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Background: Effects of depression on parenting and on cognitive development of newborns are augmented when symptoms continue throughout the first postnatal year. Current classification systems recognize maternal depression as postnatal if symptoms commence within four to six weeks. Traditional cultural rituals in Sudan offer new mothers adequate family support in the first 6-8weeks postpartum. The course of postnatal depression symptoms beyond that period is not explored in such settings. We therefore aim to investigate the change in screening status and in severity of depression and distress symptoms between three and eight months postpartum among a sample of Sudanese women using the Edinburgh Postnatal Depression Scale (EPDS) and a locally used tool: the 10-items Hopkins Symptoms Checklist (HSCL-10). Methods: Three hundred pregnant women in their 2nd or 3rd trimester were recruited from two clinics in Khartoum state. They were followed up and screened for depression symptoms eight months after delivery by EPDS at ≥12, and by HSCL-10 at ≥1.85. The same sample was previously screened for depression at three months after birth. Results: Prevalence of postnatal depression symptoms by EPDS was lower at eight months compared to three months after birth (3.6% at eight months (8/223) compared to 9.2% at three months (22/238), p< 0.001). Eight Mothers exhibited depression symptoms eight months after birth. Depressed mothers at three months had a 56% reduction in EPDS mean scores by eight months and 96.4% of participants either remained in the same EPDS category, or improved eight months after birth. Four participants with major depression symptoms at eight months were also depressed three months after birth and four participants had new onset depression symptoms. The HSCL-10 measured higher distress than EPDS across the two screening points (19.3% at three months, 9.1% at eight months postpartum, p< 0.001). Nonetheless, the two tests correlated positively at both points. Conclusions: Repeated screenings by EPDS (depression surveillance) is recommended during the first postnatal year because a subset of mothers can have symptoms beyond the early postnatal period. Existing depression screening instruments can be assessed for their validity to detect PND.
This is a follow-up study of 300 women recruited during pregnancy. Women attending two antenatal clinics (ANC) in two major public tertiary hospitals consented to participate in the study. They were screened for symptoms of postnatal depression at three and eight months by EPDS and HSCL-10. The clinics provide routine antenatal care services for pregnant women living within or outside the hospitals’ catchment population. The hospitals were Omdurman Maternity Teaching Hospital and Ibrahim Malik Teaching Hospital. Compared to other states in Sudan, Khartoum state has the highest level of utilization of ANC services and the highest level of institutional deliveries as well [22]. Antenatal care attendance in Khartoum state is 88% [22]. This is the proportion of women that attend “at least one” ANC visit provided by a skilled provider. Women from all localities of Khartoum state can access services in Omdurman Maternity Hospital irrespective of their residence [23]. The sample size was calculated using the prevalence of PND in Nigeria, an African country with a similar social context to Sudan [24]. Inclusion criteria were women of Sudanese nationality, in their 2nd or 3rd trimester, of any parity and with full contact information (at least two working telephone numbers). Availability of two working phone numbers was imperative to improve follow-up rates through house visits, as the address system in that context was unclear. Illiteracy was not an exclusion criterion as data collection was via interviews. The study protocol was approved in Sudan by the Sudan Ministry of Health and in Norway by REK (Regional Committees for Medical and Health Research Ethics, reference no. 2013/353/REK). Recruitment was intermittent during the period of April 2013 until April 2014. More than 5000 women attended the clinics during that period; the principle investigator approached approximately 700 women. The attending physician screened attendants for the required gestational age and introduced the investigator to each prospective participant at the end of her ANC visit. Random sampling from a list of ANC attendees was not possible in that setting. Approximately four hundred women were not included: almost two hundred women refused to be part of a research study and the remaining were excluded due to none eligibility because they had no telephone number. No information was available of those who refused participation. Recruitment continued during that period until 300 women consented to participate in the study. They were interviewed at recruitment (T0), and screened at three months (T1) and eight months postpartum (T2). Figure 1 illustrates the follow-up process. A flow chart illustrating the follow-up process Full contact information was obtained at recruitment to optimize follow-up and screening rate for PND after delivery. Median age of women at recruitment was 28 years (range 15 to 43); 41% were between the ages of 15–25. Twelve percent held an occupation. The majority (215 women) had no previous employment (72%), 10% (31 women) had an occupation before marriage or childbirth, and 6% (17 women) were students. [21] At three months postpartum, participants were interviewed regarding circumstances of the index pregnancy. The interview was either face-to-face (at home or ANC clinic), or through phone. Phone interviews were conducted to minimize loss of follow-up only when women were away from Khartoum state or refused home interviews. The first EPDS and HSCL-10 screening was conducted at that time. A single interviewer conducted the interviews. As reported from a previous analysis in the same study [21], the response rate at T1 was 79.3% (62 participants were lost to follow-up). The loss to follow-up was due to personal refusal (14 participants), husband’s refusal (13 participants), and contact failure (35 participants). Participants lost to follow-up were not significantly different from participants who completed the follow-up in age (the median age was 27 years old for both groups), in parity (the median parity was 1.9 children and 1.8 children, respectively) or in educational level (Pearson chi-square p-value = 0.70) [21]. At eight months postpartum, 243 women were screened for PND with EPDS and HSCL-10 resulting in a follow-up rate of 81%. Fifty-seven women were lost in the second screening due to contact failure (27 participants), personal refusal (15 participants), and husband refusal (15 participants). The Edinburgh Postnatal Depression Scale (EPDS) is a self-reporting tool specifically developed for screening for symptoms of postnatal depression at primary healthcare level [25]. It has been translated and validated into 57 languages including Arabic [26–28]. We have validated the Arabic EPDS in this sample and we have described its validity indices against a diagnostic tool [21]. The EPDS screens for PND through ten inventory questions investigating new feelings felt by the mother within the previous seven days. Each question has four possible answers rated from 0 to 3 and the scale has a total score of 30. In this study, EPDS was administered through personal interviews and a test is “positive” for major depression if the woman scores 12 or more out of 30 as set by Cox et al. [25]. A cut-off point of ≥10 is optimum for screening for minor and major depression combined [25]. Combined subscale analysis of EPDS confirms that there is an anxiety scale embedded within the tool and that the whole 10 item tool measures both depression and anxiety [29]. Although it is a self-administered tool, studies have shown that administering EPDS through directed interviews is an equivalent screening technique [30]. According to Ghubash et al. [27], the Arabic EPDS has good internal consistency and reliability with a Cronbach’s coefficient of 0.84. In the current study, the Cronbach’s coefficient was 0.83. Prevalence of PND symptoms at T1 with the EPDS at ≥12 was 9.2% [21]. Validity indices of the EPDS were 89% sensitivity, 82% specificity, 98.7% NPV and 33% PPV [21]. Only a subsample of participants was clinically interviewed for assessment of their depression symptoms (the EPDS “test positives” at T1 and their matched controls). Clinically depressed participants were referred to the outpatient mental health clinic in Khartoum for further management. Originally the Hopkins Symptoms Checklist was a 58-item self-reporting inventory symptom checklist developed in the mid-1970s for psychological distress [31]. A ten items version as well as 35, 25 and five items versions were also developed and validated against the extended version and were found of equal performance [32, 33]. The first four items in the 10-item tool evaluate “anxiety” and the remaining six items “depression”. Each item has a 4-point scale ranging from “not at all” to “extremely”. The symptoms screened were in the seven days prior to screening. HSCL-10 final score is the average of the total score. The cut-off score for “distress” used in this study is ≥1.85 [32]. It has been translated to Arabic and validated on Arab speaking populations [34]. HSCL-10 is brief and simple. It has well-documented reliability and validity and is an easily administered instrument. In this analysis, it has an acceptable internal consistency of 0.77. Prevalence of major depression symptoms at eight months postpartum (T2) was calculated based on EPDS at a cut-off point ≥12/30. The prevalence of depression symptoms at T1 and T2 with EPDS at a cut-off score ≥ 10/30 was also explored (reflecting prevalence of major and minor depression combined). Prevalence of psychological distress with HSCL-10 at three months (T1) and eight months (T2) postpartum was calculated at a cut-off point ≥1.85. Correlation coefficients among scores of the two tests were computed. Numbers of new and continuous depression symptoms between the two screening points, based on EPDS, were calculated. The change in EPDS test status between T1 to T2 was analysed for its statistical significance (i.e. if individual scores and mean scores fell below cut-off score) and for its clinical reliability using the Reliability Change Index method (RCI) as described by Jacobson and Truax [35]. This analysis is on data of participants that completed follow-up at T1 and T2 (i.e. participants with complete follow-up).
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