum.
– The study will provide valuable insights into the determinants of PND in Sudanese women and contribute to the understanding of maternal mental health in the country.
Highlights:
– History of violence increases the odds of PND sevenfold.
– Older age of mothers decreases the odds of PND by almost 20%.
– Exclusive breastfeeding and regular prenatal vitamins during pregnancy are associated with an 80% decrease in odds of PND.
Recommendations:
– Increase awareness and education about the risk factors and consequences of PND among healthcare providers, pregnant women, and their families.
– Implement interventions to address violence against women and provide support for victims.
– Promote regular prenatal care and encourage the uptake of prenatal vitamins.
– Support and promote exclusive breastfeeding practices.
Key Role Players:
– Healthcare providers: Obstetricians, gynecologists, psychologists, psychiatrists, nurses, midwives.
– Policy makers: Ministry of Health, Ministry of Women’s Affairs, Ministry of Social Welfare.
– Non-governmental organizations (NGOs): Women’s rights organizations, mental health organizations.
– Community leaders and influencers: Religious leaders, community elders, community health workers.
Cost Items for Planning Recommendations:
– Training and capacity building for healthcare providers on identifying and addressing PND.
– Awareness campaigns and educational materials for pregnant women and their families.
– Support services for victims of violence, including counseling and legal assistance.
– Provision of prenatal vitamins and promotion of their use.
– Support for breastfeeding initiatives, including lactation consultants and breastfeeding support groups.
– Research and evaluation to monitor the effectiveness of interventions.
Please note that the cost items provided are general suggestions and may vary based on the specific context and resources available in Sudan.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is rated 7 because it is based on a cross-sectional study with a sample size of 300 participants. The study used the Edinburgh Postnatal Depression Scale (EPDS) to assess postnatal depression (PND) at 3 months postpartum. The study found that a history of violence increased the odds of PND, while older age of mothers, exclusive breastfeeding, and regular prenatal vitamin intake decreased the odds of PND. However, the study acknowledges limitations, such as the high number of women who refused recruitment. To improve the evidence, future studies could consider using a larger sample size, conducting a longitudinal study design, and addressing the limitations mentioned.

Objectives: Maternal mental health is a neglected issue in Sudanese healthcare. The aim of this study was to explore the factors associated with postnatal depression (PND) at 3 months postpartum in a sample of Sudanese women in Khartoum state. Setting: Recruitment was from two major public antenatal care (ANC) clinics in two maternity teaching hospitals in Khartoum state. The study participants were recruited during their pregnancy and were followed up and screened for PND at 3 months postpartum using the Edinburgh Postnatal Depression Scale (EPDS). Participants: A sample of 300 pregnant Sudanese women in their second or third trimester was included in the study. The inclusion criteria were Sudanese nationality, pregnancy in the second or third trimester and satisfactory contact information. Outcome measures: PND was assessed using the EPDS at a cut-off score of ≥12. Maternal and sociodemographic factors of interest were illustrated in a directed acyclic graph (DAG) to identify which variables to adjust for in multivariate analyses and to show their type of effect on PND. A forward logistic regression model was built to assess the factors that are independently associated with PND. Results: History of violence increased the odds of PND sevenfold, OR=7.4 (95% CI 1.9 to 27.6). Older age of mothers decreased the odds of PND by almost 20%, OR=0.82 (95% CI 0.73 to 0.92). Exclusive breast feeding and regular prenatal vitamins during pregnancy are associated with an 80% decrease in odds of PND, OR=0.2 (95% CI 0.06 to 0.70) and 0.17 (95% CI 0.06 to 0.5), respectively. Conclusions: Factors associated with PND in this study are comparable to factors from other developing countries, although findings should be judged with caution owing to the high number of women who refused recruitment into the study.

This was a cross-sectional study of 300 participants recruited during pregnancy with demographic data and contact information collected at recruitment. At 3 months after delivery, we screened 238 participants for PND with the EPDS at a cut-off score of ≥12. We also collected data on the proposed factors of associations (eg, obstetrical and medical complications during pregnancy or birth, place of delivery, regular uptake of vitamins during pregnancy, sex of the newborn, puerperal complications and circumstances after birth). The sample size was calculated using the prevalence of PND in Nigeria, a neighbouring African country with a similar social context to Sudan.16 The prevalence of PND in Nigeria is comparable with the pooled prevalence of postpartum common mental disorders reported in 2012 by the WHO’s systematic review of perinatal mental disorders from developing and underdeveloped countries.6 Women presenting at two antenatal clinics in two major public tertiary hospitals were invited to participate in the study, and the hospitals chosen were Omdurman Maternity Teaching Hospital (90% of total sample) and Ibrahim Malik Teaching Hospital (10% of the sample). Khartoum state has the highest level of utilisation of antenatal care (ANC) services in Sudan and the highest level of institutionally based deliveries as well.17 ANC attendance in Khartoum state is 88%,17 which indicates the proportion of women who attend ‘at least one’ ANC visit with a skilled provider during a pregnancy. Women from all localities of Khartoum state can access ANC services in Omdurman Maternity Hospital because access does not depend on the location of residence.18 The inclusion criteria were women of Sudanese nationality residing in Khartoum state, in the second or third trimester, of any parity and with full contact information (at least two working telephone numbers). Illiteracy was not an exclusion criterion as data collection was via interviews. Recruitment was intermittent during the period from April 2013 to April 2014. Hospital records showed that almost 5000 women attended the clinics during that year. We approached candidates after the completion of their physical examination. The examining physician introduced the principal investigator to each candidate, and we approached and assessed 700 pregnant women for eligibility (figure 1). Two hundred women were excluded owing to insufficient contact information (unavailability of mobile or home phone numbers), a non-Sudanese nationality and being in their first trimester. Among the 500 women who satisfied inclusion criteria, 200 refused to participate in the study. The final sample for follow-up was 300 (60%), that is, the first interview (T0). A total of 238 women completed the follow-up at 3 months postpartum, that is, the second interview (T1). Last, no information was available for us on the 200 women that refused participation into the study. Flow chart of the number of participants in the study. Information was collected at recruitment on sociodemographic data, as full contact information was obtained at that time to secure follow-up and screening for PND after delivery. At 3 months, 238 participants were screened for PND with the EPDS.15 Interviews were done either face-to-face or through phone interviews. Phone interviews were conducted to minimise the loss of follow-up only when women were away from Khartoum state or refused home visits. As reported from a previous analysis in the same study,15 the follow-up rate at 3 months postpartum was 79%. Moreover, the loss to follow-up was due to personal refusal (4.7%), the husband’s refusal (4.7%) and contact failure (11.3%). Participants who lost to follow-up were not significantly different from women who completed the follow-up in age (the mean age was 27 and 28 years, respectively), in parity (the median parity was 1.9 children and 1.8 children, respectively) or in educational level (Pearson χ2 p value=0.705). The EPDS is a reliable and validated screening tool for PND developed for use at the primary healthcare level19 and has been translated and validated into 57 languages, including Arabic.20 It is a screening test consisting of 10 inventory questions that investigate feelings occurring within the previous 7 days with each question having 4 possible answers rated from 0 to 3. A woman is considered ‘test positive’ for PND if she scores 12 or more out of 30 as set by Cox et al.19 The tool was originally designed to be self-administered, but studies have shown that screening through directed interviews is an equivalent screening technique.21 Ghubash et al, the first authors to translate the EPDS into the Arabic language, stated that EPDS had a Cronbach’s coefficient of 0.84. In the current study, the Cronbach’s coefficient of the EPDS is 0.83. In addition to sociodemographic information, data on certain variables of interest were collected. Data were collected on the history of any psychological condition, history of violence, place of stay after birth, supportive person after birth, newborn gender and characteristics, complication during pregnancy and birth, planning of current pregnancy, regular uptake of prenatal vitamins, breastfeeding practices, circumstances during and after pregnancy and satisfaction with current quality of life. The analysis in this article was done after validation of the EPDS screening tool on the same sample. We constructed an initial directed acyclic graph (DAG) for a number of variables of interest (see figure 2). The aim of the analysis was to investigate multiple independent associations with PND using logistic regression. Crude measures of association between each variable and PND were first analysed by χ2/t tests and Mantel–Haenszel (crude) ORs. A multivariable regression model was then built using a forward regression selection approach. The variable with the smallest overall p value from the crude analysis was selected first and incorporated into the model. Next, each variable was included in the model in turn and a likelihood ratio test (LRT) was performed. The process was repeated until only variables with p>0.05 remained. The model was based on complete observations on all variables of interest, and interaction between the final variables in the model was also tested. A DAG was drawn with the model variables to interpret the type of effect each variable has on PND. A DAG of the factors of interest in the analysis. DAG, directed acyclic graph.

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

1. Telemedicine: Implementing telemedicine services can allow pregnant women in remote areas to access healthcare professionals and receive prenatal care through virtual consultations. This can help overcome geographical barriers and increase access to maternal health services.

2. Mobile health (mHealth) applications: Developing mobile applications that provide information and resources on maternal health can empower women to take control of their own health. These apps can offer guidance on prenatal care, nutrition, exercise, and provide reminders for important appointments and medication.

3. Community health workers: Training and deploying community health workers who can provide basic prenatal care, education, and support to pregnant women in underserved areas can help improve access to maternal health services. These workers can also act as a bridge between the community and healthcare facilities, ensuring that women receive the care they need.

4. Maternal health clinics: Establishing dedicated maternal health clinics in areas with limited access to healthcare facilities can provide comprehensive prenatal care, including screenings, vaccinations, and counseling. These clinics can also offer postnatal care and support for new mothers.

5. Public-private partnerships: Collaborating with private healthcare providers and organizations can help expand access to maternal health services. This can involve subsidizing costs, providing training and resources, and leveraging existing infrastructure to reach more women in need.

It’s important to note that these recommendations are general and may need to be tailored to the specific context and challenges faced in Sudan.
AI Innovations Description
The study titled “Determinants of postnatal depression in Sudanese women at 3 months postpartum: A cross-sectional study” aimed to explore the factors associated with postnatal depression (PND) in Sudanese women. The study was conducted in Khartoum state, with participants recruited from two major public antenatal care (ANC) clinics in two maternity teaching hospitals.

The study included a sample of 300 pregnant Sudanese women in their second or third trimester. The participants were followed up and screened for PND at 3 months postpartum using the Edinburgh Postnatal Depression Scale (EPDS). The EPDS is a reliable and validated screening tool for PND.

The study found several factors associated with PND. History of violence increased the odds of PND sevenfold, while older age of mothers decreased the odds of PND by almost 20%. Exclusive breastfeeding and regular prenatal vitamin intake during pregnancy were associated with an 80% decrease in the odds of PND.

The study highlights the importance of addressing maternal mental health in Sudanese healthcare. To improve access to maternal health and address postnatal depression, the following recommendations can be considered:

1. Increase awareness and education: Implement educational programs to raise awareness about postnatal depression among healthcare providers, pregnant women, and their families. This can help in early identification and intervention.

2. Strengthen support systems: Develop support systems for pregnant women and new mothers, including counseling services, peer support groups, and community-based programs. These support systems can provide emotional support and guidance to women experiencing postnatal depression.

3. Improve screening and detection: Integrate routine screening for postnatal depression into antenatal and postnatal care services. Train healthcare providers to use validated screening tools, such as the EPDS, to identify women at risk of postnatal depression.

4. Enhance access to mental health services: Ensure that mental health services are readily available and accessible to women experiencing postnatal depression. This can include increasing the number of mental health professionals, establishing specialized clinics, and integrating mental health services into primary healthcare settings.

5. Address social determinants: Address underlying social determinants of postnatal depression, such as violence against women, by implementing policies and programs aimed at preventing and addressing gender-based violence.

By implementing these recommendations, access to maternal health can be improved, and the burden of postnatal depression can be reduced in Sudanese women.
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 raise awareness about maternal mental health issues, including postnatal depression, among healthcare providers, pregnant women, and their families. This can be done through community outreach, educational campaigns, and training programs for healthcare professionals.

2. Improve screening and identification: Develop standardized screening protocols for postnatal depression in healthcare settings, including antenatal care clinics and maternity hospitals. Train healthcare providers to effectively identify and assess women at risk of postnatal depression using validated screening tools such as the Edinburgh Postnatal Depression Scale (EPDS).

3. Enhance support systems: Establish support systems for women experiencing postnatal depression, including counseling services, peer support groups, and referral networks. Collaborate with community organizations and mental health professionals to provide comprehensive support for women and their families.

4. Strengthen antenatal care services: Ensure that antenatal care services are accessible, comprehensive, and culturally sensitive. This includes providing regular prenatal check-ups, promoting healthy behaviors during pregnancy, and addressing any obstetrical and medical complications that may increase the risk of postnatal depression.

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

1. Define the target population: Identify the specific population that will be affected by the recommendations, such as pregnant women in a certain region or healthcare providers in a particular setting.

2. Collect baseline data: Gather data on the current state of access to maternal health services, including rates of postnatal depression, utilization of antenatal care, and availability of support systems.

3. Develop a simulation model: Create a mathematical or computational model that represents the interactions and dynamics of the target population, healthcare system, and recommended interventions. This model should incorporate relevant variables and parameters, such as population demographics, healthcare resources, and the effectiveness of the interventions.

4. Validate the model: Validate the simulation model by comparing its outputs with real-world data or expert opinions. Adjust the model parameters and assumptions as needed to ensure its accuracy and reliability.

5. Implement the recommendations in the model: Introduce the recommended interventions into the simulation model and simulate their impact on access to maternal health. This can be done by adjusting relevant variables, such as the coverage and effectiveness of the interventions, and running the simulation over a specified time period.

6. Analyze the results: Analyze the simulation results to assess the impact of the recommendations on improving access to maternal health. This may include evaluating changes in rates of postnatal depression, utilization of antenatal care, and availability of support systems.

7. Refine and iterate: Use the simulation results to refine the recommendations and the simulation model itself. Iterate the process by incorporating new data, adjusting parameters, and running additional simulations to further optimize the interventions and their impact on access to maternal health.

By following this methodology, stakeholders can gain insights into the potential benefits and challenges of implementing the recommended innovations to improve access to maternal health.

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