Maternal PPD varies widely in different countries and regions worldwide due to different instrument measures, study design methods, sample sizes, timing and studied population(31–33). The objective of the study was to determine the prevalence of comorbid PPD and anxiety among mothers of preterm infants in NICU at KNH, compared to mothers of normal full-term infants at Umoja health center; using self-reported socio-demographic questionnaire, EPDS at cut off (>=13) Kessler 10 at a cutoff (>=20) and PHQ4 at a cutoff (>=3) screening instrumentsDepression and anxiety in pre-term mother cohort and in full term mothers
The prevalence of PPD in HICs has been estimated at 10% -15%and 0.5% - 60% in LMICs. In most African countries, it has been estimated at 0.7% -18%(34).In this study (see Table 2), using EPDS, K10 and PHQ4, the overall prevalence of PPD and anxiety in both groups of mothers was estimated at 25% for comorbid depression and anxiety, 44.2% for depression and 35.1% for anxiety. Our study finding was lower than that of Ethelwynn et al’s study from South Africa that rated postpartum depression at 50.3% in their rural community health center sample. This study used EPDS (cutoff score was not indicated however) and BDI (with only severity proportions reported) (35). This study’s higher scores may be explained by their design method, setting and timing, which are clearly different from the current study. Another study from Nigeria focusing on depression and anxiety in 270 postnatal women found 25.5% (n=69) of its sample with anxiety assessed using HAD-A (10). This study also found that it was history of depression (AOR = 0.12, 95% (CI 0.02, 0.76), and being a mother aged 15–29 years (AOR = 10.31, 95% (CI 1.13, 94.11) that had a significant effect on the development of anxiety symptoms in women..Our study results however were comparable to Muliira et. al.’s study conducted in rural Uganda, which found postpartum depression to be prevalent in43 % of its sample. These authors once again used EPDS screening tool at cut off (≥10) on mothers attending child clinic from birth up to 12 weeks (36). The finding of the current study were also slightly lower than that of Yator et al.’s work which estimated postpartum depression at 48 % using EPDS cut off (≥11) (27). The reason for Yator et al.’s study higher rates may be explained by his study sample which was purely postnatal women living with HIV, unlike the current study sample (25). Overall, with some variations notwithstanding, the findings of this study concur with several studies conducted in some LMICs (12,13,31,34).
The prevalence of postpartum depression among NICU mothers in our study was estimated at 77.6% compared to the full-term group at 22.4%. The PPD rates of the comparison group was slightly higher that of Ghubash & Abousaleh’s study conducted in United Arab Emirates that estimated PPD of 17.3% among sample of postnatal Arab women (37). In another study from Nigeria by Owoeye et al which looked into postnatal risk factors, found postpartm depression at 23% which is closer to what we have found in our comparison group of full term mothers(38). Owoeye’s study was a cross sectional hospital based within the first week postnatal, however in the current study, which was clinic based for the comparison group was screened at six weeks postpartum.
In another study similar to ours, once again, carried out, in Nigeria by Ukpang et al. found that, the NICU mothers had psychological distress rated at 27.3% and postpartum depression at 15.1% compared to mothers of full term births; 3.7% of those had PPD (31). Ukpang et al’s findings were lower than the current study findings. This may be explained by different screening tools used in this study (GHQ-30 and BDI). Similarly, Gulamani et al in their study in Pakistan found mothers of preterm infants had higher postpartum depression at 35.3% compared to mothers of full-term infants which were found to be 15.3% respectively. Gulamini et al’s lower rates could be explained by the difference in geographical region where this study was conducted and also due to the study design. This was a cohort study with smaller preterm infants mothers’ and larger full term infants mothers’ sample sizes -clearly different that of the current study samples. Additionally, all their respondents were out-patients as this was a clinic based study (39).
The prevalence rate of psychological distress in both groups in the current study as measured by Kessler10 scale was estimated at 26.2%. The NICU preterm mothers had higher PPD and anxiety levels 77.6% (depression), 75% (anxiety) compared to 22.4% (depression) and 25% (anxiety) in the comparison group. The overall rates in this study was slightly lower that of Tesfaye et al.’s study based in Ethiopia where psychological distress was rated 29% using K10 scale. Tesfaye et al.’s findings were slightly higher that of the overall rates and of comparison group, but lower than that of NICU cases in this study. This difference could be explained by the methods used in his study (32) and higher risk factors associated with depression and anxiety in the NICU sample. Finally, comparing to another community-based sample from rural India by Prost et al (33) where K10 was used, the estimated prevalence of psychological distress was rated at 11.5%. This was close to that of the comparison group but much lower that of NICU cases and of the overall rates in the current study.
Risk factors for comorbid depression and anxiety in the overall sample
This study found that pre-term mothers had 5.75 times higher odds of developing depression and anxiety features than full term mothers. This could be explained by the fact that premature delivery almost always was sudden; the mothers were caught unawares and unprepared for child birth at that particular point in time. This study found that, a large number of mothers were destabilized by their preterm birth and majority of them were worried about the infant’s survival. Studies have found that, preterm babies have a high mortality rate than normal full- term babies particularly in LMICs (20).
The study found that, most mothers were worried about prolonged mother – child separation. These findings with a mixture of other stressors such as frightening and unfamiliar NICU environment and settings, fragile unresponsive, small size looking infants in incubators, were indicated as triggers to psychological distress, anxiety and depression among NICU cases. These findings concur with several studies that found that stressful life experiences surrounding the preterm births, stressful NICU unfamiliar, frightening settings, infants’ small size, appearance and general condition predisposed to high levels of distress, anxiety and PPD in mothers (14,20,21,37,40).
Intimate Partner Violence
Intimate Partner Violence is a significant risk factor and several studies have documented the relationship between IPV and women’s reproductive health, maternal health, mental health, and birth outcomes (41). There is significant evidence that in comparison to women who experienced IPV and those who did not, the prevalence of anxiety disorder and depressive disorder was high among IPV group (41,42). The exposure to IPV significantly increases the odds of PPD and anxiety (43). In another study, four out of ten women reported to have experienced adverse childhood experiences and two out of ten women reported IPV in the index pregnancy which was significantly associated with symptoms of postpartum depression (44).IPV experience is strongly and consistently associated with depression, including depressive symptoms and depressive disorders, and suicide in cross-sectional studies of women in both high- and lower-income settings.(45,46). Although it is easy to assume that IPV is causally related to subsequent depression and suicidal behavior, evidence suggests a more complex relationship. There are three modes of association, which are possible in any combination: (1) IPV exposure causes subsequent depression and suicide attempts, (2) depression and/or suicide attempts cause subsequent IPV, and (3) there are common risk factors for both IPV and depression and suicide attempts that explain the association between them.(45)There is also evidence that exposure to physical violence is associated with higher scores on the depression subscale (β = 3.09, p = 0.005), but not on anxiety subscale and that physical violence has a more direct association to PPD than psychological violence but these mechanisms have to be contextualized and better understood.
The type of violence and socioeconomic characteristics were more strongly associated with anxiety and depressive symptoms in women experiencing IPV than demographic variables (47)
Routine screening and interventions with adequate social protection mechanisms are crucial for reduction in IPV to make a lasting impact on maternal and neonatal well being.
Psychological distress
Perinatal period presents added psychosocial challenges to vulnerable women. There are several risk factors for development of anxiety and depression in perinatal period such as lack of partner or of social support; history of abuse or of domestic violence; personal history of mental illness; unplanned or unwanted pregnancy; adverse events in life and high perceived stress; present/past pregnancy complications; and pregnancy loss (24). In a study looking at specific demographics, maternal psychosocial and infant factors of mothers of very preterm infants at risk for postpartum depression or anxiety at the time of discharge from a level III urban Neonatal Intensive Care Unit (NICU), it was found that maternal factors, such as marital status, stress from parental role alteration and infant factors, such as prolonged ventilation, are associated with increased depression (24).
Multiple Risk Factors at Play
The current study found that there was not just one risk factor, but multiple factors contributed to the development of PPD and anxiety, particularly among the more vulnerable preterm births mothers. These were identified as (given in table 3):
- Preterm birth presents itself as a risk factor and predisposes the women to greater anxiety and depression
- Intimate partner violence was found to have contributed to 4.76 times higher odds of women developing depression and anxiety
- Psychological distress which could be due to several environmental factors could contribute to the two disorders and those with distress symptoms were 5.95 times more likely to develop depression and anxiety disorders speaks to the need for early screening and treatment.
Our work was not without its own limitations. Delays in data collection as a result of country wide doctors’ and lecturers’ industrial action in public hospitals and universities- in particular at KNH and Umoja health centre where the study was carried out- posed a considerable challenge. This study was hospital based for the preterm mothers who were also separated from their own families, compared to community based, for full term mothers (well mother baby clinic).The results of the study may be generalised as a true representation of the larger population only in the public hospitals with similar settings as KNH, because the pre-term mothers would be in hospital facilities for long periods. Self-reporting by the respondents may have over or under reported their true-self rating picture; however, the researcher was present all through at the time of data collection and she tried to ensure that the few participants who needed any clarification were helped in understanding the questions and purpose of the study.
Routine screening for depression and anxiety (psychological distress) for all mothers with preterm infants in NICU is recommended. The health care team (nurses, doctors and counselors) in Newborn Unit and in postnatal wards at KNH need to be sensitized around how to identify early signs of psychological disturbance among mothers of preterm infants in NICU.Routine group psychological counselling to NICU mothers soon after admission, and thereafter, to allay their fears and anxieties. NICU mothers to be afforded with sufficient rest in the wards, between the three hourly feeding program to take care of mental and physical drain. More research on postpartum depression, psychological distress and dissatisfactions among NICU mothers and follow up mother-infant outcome after discharge.