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Objectives: Maternal mental health is a neglected issue in Sudanese healthcare. The aim of this study was to explore the factors associated with postnatal depression (PND) at 3 months postpartum in a sample of Sudanese women in Khartoum state. Setting: Recruitment was from two major public antenatal care (ANC) clinics in two maternity teaching hospitals in Khartoum state. The study participants were recruited during their pregnancy and were followed up and screened for PND at 3 months postpartum using the Edinburgh Postnatal Depression Scale (EPDS). Participants: A sample of 300 pregnant Sudanese women in their second or third trimester was included in the study. The inclusion criteria were Sudanese nationality, pregnancy in the second or third trimester and satisfactory contact information. Outcome measures: PND was assessed using the EPDS at a cut-off score of ≥12. Maternal and sociodemographic factors of interest were illustrated in a directed acyclic graph (DAG) to identify which variables to adjust for in multivariate analyses and to show their type of effect on PND. A forward logistic regression model was built to assess the factors that are independently associated with PND. Results: History of violence increased the odds of PND sevenfold, OR=7.4 (95% CI 1.9 to 27.6). Older age of mothers decreased the odds of PND by almost 20%, OR=0.82 (95% CI 0.73 to 0.92). Exclusive breast feeding and regular prenatal vitamins during pregnancy are associated with an 80% decrease in odds of PND, OR=0.2 (95% CI 0.06 to 0.70) and 0.17 (95% CI 0.06 to 0.5), respectively. Conclusions: Factors associated with PND in this study are comparable to factors from other developing countries, although findings should be judged with caution owing to the high number of women who refused recruitment into the study.
This was a cross-sectional study of 300 participants recruited during pregnancy with demographic data and contact information collected at recruitment. At 3 months after delivery, we screened 238 participants for PND with the EPDS at a cut-off score of ≥12. We also collected data on the proposed factors of associations (eg, obstetrical and medical complications during pregnancy or birth, place of delivery, regular uptake of vitamins during pregnancy, sex of the newborn, puerperal complications and circumstances after birth). The sample size was calculated using the prevalence of PND in Nigeria, a neighbouring African country with a similar social context to Sudan.16 The prevalence of PND in Nigeria is comparable with the pooled prevalence of postpartum common mental disorders reported in 2012 by the WHO’s systematic review of perinatal mental disorders from developing and underdeveloped countries.6 Women presenting at two antenatal clinics in two major public tertiary hospitals were invited to participate in the study, and the hospitals chosen were Omdurman Maternity Teaching Hospital (90% of total sample) and Ibrahim Malik Teaching Hospital (10% of the sample). Khartoum state has the highest level of utilisation of antenatal care (ANC) services in Sudan and the highest level of institutionally based deliveries as well.17 ANC attendance in Khartoum state is 88%,17 which indicates the proportion of women who attend ‘at least one’ ANC visit with a skilled provider during a pregnancy. Women from all localities of Khartoum state can access ANC services in Omdurman Maternity Hospital because access does not depend on the location of residence.18 The inclusion criteria were women of Sudanese nationality residing in Khartoum state, in the second or third trimester, of any parity and with full contact information (at least two working telephone numbers). Illiteracy was not an exclusion criterion as data collection was via interviews. Recruitment was intermittent during the period from April 2013 to April 2014. Hospital records showed that almost 5000 women attended the clinics during that year. We approached candidates after the completion of their physical examination. The examining physician introduced the principal investigator to each candidate, and we approached and assessed 700 pregnant women for eligibility (figure 1). Two hundred women were excluded owing to insufficient contact information (unavailability of mobile or home phone numbers), a non-Sudanese nationality and being in their first trimester. Among the 500 women who satisfied inclusion criteria, 200 refused to participate in the study. The final sample for follow-up was 300 (60%), that is, the first interview (T0). A total of 238 women completed the follow-up at 3 months postpartum, that is, the second interview (T1). Last, no information was available for us on the 200 women that refused participation into the study. Flow chart of the number of participants in the study. Information was collected at recruitment on sociodemographic data, as full contact information was obtained at that time to secure follow-up and screening for PND after delivery. At 3 months, 238 participants were screened for PND with the EPDS.15 Interviews were done either face-to-face or through phone interviews. Phone interviews were conducted to minimise the loss of follow-up only when women were away from Khartoum state or refused home visits. As reported from a previous analysis in the same study,15 the follow-up rate at 3 months postpartum was 79%. Moreover, the loss to follow-up was due to personal refusal (4.7%), the husband’s refusal (4.7%) and contact failure (11.3%). Participants who lost to follow-up were not significantly different from women who completed the follow-up in age (the mean age was 27 and 28 years, respectively), in parity (the median parity was 1.9 children and 1.8 children, respectively) or in educational level (Pearson χ2 p value=0.705). The EPDS is a reliable and validated screening tool for PND developed for use at the primary healthcare level19 and has been translated and validated into 57 languages, including Arabic.20 It is a screening test consisting of 10 inventory questions that investigate feelings occurring within the previous 7 days with each question having 4 possible answers rated from 0 to 3. A woman is considered ‘test positive’ for PND if she scores 12 or more out of 30 as set by Cox et al.19 The tool was originally designed to be self-administered, but studies have shown that screening through directed interviews is an equivalent screening technique.21 Ghubash et al, the first authors to translate the EPDS into the Arabic language, stated that EPDS had a Cronbach’s coefficient of 0.84. In the current study, the Cronbach’s coefficient of the EPDS is 0.83. In addition to sociodemographic information, data on certain variables of interest were collected. Data were collected on the history of any psychological condition, history of violence, place of stay after birth, supportive person after birth, newborn gender and characteristics, complication during pregnancy and birth, planning of current pregnancy, regular uptake of prenatal vitamins, breastfeeding practices, circumstances during and after pregnancy and satisfaction with current quality of life. The analysis in this article was done after validation of the EPDS screening tool on the same sample. We constructed an initial directed acyclic graph (DAG) for a number of variables of interest (see figure 2). The aim of the analysis was to investigate multiple independent associations with PND using logistic regression. Crude measures of association between each variable and PND were first analysed by χ2/t tests and Mantel–Haenszel (crude) ORs. A multivariable regression model was then built using a forward regression selection approach. The variable with the smallest overall p value from the crude analysis was selected first and incorporated into the model. Next, each variable was included in the model in turn and a likelihood ratio test (LRT) was performed. The process was repeated until only variables with p>0.05 remained. The model was based on complete observations on all variables of interest, and interaction between the final variables in the model was also tested. A DAG was drawn with the model variables to interpret the type of effect each variable has on PND. A DAG of the factors of interest in the analysis. DAG, directed acyclic graph.
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