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The objective of the study was to investigate the association between maternal common mental disorder (CMD) and infant growth in rural Malawi. A cross-sectional study was conducted at a district hospital child health clinic. Participants were consecutive infants due for measles vaccination, and their mothers. Mean infant weight-for-age and length-for-age z-scores were compared between infants of mothers with and without CMD as measured using the self-reporting questionnaire (SRQ). Of 519 eligible infants/mothers, 501 were included in the analysis. Median infant age was 9.9 months. 29.9% of mothers scored 8 or above on the SRQ indicating CMD. Mean length-for-age z-score for infants of mothers with CMD (-1.50 SD 1.24) was significantly lower than for infants of mothers without CMD (-1.11 SD 1.12) Student’s t-test: P=0.001. This association was confirmed in multivariate analysis. Mean weight-for-age z-score for infants of mothers with CMD (-1.77 SD 1.16) was lower than for infants of mothers without CMD (-1.59 SD 1.09) but this difference was not significant on univariate (Student’s t-test: P=0.097) or multivariate analysis. The study demonstrates an association between maternal CMD and infant growth impairment in rural sub-Saharan Africa. © Journal compilation © 2008 Blackwell Publishing Ltd.
The study site was the child health clinic at Thyolo District Hospital, Malawi. This government hospital is situated in a rural district with a population of approximately 550 000 [NSO (Malawi) 2006]. The predominant work in the area is subsistence farming and employment on tea‐growing estates. The child health clinic is run according to World Health Organisation (WHO) Integrated Management of Childhood Illness guidelines. Infants are brought to the clinic for immunization, growth monitoring and medical assessment/treatment. The non‐governmental organization, Medicine Sans Frontiers (Belgium), supports a ‘Prevention of Mother to Child [HIV] Transmission’ (PMTCT) programme integrated into the government health service. The majority of pregnant women who attend Thyolo Hospital are tested at their first antenatal visit, and are aware of their HIV status. HIV positive mothers are offered ongoing health and infant feeding advice within the child health clinic. Mothers fulfilling disease progression criteria also have access to free anti‐retroviral treatment. Vaccination against measles is given to any non‐immunized child aged 9 months or over, irrespective of the primary reason for clinic attendance. Measles immunization coverage by 2 years of age in Malawi is 87% [NSO (Malawi) 2006]. In this study, all infants brought to the clinic were screened by the research fieldworkers while in the waiting area. Any infant who was due for measles immunization, and who had been brought to the clinic by his/her own mother, was recruited. Infants who were not accompanied by their mother, were too unwell to be immunized, or had obvious physical deformity, were excluded. Mothers who were not Chichewa speakers were also excluded. The purpose of the study was explained to each mother by a trained fieldworker, and written consent was obtained (or thumbprint for those mothers who were illiterate). Interviews were conducted in Chichewa, the official (and most widely spoken) language of Malawi. Mothers were administered a health and demographics questionnaire. Their weight, height and mid upper arm circumference (MUAC) were measured. Infant weight, length and MUAC were then measured. The mothers were next administered the Chichewa version of the self‐reporting questionnaire (SRQ) by a second fieldworker blind to infant weight‐for‐age or length‐for‐age z‐score. The SRQ is a WHO‐designed brief measure of CMD (WHO 1994). It consists of 20 questions with ‘yes/no’ answers exploring symptoms of depression, anxiety and somatic manifestations of distress. It has been validated for use in many developing countries. We undertook a rigorous process of forward and back translation, piloting and validation of the SRQ against the Structured Clinical Interview for DSM‐IV (SCID) (First et al. 2002) in a randomly selected group from the study sample (n = 114). SCID is a semi‐structured interview that determines formal diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders 4th edition classification. We used a score of 8 or more on the SRQ to define CMD, as we determined that this was the optimal cut‐off for detecting major and minor depressive episode. This was consistent with previous similar studies (Harpham et al. 2005). The two fieldworkers were experienced Chichewa‐speaking Malawian nurses. They were trained in administration of the SRQ, and were also given refresher training in anthropometric techniques by a paediatrician (JB). Infants were weighed naked on electronic scales accurate to 0.01 kg. Lengths were measured on a locally made calibrated length‐board by the two fieldworkers. Data were collected on variables that may act as confounders to any association between maternal CMD and poor infant growth. Infant weights and lengths were converted into weight‐for‐age and length‐for‐age z‐scores based on WHO standardized growth data (1978) using Epi‐Info. Univariate analyses compared mean weight‐for‐age and length‐for‐age z‐scores against maternal CMD and potential confounding variables (using Spearman correlation coefficients for continuous variables and Student’s t‐test for categorical variables). Those variables which could potentially confound the association between maternal CMD and the infant growth outcome measures (except those that would cause problematic multicollinearity) were entered into multiple regression analyses. All these variables were entered simultaneously into linear regression with mean substitution of missing data. Analyses were conducted using spss 13.0 (SPSS Inc. 2004). Of the variables included in the regressions, only HIV status had greater than 10% missing data (see last column of of1,1, ,2).2). Analyses were repeated with and without HIV status and those results are presented. Continuous variables associated with infant weight‐for‐age and length‐for‐age z‐scores on univariate analysis (Spearman Correlation Coefficients) Categorial variables associated with mean infant weight‐for‐age and length‐for‐age z‐scores on univariate analysis (Student’s t‐test) Based on estimates from studies in developing world settings, we assumed a prevalence of maternal CMD of 20% among mothers of normal weight children, and 40% among mothers of underweight infants (Rahman et al. 2004b). To detect this difference with 95% confidence and 80% power, a total of 91 infants in each group would be required. Ethical Approval for the study was given by the University of Manchester Research Ethics Committee, UK, and the College of Medicine Research Ethics Committee, Malawi.
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