The impact of depression at preconception on pregnancy planning and unmet need for contraception in the first postpartum year: a cohort study from rural Malawi

Background: The impact of depression on women’s use of contraception and degree of pregnancy planning in low-income settings has been poorly researched. Our study aims to explore if symptoms of depression at preconception are associated with unplanned pregnancy and nonuse of contraception at the point of conception and in the postpartum period. Methods: Population-based cohort of 4244 pregnant women in rural Malawi were recruited in 2013 and were followed up at 28 days, 6 months and 12 months postpartum. Women were asked about symptoms of depression in the year before pregnancy and assessed for depression symptoms at antenatal interview using the Self‐Reporting Questionnaire‐20, degree of pregnancy planning using the London Measure of Unplanned Pregnancy and use of contraception at conception and the three time points postpartum. Results: Of the 3986 women who completed the antenatal interview, 553 (13.9%) reported depressive symptoms in the year before pregnancy and 907 (22.8%) showed current high depression symptoms. History of depression in the year before pregnancy was associated with inconsistent use of contraception at the time of conception [adjusted relative risk (adjRR) 1.52; 95% confidence interval (1.24–1.86)] and higher risk of unplanned [adjRR 2.18 (1.73–2.76)] or ambivalent [adj RR 1.75 (1.36–2.26)] pregnancy. At 28 days post-partum it was also associated with no use of contraception despite no desire for a further pregnancy [adjRR 1.49 (1.13–1.97)] as well as reduced use of modern contraceptives [adj RR 0.74 (0.58–0.96)]. These results remained significant after adjusting for socio-demographic factors known to impact on women’s access and use of family planning services, high depression symptoms at antenatal interview as well as disclosure of interpersonal violence. Although directions and magnitudes of effect were similar at six and 12 months, these relationships were not statistically significant. Conclusions: Depression in the year before pregnancy impacts on women’s use of contraception at conception and in the early postpartum period. This places these women at risk of unplanned pregnancies in this high fertility, high unmet need for contraception cohort of women in rural Malawi. Our results call for higher integration of mental health care into family planning services and for a focus on early postnatal contraception. We conducted a secondary analysis of a cohort study set in rural Malawi to assess pregnancy intention and its relation to maternal, perinatal and neonatal outcomes [13, 14]. A population-based sample of 4244 pregnant women were recruited in 2013 and were followed up at 28 days, 6 months and 12 months postpartum. This study was conducted in the Mchinji District, a rural district in Malawi, in southern-central Africa, with a population over 530,000, 23% of whom are women of childbearing age (121,950). Around 90% of the population are subsistence farmers. Fertility rates in this region remain high, with a total fertility rate of 6.3 children per woman at the time the study was being conducted, yet the total wanted fertility rate was 4.6 children per woman, and there was a high unmet need for family planning (29.3% in married women) [15]. Family planning services are provided free of charge in Malawi through government health facilities, and are available for purchase through private clinics such as ‘Banja la Mtsogolo’, a Marie Stopes International Partner. On average women live almost 6 km from the nearest health facility; a distance often needed to be covered on foot [13]. Previous research divided Mchinji District into 49 geographical areas; from this sampling frame a random sample of 25 areas were selected. Eligible participants were all pregnant women aged 15 and over living within the district demographic surveillance areas selected between March and December 2013 [14]. Women were eligible to participate at any point during their pregnancy and were interviewed at home by trained data collectors, after giving informed consent, using a questionnaire programmed using CommCareODK software on a smartphone. 4244 pregnant women between two and nine months pregnant (median six, mean 5.98) completed the antenatal interview; 3986 (93.9%) were followed up at 28 days postpartum. This was a rolling cohort and was stopped when the last recruited woman reached the 28-day postpartum point. As women were recruited at different gestations, some women, but not all, were eligible and completed interviews at 6 months and 12 months postpartum. In the absence of a locally validated tool, we ascertained history of depression in the year before pregnancy by asking women at the antenatal interview if they had experienced 2 weeks or more of low mood or two weeks of more of anhedonia. A positive reply to any of these questions was defined as history of depression in the year preconception. Postnatal depression was assessed using the validated Chichewa version of the World Health Organization’s 20-question screening tool, the Self-Reporting Questionnaire 20 (SRQ 20). The SRQ 20 was previously found to be valid (Sensitivity = 76.3%, Specificity = 81.3%) and reliable (Cronbach’s α = 0.83) instrument for screening perinatal depression in Malawi [16]. In this study, a cut off score of ≥ 8 was used to determine depression before pregnancy [17]. The degree of intention of women’s current pregnancy was assessed using the London Measure of Unplanned Pregnancy (LMUP) at antenatal interview. By asking six questions, each scored zero, one or two, the LMUP scores pregnancy intention on a continuous scale from zero to 12 with each increase in score representing an increase in the degree of pregnancy intention [18]. The LMUP was validated for use in the Chichewa language in Malawi prior to the establishment of this cohort and found to be a valid and reliable measure of pregnancy intention in this setting [19]. Women’s scores were grouped into three categories unplanned, ambivalent and planned. At the antenatal questionnaire women were asked if in the month they became pregnant they were using contraception and how regularly. Postnatally women were asked if they were using family planning methods and which methods were being used. Contraceptive methods were classified as modern if they were products or medical procedure that interfere with reproduction from acts of sexual intercourse, therefore condoms, oral contraceptive pills, tubal ligation (postnatally), coil, injectable contraceptives and implants were classified as modern methods. Abstinence and withdrawal methods were considered traditional. Lactation amenorrhea (LAM) was considered traditional as although is a very effective method if practiced correctly, it is well acknowledged that often only a minority of women who report breastfeeding as a method of contraception meet the correct-practice criteria for LAM and this method is not considered effective after the early postpartum period [20]. Socio-economic and demographic factors known to impact on women’s unmet need for contraception were selected from available literature [21]. These included maternal age, education, marital status, distance to the health facility, socio-economic status, parity and religion. A principal components analysis (PCA) was conducted to generate an asset-based measure of socio-economic status (SES). In addition to ownership of assets such as a bicycle and radio, variables included in the PCA were household characteristics, such as floor and roof materials, household density, and access to water and sanitation facilities [14]. GPS readings of the location of the interview were taken and were used to calculate the distance to the nearest health facility, ‘as the crow flies’. Interpersonal Violence (IPV) was assessed using the Abuse Assessment Screen [22]. This asks about experience of abuse ever, in the last year or while pregnant as well as experience of sexual abuse. Stata version 15 software was used for data analysis [23]. Our analysis strategy was hypothesis-driven, using multinominal logistic regression to investigate the association between depression in the preconception year and use of contraception at conception; in early postpartum (28 days) and late postpartum period (at 6 and 12 months). Women who reported to be planning a pregnancy or no current partner were excluded from the analysis. These hypotheses were partially and fully adjusted for known confounders identified a priori, including demographic and socio-economic characteristics. The analysis of the relationship between depression at preconception and unmet need for contraception at 28 days postpartum was adjusted for high depression symptoms at pregnancy (SRQ score >  = 8) and the analysis for the relationship between depression at preconception and unmet need for contraception at 6 months was adjusted for high depression symptoms at pregnancy as well as in the early postpartum. Missing data on use of contraception (< 8% of total sample at 6 months) was addressed by case wise deletion at the analysis stage.