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Objectives: To assess the impact of probable depression in the immediate postnatal period on subsequent infant mortality and morbidity. Design: Cohort study nested within 4 weekly surveillance of all women of reproductive age to identify pregnancies and collect data on births and deaths. Setting: Rural/periurban communities within the Kintampo Health Research Centre study area of the Brong-Ahafo Region of Ghana. Participants: 16 560 mothers who had a live singleton birth reported between 24 March 2008 and 11 July 2009, who were screened for probable postnatal depression (pPND) between 4 and 12 weeks post partum (some of whom had also had depression assessed at pregnancy), and whose infants survived to this point. Primary/secondary outcome measures: All-cause early infant mortality expressed per 1000 infant-months of follow-up from the time of postnatal assessment to 6 months of age. The secondary outcomes were (1) all-cause infant mortality from the time of postnatal assessment to 12 months of age and (2) reported infant morbidity from the time of the postnatal assessment to 12 months of age. Results: 130 infant deaths were recorded and singletons were followed for 67 457.4 infant-months from the time of their mothers’ postnatal depression assessment. pPND was associated with an almost threefold increased risk of mortality up to 6 months (adjusted rate ratio (RR), 2.86 (1.58 to 5.19); p=0.001). The RR up to 12 months was 1.88 (1.09 to 3.24; p=0.023). pPND was also associated with increased risk of infant morbidity. Conclusions: There is new evidence for the association between maternal pPND and infant mortality in low-income and middle-income countries. Implementation of the WHO’s Mental Health Gap Action Programme (mhGAP) to scale up packages of care integrated with maternal health is encouraged as an important adjunct to child survival efforts.
DON is a cohort study of perinatal Depression nested within the ObaapaVitA12 and Newhints13 cluster randomised controlled trials conducted in seven contiguous districts in the Brong-Ahafo Region of Ghana. The ObaapaVitA trial evaluated the effect of weekly vitamin A supplementation in women of reproductive age on maternal mortality, and the Newhints trial assessed the impact of home visits by lay community health volunteers on neonatal mortality. These trials were supported by 4 weekly home surveillance of women of reproductive age to identify pregnancies, births, infant and maternal deaths and morbidity information. DON was carried out from late January 2008 to early August 2009, and comprised depression assessments in the 4 weekly surveillance visits following identification of pregnancy and in the visits following reporting of a delivery. Both trials were registered with clinicaltrials.gov: ObaapaVitA, number {“type”:”clinical-trial”,”attrs”:{“text”:”NCT00211341″,”term_id”:”NCT00211341″}}NCT00211341; Newhints, number {“type”:”clinical-trial”,”attrs”:{“text”:”NCT00623337″,”term_id”:”NCT00623337″}}NCT00623337. The study area covers a population of about 700 00014 with more than 120 000 women of reproductive age,13 and more than 15 000 births a year. The infant mortality rate (IMR) is 63/1000 child-years and the neonatal mortality rate is 31/1000 live births.12 The area is predominantly rural, but has four medium-sized towns (populations of at least 40 000). Routine identification and treatment for antenatal/postnatal depression in primary care does not exist. Access to orthodox mental health services is limited, and help for mental ill health is generally provided by traditional healers and spiritual/healing churches.15 Participants were mothers who had a live birth reported between 24 March 2008 and 11 July 2009, who were screened for probable postnatal depression between 4 and 12 weeks post partum (some of whom had also had depression assessed at pregnancy), and whose infants survived to this point. Data were collected through the surveillance system supporting the ObaapaVitA and Newhints trials, in which all women of reproductive age were visited every 4 weeks by resident fieldworkers, who collected data on pregnancies, births and deaths. The sociodemographic, socioeconomic, pregnancy and obstetric history data were collected when a pregnancy was identified, and a pregnancy depression assessment was conducted at the next 4 weekly visit. Information about the pregnancy, delivery, the baby (or babies) and the newborn care practices was collected at the first visit after the birth. A postnatal assessment was carried out at the following 4 weekly visit. Subsequent 4 weekly visits were made to collect data on the infant until their first birthday. The assessments of antenatal and postnatal depression were made by administering the Twi (widely spoken language in Ghana and the study area) version of the nine-item Patient Health Questionnaire (PHQ-9). The PHQ-9 is a structured questionnaire that enquires after the nine symptom-based criteria for a probable diagnosis of Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV)16 depression, duration and severity of the symptoms. Symptoms reported as present for at least half the time in the previous 2 weeks are rated positively. Either depression or anhedonia (loss of interest or pleasure) must be rated, with a total of five or more symptoms for major depression and two to four symptoms for minor depression. In contrast with symptom-based scale scores, these criteria therefore identify individuals with persistent and pervasive symptoms, characteristic of a clinically significant depressive episode. In its initial review, it recorded sensitivity and specificity of 0.88 at a cut-off of 10,16 and high positive predictive value.17 The PHQ-9 has been previously validated among women who recently delivered within the same study population and showed superior psychometric properties when compared with the Edinburgh Postnatal Depression Scale18—it recorded a sensitivity of 0.94 and specificity of 0.75 at a cut-off of 5. As part of the cross-cultural adaptation of the PHQ-9 to the study setting referred to above, qualitative accounts supported the construct of depression that existed in this setting, as mothers referred to the experience as a ‘worrying’ or ‘thinking’ sickness. Outcomes were assessed every 4 weeks by resident fieldworkers until 1 year after birth and, in one of these visits, a postnatal depression assessment was also completed. The primary outcome was all-cause early infant mortality expressed per 1000 infant-months of follow-up from the time of postnatal assessment to 6 months of age. The secondary outcomes were (1) all-cause infant mortality from the time of postnatal assessment to 12 months of age and (2) reported infant morbidity from the time of the postnatal DON assessment to 12 months of age. Morbidity indicators were: any ill health on the day of visit; any serious illness in the past month requiring care-seeking outside the home; and occurrence in the past 24 h of diarrhoea, vomiting, cough, fever and frequent crying. A priori potential confounders were: maternal characteristics (age, marital status, education status, occupation, ethnicity, religion and rural or urban residence); pregnancy and obstetric variables (parity, preterm delivery and mode of delivery); and infant characteristics (sex and perceived size of baby as a proxy for birth weight). In addition, an overall socioeconomic ‘score’ for each woman was generated using factor analysis techniques after the methods described by Vyas and Kumaranayake.19 Briefly, this score is based on household possession/absence of a set of assets grouped under several themes including ownership of land, animals, presence of electricity and/or electrical goods, water source, type of latrine, number of residents per room and materials used in construction of housing. Principal component analysis (using the correlation matrix to ensure that all included variables had equal weight) was then performed to assign each asset a factor score based on the strength of its correlation to the first principle component (which is assumed to be the optimal measure of economic status). Individual asset factor scores were summed for each woman to provide a measure of her overall socioeconomic score, where the higher the score, the higher the assumed economic status of the household. Women were ranked according to these socioeconomic scores into wealth quintile groups. Intervention status was not included as prevalence of postnatal depression was comparable in the intervention and control arms of the Newhints trial. Multiple births were excluded from all analyses given the high risk associated with infant mortality, particularly in Africa,20 and the possible association with probable postnatal depression.21 Poisson regression was used to examine the association between probable postnatal depression and infant mortality, adjusting for the a priori potential confounders listed above. In addition, we tested for the moderating effect of relevant covariates by fitting appropriate interaction terms in the model. In order to account for the possible influence of reverse causality from illness that culminated in the deaths that occurred close to ascertainment of probable postnatal depression status, we conducted sensitivity analyses excluding those deaths that occurred, first within 1 week and second within 30 days after postnatal depression assessment. Only those babies whose deaths were ascertained within the period of follow-up were included in the analyses. Additional analyses compared infant mortality between: women not depressed at either antenatal or postnatal assessments, women depressed only at antenatal assessment, women depressed only at postnatal assessment and those depressed at both. Kaplan-Meier survivor function was used to plot cumulative infant survival graphs for the four groups from birth until 12 months of age, excluding any deaths that occurred before the postnatal depression assessment. For the association between probable postnatal depression and infant morbidity, we used mixed-effects repeated measures logistic regression models with random intercept at the infant level, including the same potential confounders aforementioned, plus month of visit. The delta method was applied to predict risk/rate ratios (RR) with 95% CIs for individuals with zero random effect using the marginal standardisation technique.22 We also estimated the attributable risk per cent (percentage of early infant deaths among women with probable postnatal depression, ie, attributed to exposure to probable postnatal depression) and the population attributable fraction (percentage of early infant deaths that would be prevented if the effect of probable postnatal depression is removed). All analyses were conducted using STATA V.11.23 Informed consent (by signature or thumbprint) was obtained for each woman.
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