Postpartum depressive symptoms in the context of high social adversity and reproductive health threats: A population-based study

International Journal of Mental Health Systems, Volume 12, No. 1, Year 2018

Ukuhunyushwa

Background: Postpartum depression is an important but neglected public health issue in low- and middle-income countries. The aim of this study was to assess postpartum depressive (PPD) symptoms and associated factors in a rural Ethiopian setting characterized by high social adversity and reproductive health threats. We hypothesized that infant gender preference would be associated with PPD symptoms. Methods: A cross-sectional, population-based study was conducted in Sodo district, southern Ethiopia, between March and June 2014. A total of 3147 postpartum women (one to 12 months after delivery) were recruited and interviewed in their homes. The questionnaire included demographic, reproductive health and psychosocial factors in addition to a culturally validated measure of depressive symptoms, the Patient Health Questionnaire. Scores of 5 or more were indicative of high levels of PPD symptoms. Results: The prevalence of high PPD symptoms was 12.2%, with 95% confidence interval (CI) between 11.1 and 13.4. Of these, 12.0% of the study participants had suicidal ideation. Preference of the husband for a boy baby was associated with PPD symptoms in univariate analysis (crude odds ratio 1.43: 95% CI 1.04, 1.91) but became non-significant after adjusting for confounders. In the final multivariable analysis, rural residence [adjusted odds ratio (aOR) 2.56: 95% CI 2.56, 4.19], grand multiparity (aOR 2.00: 1.22, 3.26), perinatal complications (aOR: 2.55: 1.89, 3.44), a past history of abortion (aOR 1.50: 1.07, 2.11), experiencing hunger in the preceding 1 month (aOR 2.38: 1.75, 3.23), lower perceived wealth (aOR 2.11: 1.19, 3.76), poor marital relationship (aOR 2.47: 1.79, 3.42), and one or more stressful events in the preceding 6 months (aOR 2.36: 1.82, 3.06) were associated significantly with high PPD symptoms. Conclusion: PPD symptoms affected more than one in 10 women in this Ethiopian community setting. Social adversity and reproductive health threats were associated with poorer mental health. Interventions focusing on poor rural women with low access to care are necessary. This research can serve as an entry point for the adaptation of a psychosocial intervention. The study was conducted in Sodo district, of the Gurage zone, Southern Nations, Nationalities and Peoples’ Region (SNNPR) of Ethiopia. SNNPR is one of the largest regions in Ethiopia, accounting for more than 10 percent of the country’s land area. The SNNPR is an extremely ethnically diverse region of Ethiopia. These ethnic groups are distinguished by different languages, cultures and socioeconomic organizations. The Gurage zone has 15 districts. Sodo district is the second largest in terms of population (161,952 persons; 79,356 men and 82,596 women), with 88% of the population residing in rural areas [38] and comprises 58 sub-districts. It is located about 100 km south of the capital city, Addis Ababa. In Sodo district, there are eight health centers, each linked to five health posts served by health extension workers. There is a general hospital 30 km away from the district town, Buee, which has an outpatient psychiatric service provided by a psychiatric nurse. However, at the time of the study there was no specialist mental health professional located within the district and no health care personnel trained in mental health care. As part of the Program for Improving Mental health carE (PRIME), plans were being made to integrate mental health care into primary care and maternal health care settings across the district [39]. PRIME is a multi-country implementation research project involving five LMICs (Ethiopia, India, Nepal, South Africa and Uganda) [40]. The analyses presented in this paper were from a formative study which was conducted to identify the treatment gap for women with post-partum depression and their preferred help-seeking [41] and coping strategies [42] in order to inform service development. In this paper we focus on the identification of risk factors for development of PPD. We attempted to identify and recruit all women between one and 12 months postpartum with live infants who were residing in Sodo district. A total of 3147 women were recruited from the 58 sub-districts of the study district, identified by locators in a house-to-house census triangulated with the list of infants from the PRIME census [43] and immunization reports for the whole district obtained from the district health office. Further details of the sample identification have been described previously [41]. The eligibility criteria included being a resident of the study district for 1 year or more, having a live infant, being between one and 12 months postpartum and not exhibiting overt behavioral disturbance indicative of severe mental illness. Each household containing an eligible woman was visited by a data collector who then explained the purpose of the research and gave the woman an information sheet or read the information aloud for those who were unable to read. Women who consented to participate were interviewed at a time and place that was convenient for them, but for the most part the interview took place within their homes. The interviews took approximately 1 hour to complete. PPD symptoms were measured using the Patient Health Questionnaire (PHQ-9). The PHQ-9 was developed originally to measure depression in primary care settings [44]. The PHQ-9 has been culturally validated for use in several African country settings [3, 29, 45–47] including in postpartum women in rural Ghana [48] and in the primary health care and antenatal care settings in the neighbouring district to this study [49, 50]. In the Ethiopia primary care validation, a score of 5 or more was found to have a sensitivity of 83% and specificity of 75% for the detection of major depressive disorder. In antenatal women, the validated cut-off was four and above, giving a sensitivity of 86.7% and a specificity of 80.4%. Gender preference was measured by asking the woman whether she was happy with her child’s gender (yes/no) and whether she perceived that her husband was happy with the child’s gender (yes/no). Social support was assessed using the Oslo Social Support Scale (OSSS-3). The total score as well as the individual items of the OSSS-3 may be used. A total score ranging between 3 and 8 is classified as poor social support, a score between 9 and 11 as intermediate support, and a score between 12 and 14 as strong support [51]. The OSSS-3 has been used in Ethiopia in various settings, including the community for this study [43, 52–54]. Stressful events were measured by the list of threatening experiences (LTE-12) [55]. The LTE has been found to have convergent validity in various studies in Ethiopia [43, 53, 54]. Alcohol use disorder was indicated using the Fast Alcohol Screening Test [56], a four item questionnaire that has been adapted and used in the study site previously [43]. A score of 3 or more indicates probable hazardous or harmful drinking. Perinatal complications were assessed by asking the woman “Have you had pregnancy, or birth-related difficulties? If yes, what were they?” (coded as haemorrhage, prolonged labour or high blood pressure). A total of 36 data collectors and four supervisors, who were recruited from the district by the PRIME project and had experience of data collection, were trained for 9 days. The educational levels of the data collectors ranged from tenth grade completed to first degree. They were supervised by four supervisors who were also trained and assisted by the investigators. The supervisors were diploma or degree graduates. A pre-test was conducted in three sub-districts near the study area. Data were collected between April and June 2014. Data were double entered into EpiData version 3.1 and exported to the Statistical Packages for Social Sciences, version 20 (SPSS-20) for analysis. Frequencies, percentages, and mean values were used to describe the categorical and continuous variables. Bivariate analyses were carried out to investigate the association between symptoms of PPD and several demographic, obstetric, and psychosocial variables. The hypothesis that the woman’s perception that her husband was unhappy with the gender of the baby would be associated with PPD was tested by controlling for demographic and obstetric factors in the multivariable analysis. All variables with a p-value < 0.2 were included in the multivariable model. Adjusted odds ratios with associated 95% confidence intervals were reported in the final multiple logistic regression model. Ethical approval was obtained from the Institutional Review Board of the College of Health Sciences, Addis Ababa University. Permission was also obtained from the Sodo District Health Office and administration. Women who agreed to participate gave written consent. For those who were not literate, independent witnesses were invited to sign to indicate that the information had been read out correctly. Non-literate participants then gave a finger print to indicate consent. Women who endorsed the PHQ item indicating suicidal ideation and those with higher than or equal to 10 in the PHQ were linked to the Butajira hospital psychiatric nurse-led outpatient clinic.

I-AI Digest

Study Justification:

– Postpartum depression is an important public health issue in low- and middle-income countries.
– The study aimed to assess postpartum depressive symptoms and associated factors in a rural Ethiopian setting characterized by high social adversity and reproductive health threats.
– The study aimed to identify risk factors for the development of postpartum depression in this population.

Study Highlights:

– The prevalence of high postpartum depressive symptoms in the study population was 12.2%.
– Rural residence, grand multiparity, perinatal complications, a past history of abortion, experiencing hunger, lower perceived wealth, poor marital relationship, and stressful events were significantly associated with high postpartum depressive symptoms.
– Preference of the husband for a boy baby was initially associated with postpartum depressive symptoms but became non-significant after adjusting for confounders.

Study Recommendations:

– Interventions focusing on poor rural women with low access to care are necessary to address postpartum depressive symptoms.
– The study can serve as an entry point for the adaptation of a psychosocial intervention to improve mental health in this population.

Key Role Players:

– Health extension workers
– Primary care providers
– Maternal health care providers
– Mental health care professionals

Cost Items for Planning Recommendations:

– Training and capacity building for health extension workers and primary care providers
– Development and implementation of psychosocial interventions
– Mental health care services integration into primary care and maternal health care settings
– Outreach programs to reach rural women with limited access to care

Amandla Obufakazi

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong, but there are some areas for improvement. The study was conducted in a large sample size and used a culturally validated measure of depressive symptoms. The prevalence of high PPD symptoms was reported with a confidence interval. The study also identified several risk factors associated with PPD symptoms. However, the abstract could be improved by providing more details about the study design, such as the sampling method and data collection procedures. Additionally, it would be helpful to include information about the statistical analysis performed and any limitations of the study. Overall, the evidence is strong, but providing these additional details would enhance the clarity and transparency of the study.

Abstract

The study was conducted in Sodo district, of the Gurage zone, Southern Nations, Nationalities and Peoples’ Region (SNNPR) of Ethiopia. SNNPR is one of the largest regions in Ethiopia, accounting for more than 10 percent of the country’s land area. The SNNPR is an extremely ethnically diverse region of Ethiopia. These ethnic groups are distinguished by different languages, cultures and socioeconomic organizations. The Gurage zone has 15 districts. Sodo district is the second largest in terms of population (161,952 persons; 79,356 men and 82,596 women), with 88% of the population residing in rural areas [38] and comprises 58 sub-districts. It is located about 100 km south of the capital city, Addis Ababa. In Sodo district, there are eight health centers, each linked to five health posts served by health extension workers. There is a general hospital 30 km away from the district town, Buee, which has an outpatient psychiatric service provided by a psychiatric nurse. However, at the time of the study there was no specialist mental health professional located within the district and no health care personnel trained in mental health care. As part of the Program for Improving Mental health carE (PRIME), plans were being made to integrate mental health care into primary care and maternal health care settings across the district [39]. PRIME is a multi-country implementation research project involving five LMICs (Ethiopia, India, Nepal, South Africa and Uganda) [40]. The analyses presented in this paper were from a formative study which was conducted to identify the treatment gap for women with post-partum depression and their preferred help-seeking [41] and coping strategies [42] in order to inform service development. In this paper we focus on the identification of risk factors for development of PPD. We attempted to identify and recruit all women between one and 12 months postpartum with live infants who were residing in Sodo district. A total of 3147 women were recruited from the 58 sub-districts of the study district, identified by locators in a house-to-house census triangulated with the list of infants from the PRIME census [43] and immunization reports for the whole district obtained from the district health office. Further details of the sample identification have been described previously [41]. The eligibility criteria included being a resident of the study district for 1 year or more, having a live infant, being between one and 12 months postpartum and not exhibiting overt behavioral disturbance indicative of severe mental illness. Each household containing an eligible woman was visited by a data collector who then explained the purpose of the research and gave the woman an information sheet or read the information aloud for those who were unable to read. Women who consented to participate were interviewed at a time and place that was convenient for them, but for the most part the interview took place within their homes. The interviews took approximately 1 hour to complete. PPD symptoms were measured using the Patient Health Questionnaire (PHQ-9). The PHQ-9 was developed originally to measure depression in primary care settings [44]. The PHQ-9 has been culturally validated for use in several African country settings [3, 29, 45–47] including in postpartum women in rural Ghana [48] and in the primary health care and antenatal care settings in the neighbouring district to this study [49, 50]. In the Ethiopia primary care validation, a score of 5 or more was found to have a sensitivity of 83% and specificity of 75% for the detection of major depressive disorder. In antenatal women, the validated cut-off was four and above, giving a sensitivity of 86.7% and a specificity of 80.4%. Gender preference was measured by asking the woman whether she was happy with her child’s gender (yes/no) and whether she perceived that her husband was happy with the child’s gender (yes/no). Social support was assessed using the Oslo Social Support Scale (OSSS-3). The total score as well as the individual items of the OSSS-3 may be used. A total score ranging between 3 and 8 is classified as poor social support, a score between 9 and 11 as intermediate support, and a score between 12 and 14 as strong support [51]. The OSSS-3 has been used in Ethiopia in various settings, including the community for this study [43, 52–54]. Stressful events were measured by the list of threatening experiences (LTE-12) [55]. The LTE has been found to have convergent validity in various studies in Ethiopia [43, 53, 54]. Alcohol use disorder was indicated using the Fast Alcohol Screening Test [56], a four item questionnaire that has been adapted and used in the study site previously [43]. A score of 3 or more indicates probable hazardous or harmful drinking. Perinatal complications were assessed by asking the woman “Have you had pregnancy, or birth-related difficulties? If yes, what were they?” (coded as haemorrhage, prolonged labour or high blood pressure). A total of 36 data collectors and four supervisors, who were recruited from the district by the PRIME project and had experience of data collection, were trained for 9 days. The educational levels of the data collectors ranged from tenth grade completed to first degree. They were supervised by four supervisors who were also trained and assisted by the investigators. The supervisors were diploma or degree graduates. A pre-test was conducted in three sub-districts near the study area. Data were collected between April and June 2014. Data were double entered into EpiData version 3.1 and exported to the Statistical Packages for Social Sciences, version 20 (SPSS-20) for analysis. Frequencies, percentages, and mean values were used to describe the categorical and continuous variables. Bivariate analyses were carried out to investigate the association between symptoms of PPD and several demographic, obstetric, and psychosocial variables. The hypothesis that the woman’s perception that her husband was unhappy with the gender of the baby would be associated with PPD was tested by controlling for demographic and obstetric factors in the multivariable analysis. All variables with a p-value < 0.2 were included in the multivariable model. Adjusted odds ratios with associated 95% confidence intervals were reported in the final multiple logistic regression model. Ethical approval was obtained from the Institutional Review Board of the College of Health Sciences, Addis Ababa University. Permission was also obtained from the Sodo District Health Office and administration. Women who agreed to participate gave written consent. For those who were not literate, independent witnesses were invited to sign to indicate that the information had been read out correctly. Non-literate participants then gave a finger print to indicate consent. Women who endorsed the PHQ item indicating suicidal ideation and those with higher than or equal to 10 in the PHQ were linked to the Butajira hospital psychiatric nurse-led outpatient clinic.

Izinto zokwakha

N/A

Emisha

Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Telemedicine: Implementing telemedicine services can provide remote access to healthcare professionals, allowing pregnant women in rural areas to receive medical advice and support without having to travel long distances.

2. Mobile health (mHealth) applications: Developing mobile applications that provide information and resources related to maternal health can empower women to take control of their own health and make informed decisions. These apps can include features such as appointment reminders, educational content, and access to support groups.

3. Community health workers: Training and deploying community health workers in rural areas can help bridge the gap in access to maternal health services. These workers can provide basic healthcare services, education, and support to pregnant women and new mothers in their communities.

4. Transportation solutions: Improving transportation infrastructure and implementing transportation services specifically for pregnant women can help overcome geographical barriers and ensure timely access to healthcare facilities.

5. Integrated care models: Integrating maternal health services with other healthcare services, such as mental health and primary care, can improve overall health outcomes for pregnant women. This approach ensures that women receive comprehensive care that addresses all their healthcare needs.

6. Health education programs: Implementing health education programs that focus on maternal health can increase awareness and knowledge among women and their families. These programs can cover topics such as prenatal care, nutrition, breastfeeding, and postpartum mental health.

7. Public-private partnerships: Collaborating with private healthcare providers and organizations can help expand access to maternal health services. This can involve leveraging private sector resources and expertise to improve infrastructure, training, and service delivery in underserved areas.

8. Financial incentives: Providing financial incentives, such as subsidies or cash transfers, to pregnant women in low-income communities can help alleviate the financial burden of accessing maternal health services. This can encourage more women to seek care and reduce disparities in access.

9. Mobile clinics: Setting up mobile clinics that travel to remote areas can bring essential maternal health services directly to communities that lack access to healthcare facilities. These clinics can provide prenatal care, vaccinations, screenings, and other necessary services.

10. Task-shifting and training: Training healthcare workers, such as nurses and midwives, to take on additional responsibilities and tasks traditionally performed by doctors can help address the shortage of skilled healthcare professionals in rural areas. This can increase the availability of maternal health services and improve access for women in need.

AI Innovations Description

Based on the study, here is a recommendation that can be developed into an innovation to improve access to maternal health:

1. Implement a psychosocial intervention program: Based on the findings of the study, it is important to develop and implement a psychosocial intervention program specifically targeting women in rural areas with low access to care. This program should focus on addressing social adversity and reproductive health threats, which were found to be significantly associated with high postpartum depressive (PPD) symptoms. The intervention should aim to improve mental health outcomes for women during the postpartum period.

2. Integrate mental health care into primary care and maternal health care settings: As part of the Program for Improving Mental health carE (PRIME), plans were being made to integrate mental health care into primary care and maternal health care settings across the district. This integration should be prioritized and implemented to ensure that women have access to mental health services during the postpartum period. This can be achieved by training health care personnel in mental health care and providing resources and support for the implementation of mental health services.

3. Increase awareness and education about postpartum depression: It is crucial to increase awareness and education about postpartum depression among women, their families, and the community. This can be done through community outreach programs, educational campaigns, and training sessions for health care providers. By increasing awareness and education, women and their families will be better equipped to recognize the signs and symptoms of postpartum depression and seek appropriate help and support.

4. Strengthen social support networks: The study found that poor social support was associated with high PPD symptoms. Therefore, it is important to strengthen social support networks for women during the postpartum period. This can be done by promoting community support groups, providing counseling services, and encouraging family and community involvement in supporting women’s mental health.

5. Improve access to maternal health care services: To address the barriers to accessing maternal health care services, efforts should be made to improve access to quality and affordable maternal health care services in rural areas. This can be achieved by increasing the number of health centers and health posts, training and deploying more health care personnel, and ensuring the availability of essential maternal health care services and resources.

By implementing these recommendations, it is possible to improve access to maternal health and address the issue of postpartum depression in low- and middle-income countries like Ethiopia.

AI Innovations Methodology

Based on the provided study, here are some potential recommendations to improve access to maternal health:

1. Increase availability of mental health professionals: As the study mentioned, there was no specialist mental health professional located within the district. To address this, it would be beneficial to train and deploy mental health professionals, such as psychiatrists or psychiatric nurses, to provide mental health care services specifically for postpartum women.

2. Integrate mental health care into primary care and maternal health care settings: As part of the Program for Improving Mental health carE (PRIME), plans were being made to integrate mental health care into primary care and maternal health care settings across the district. This integration can help ensure that mental health services are easily accessible to women during their postpartum period.

3. Improve access to care for rural women: The study found that rural residence was significantly associated with high postpartum depressive symptoms. To address this disparity, efforts should be made to improve access to maternal health care services for rural women. This can include increasing the number of health centers and health posts in rural areas, as well as providing transportation options for women who need to travel to access care.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the indicators: Identify specific indicators that can measure the impact of the recommendations on improving access to maternal health. This can include indicators such as the number of mental health professionals deployed, the number of primary care and maternal health care settings that have integrated mental health care, and the number of rural women accessing maternal health care services.

2. Collect baseline data: Gather data on the current status of access to maternal health care in the study area. This can include data on the availability of mental health professionals, the integration of mental health care into primary care and maternal health care settings, and the number of rural women accessing care.

3. Simulate the impact: Use modeling techniques to simulate the impact of the recommendations on the identified indicators. This can involve creating scenarios where the recommendations are implemented and estimating the potential changes in the indicators based on these scenarios.

4. Analyze the results: Analyze the simulated results to assess the potential impact of the recommendations on improving access to maternal health. This can include comparing the baseline data with the simulated data to determine the extent of improvement.

5. Refine and iterate: Based on the analysis, refine the recommendations and simulation methodology as needed. Iterate the process to further refine the recommendations and assess their potential impact on improving access to maternal health.

By following this methodology, policymakers and stakeholders can gain insights into the potential impact of the recommendations and make informed decisions on implementing interventions to improve access to maternal health.

Umbhali

Dima Health

Statistics:

Citations: 24

Identifiers:

DOI: 10.1186/s13033-018-0219-x

Research Areas:

Community Interventions, Disparities, Food Security, Health System and Policy, Maternal Access, Maternal and Child Health, Mental Health, Noncommunicable Diseases, Quality of Care, Sexual and Reproductive Health, Social Determinants, Substance Abuse

Study Countries:

Ethiopia, Ghana, Multi-Countries, South Africa, Uganda

Study Design:

Case-Control Study, Cross Sectional Study, Exploratory Study, Grounded Theory, randomised-control-trial

Study Approach:

Quantitative

Participants Gender:

Male & Female

Yabelana ngalokhu: