Maternal depression is associated with child undernutrition: A cross-sectional study in Ethiopia

Child undernutrition is widespread in low- and middle-income countries (LMIC) and is associated with health and economic losses. Undernutrition is estimated to contribute to 3.1 million deaths per year in children less than 5 years of age. A complex causal and contextual factors contributing to child undernutrition have been assessed, but maternal depression, which could contribute to child undernutrition by interfering with the mother’s child caring practice and ability, has been received little attention. The objective of this study was to assess the association between maternal postpartum depression symptoms and infant (5–10 months of age) stunting in northern Ethiopia. A community-based cross-sectional study was conducted among mother–infant pairs (n = 232) between March and April 2018. Through interviewer-administrated questionnaire, information on sociodemographic variables were collected, and maternal depression symptoms were assessed using the Edinburgh Postnatal Depression Scale (EPDS≥13). Infants’ length and weight were measured and converted to length and weight for age Z scores using the WHO growth standards. Breastfeeding was a norm, but the adequacy of complementary feeding practice was sub-optimal. Only 25% of the infants met the minimum meal frequency (MMF), less than 10% met the minimum dietary diversity (MMD; 9%) or minimum acceptable diet (7%). Maternal depression was prevalent (22.8%) and was significantly associated with inappropriate complementary feeding and stunting (P <.05). Improving complementary feeding practices is central to preventing stunting in this and other settings. However, such efforts should integrate interventions that address maternal depression to improve child feeding and caring practices to effectively prevent stunting. This community‐based cross‐sectional study was conducted between March and April 2018 in rural areas of northern Ethiopia. The region is characterized by high prevalence of child undernutrition, with a stunting prevalence of 46%, which is above the national average (38%) (CSA). The study was conducted in 10 kebeles (smallest administration unit) in the Meket district. A total of 238 households targeted for the Ethiopian government's Productive Safety Net Program (PSNP4) were included in this study using a multi‐stage sampling technique. Of the 27 kebeles in Meket district, 10 were randomly selected. A listing of PSNP4 households with infants 5–10 months of age was compiled through house‐to‐house visits, and a random sample in proportion to the size of the kebeles was selected. Being resident in the district and having an infant 5–10 months old were the eligibility criteria for participating in the study. The interviewees were mothers with infants 5–10 months. Data were collected by face‐to‐face interviews with the mother in a quiet room at the health post. Basic sociodemographic data such as age of the mother, marital status, estimated household's average monthly income, religion, educational status and occupation as well as other data concerning household economic status were collected. The Household Food Insecurity Access Scale (HFIAS) (Coates, Swindale, & Bilinsky, 2007) was used to assess household food insecurity during the 4 weeks preceding the survey. The households were categorized into four groups: food secure, mildly food insecure, moderately food insecure and severely food insecure. Finally, these were merged in to two groups: food secure and food insecure (mildly, moderately and severely) households. All anthropometric measurements were taken by the lead author. Length was measured to the nearest 0.1 cm using a portable wooden recumbent length board with a fixed head and sliding foot piece. Weight was measured to the nearest 0.01 kg, with an electronic scale (UNICEF Seca 770) with light clothing. Measurements were done in duplicate, and the mean value was calculated. Infant's age was recorded from the immunization card or birth certificate. However, in the absence of such documents, maternal recall with a calendar of events was used. Infant anthropometric status was calculated as length for age z‐score (LAZ), weight for length z‐score (WLZ) and weight for age z‐score (WAZ) (WHO, 2006) reference data. Household wealth index (low, medium and high) was constructed using principal component analysis (PCA). Selected household assets, ownership and number of livestock, materials used to build house and agricultural land size were used to calculate the index. The factor scores used explained 68.4% of the total variance in the household's wealth index. PCA was also used to calculate maternal workload. The 10 distinct laborious activities in the community in the preceding 1 week of the survey were included in the analysis. The variables included in the analysis were collecting firewood and fetching water (walking distance > 30 min), washing clothes, land preparation, weeding, manual mowing, threshing, grinding and pounding grain and terracing. The final components which explained 70.6% of the total variance were retained and women were classified into three categories (low, medium and heavy) of workload based on their scores. Data on infant feeding practices were assessed using the WHO IYCF indicators (WHO, 2008). Early initiation of breastfeeding, exclusive and continued breastfeeding, introduction to complementary foods and complementary feeding indicators such as MMF, MMD and minimum adequate diet were assessed. Foods consumed in the 24 h prior the survey were categorized into the following seven food groups to calculate the dietary diversity score: (i) grains, roots and tubers; (ii) legumes and nuts; (iii) dairy products; (iv) eggs; (v) flesh foods (meat, fish, poultry and organ meats); (vi) vitamin A‐rich fruits and vegetables; and (vii) other fruits and vegetables. The proportion of breastfed infants meeting the MMF (≥3) and the MMD score (≥4) was calculated. The place of delivery of the infant and immunization status was recalled by the mother, and whenever available was confirmed by checking the immunization cards. Infant illness (morbidity) and healthcare‐seeking practices of the mother were assessed through maternal recall of signs and symptoms related to acute respiratory infections, diarrhoea, cough and/or cold and fever over the 2 weeks prior the survey. Maternal depression was assessed using the Edinburgh Postnatal Depression Scale (EPDS) (Cox, Holden, & Sagovsky, 1987) which included 10 items. Mothers rated the extent to which each item matched their feelings during the 7 days prior to the survey. Possible scores ranges from 0 to 30, with higher scores indicating greater severity of depression. A score of 13 and above indicated the postnatal depression. The EPDS has been used as a screening tool for detecting postnatal depression in different cultures (Kakyo et al., 2012) and has been used in several African countries (Madeghe, Kimani, Stoep, Nicodimos, & Kumar, 2016; Ukaegbe, Iteke, Bakare, & Agbata, 2012; Yator, Mathai, der Stoep, Rao, & Kumar, 2016). A validation study in Ethiopia also demonstrated the acceptability and utility of the Amharic version for use as a screening tool for postnatal depression (Tesfaye, Hanlon, Wondimagegn, & Alem, 2009). The internal consistency measured by Cronbach’s alpha (0.80) was acceptable. Data were checked, coded and entered into SPSS, v. 20, for analysis. Categorical data were analysed by descriptive statistics (frequency and percentage), whereas range, mean and standard deviations were used to present continuous variables. The normal distribution of the data was checked with the Kolmogorov‐Smirnov test (Mishra et al., 2019). Bivariate analyses were conducted, and all variables with P < .25 were included in multivariate logistic regression. The model fit was checked using the Hosmer–Lemeshow goodness of fit test. Statistical significance was considered at the 95% confidence interval, and both crude and adjusted odds ratios are reported.