Prevalence and associated factors of antenatal depression among women attending antenatal care follow up at Michu Clinic in Ayder Comprehensive Specialized Hospital, Mekelle, Tigray, Ethiopia 2019.

Background Antenatal depression is a serious mental health problem that can negatively affect the lives of women. Depressive disorders are not only common and chronic among women throughout the world but also the principal source of disability. The scarce information and limited attention to the problem might aggravate the consequence of the problem and can limit the intervention to be taken. So the purpose of the study is to determine the prevalence and associated factors of antenatal depression among women. Methods An institutional based cross sectional study was conducted by systemic random sampling technique among 203 pregnant women following Antenatal care at Michu clinic in Ayder Comprehensive Specialized Hospital from March to June 2019. An interviewer administered Beck Depression Inventory (II) questionnaire was used to assess individual’s depression condition after consent obtained from participants. Data was entered and analyzed by using statically package for social science version 22. Then bivariate regression with p-value ≤ 0.25 was entered in to multivariate regression with p-value


Introduction
Antenatal depression is a depression occurred during the period of pregnancy of mothers. Depression is the 4 th leading causes of disease burden and the largest causes of non-fatal burden accounting for almost 12% of all total years lived with disability worldwide (1).it is one of the most ancient and common diseases of the human race. Depressed patients are at least as heavily disabled as patients affected by other chronic diseases such as hypertension, rheumatoid arthritis and diabetes (2).
Depression is the most prevalence psychiatric disorder during pregnancy. Almost one woman out of four was experience depression at some point in her life, most commonly during the childbearing years (3) . Depressive disorders are not only common and chronic among women throughout the world but also the principal source of disability (1)(2)(3).
Antenatal depression often precedes postnatal depression (4) and causes great suffering to the women and her family (3) . On top of that, untreated depression is associated with higher rates of morbidity and mortality. Similarly, discontinuation of antidepressant drug therapy in women with medication responsive illness carries a high risk for relapse and suicide attempts (5). More worryingly, per-natal depression has been found to be linked with infant under nutrition in many low income countries (6).
Negatively and low caregiver responsiveness may contribute to high rates of insecure attachment found among infants of depressed mothers (7). Children of depressed mothers are also at risk for slower cognitive development (8), low activity, di culty interacting with unfamiliar and adults and unresponsiveness (9). Biomedical consequences including an increased risk for breastfeeding problems (10) , eating and sleep disturbance (11) , and a reduced likelihood of receiving preventative health care (12) or daily vitamin supplementation (13). Depressed mood during pregnancy has also been associated with poor attendance at antenatal clinics, substance misuse, low birth weight, and preterm delivery (7,8).
Antenatal depression is de ned as the occurrence of a depressive episode in women during pregnancy. Prenatal depression is a non-psychotic depressive episode ranging from mild to severe symptoms that occur while a woman is pregnant period (14,15). The WHO ranked depression as a single largest contributor to global disability in 2015.Depression has been reported more common among female population group as compared to male population group (16).
Depression affects an estimated 10 % to 20% of pregnant women worldwide. Traditionally, pregnancy was viewed as a time protective against developing depression; consequently, the existence and consequences of have received little attention in either obstetrical, psychiatric, family medical practice, or mental health services. Depression is characterized by feeling of low self-worth, loss of interest, feelings of regret, restlessness, loss of appetite, feelings of fatigue, and poor concentration. Prenatal depression is a non-psychotic depressive episode ranging from mild to severe symptoms that occur while a woman is pregnant or during postnatal period.
Depression is one of the top contributors of global burden of diseases, which affects around 322 million people worldwide and is the leading reason for suicide. WHO, Global Health Estimates of 2015 reported that 788,000 people died due to suicide for every person who dies of suicide, 20 additional people attempted suicide. Depressive disorders led to a global total of over 50 million Years Lived with Disability in 2015 throughout the world (1,2).
The estimated prevalence of depression worldwide is increased by 18.4% from 2005 to 2015 in the world (3).Depression in pregnancy may diminish one's capacity for self-care including inadequate nutrition, drug or alcohol abuse, and poor antenatal clinic attendance all of which may compromise a women's physical and mental health and may reduce optimal fetal monitoring or restrict the growth and development of the fetus although nearly 90% of the world's children live in low and middle income countries (3).
In Ethiopia, depression is the third leading cause of burden of diseases and is also predicted to become the second leading cause of the global disease burden by the year 2020 (4). Depression is an emotional or affective state where a person may feel sad, lonely, or miserable with a "lack of interest" in their usual pleasurable activities (17).
In conclusion enormous numbers of individuals are being affected with general depression and it is responsible for 850,000 deaths per year. Results showed that 15% of the population from high income countries to 11% for low income countries is suffering with this problem. Antenatal depression is one of the ever maternal mental health problems that can be categorized under general depression which affects 10-15% of women before delivery.
The major aim of this study was to determine the prevalence and associated factors of antenatal depression among women attending antenatal care follow up at Michu clinic in ACSH. Therefore, early identi cation of maternal depression and the associated factors are potentially an effective strategy for decreasing maternal mortality and morbidity related to antenatal depression so that early screening of antenatal depression would improve the ability to recognize this disorder and enhances care that ensures appropriate health outcomes.
The evidence from this study would assist policy makers and program planners to take action to reduce the mortality and morbidity of mothers would able to take appropriate measurement.
Additionally, this study would provide relevant information for health workers to assess the magnitude and associated factors of antenatal depression which leads them to provide intensive professionally based antenatal support, to remain alert for associated factors of antenatal depression and would implement psychosocial support during the antenatal period and at the last it would be as an initial for other researchers for additional investigation.
Worldwide depression is the 4 th leading of diseases burden and the largest causes of non-fatal burden accounting almost 12% of all years lived with disability worldwide(1). AD precedes post-natal depression (4). Most of the core maternal symptoms of prenatal depression such as sleep disturbance and fatigue are frequently attributed to normal response of motherhood, which lowers the detection of prenatal depression (18).
One of the main components of sustainable development goal is improving maternal health and the vitality of mental health is stated through the theme "no health without mental health." In developing countries, one in three to one in ve pregnant and postpartum mothers have mental illness (14) . To realize sustainable development goals, efforts must include procedures to avert and manage the issue of maternal mental health during pregnancy and following birth of a baby (15) . Prenatal depression's even milder symptoms impose a considerable health, social, and economic impact on the woman, her family, and her country at large (19,20) .

Prevalence of antenatal depression
Epidemiological data suggests that 15% of women are depressed at any one time throughout the world (21). The prevalence of AD varies across different countries. For instance, the prevalence of AD ranges from 7 to 15% in high-income countries throughout the world (22). The prevalence of AD is also twofold higher among women from low-and middle-income countries (20%) as compared to women from high-income countries in the world (10%), (15,18). Some researchers suggest that mothers of young children may have high rate of depression than general population of women in the world (23). The prevalence of AD ranges from 19 to 25% in low-and middleincome countries worldwide (24).
The prevalence of AD in Asia among 543 pregnant women attending antenatal care with beck depression inventory was used to assess the individual's depression condition and the prevalence was 15%-28% (8)(9)(10)(11). In Pakistan 28%-57% among 312 pregnant women attending ANC follow up at public health center with BDI (I) (12) and 35%-50% in Latin America among 234 pregnant mothers attending ANC follow up by BDI (I), (13).
A cohort study of women attending a district hospital antenatal clinic in Goa a speci c place in china with study participants of 453, and community based study from Tamil Nadu, India with a total pregnant women of 387reported a prevalence of 23% and 19% respectively where BDI (I) was used to assess the individuals depression condition (25,26).
Another community cohort study from Pakistan reported a prevalence of 28% (27). A meta-analysis shows a prevalence of AD is also high ranging from 0.5% to 51% in Pakistan (10) . The prevalence of maternal depression is estimated to 15%-28% in Africa among 256 pregnant mothers attending ANC by BDI (II), (13) .
The prevalence of AD in South Africa is as high as 30-50% in one cross sectional study conducted in rural area of South Africa among 500 pregnant women attending ANC follows up in public health center (13) .
In Ethiopia very few published studies are their concerning AD. These published researches show the prevalence of depression among pregnant women generally ranging from 4.4 % to 12% (28)(29)(30). The prevalence of antenatal depression is reported to be 31.2% in Adama Hospital among 345 pregnant mothers attending ANC at public health center by using BDI II (31), 31.1 % in Maichew among 209 women attending antenatal care of the total women attending ANC follow up out of the source population of 600 pregnant mothers in public health centers using beck depression inventory to assess individual's depression condition with a cutoff point greater or equals to 14 (32), 29.5% in Sodo district of Gurage Zone among 254 pregnant mothers with BDI I with a cutoff point greater or equals to 14 (33) . 24.9%inAddis Ababa Public Health Centers among 542 pregnant mothers attending ANC follow up at public health center by using BDI I with a cutoff point greater or equals to 14 (34).23% in Gondar University Hospital among 388 pregnant mothers attending ANC follow up at Gonder University Hospital with BDI (35, 36) and a recent study in Dubti hospital located 10 Km from Samara which is the capital city of Afar Regional state with prevalence of 17.9% and the sample size was 363 among a total of 4560 women following antenatal care per one year and the research was conducted with Beck depression inventory II with a cutoff point > or equals to 17 to assess the individual's depression condition (37).
The objective of the current review was to present an over view on the magnitude and associated factors of perinatal depression in Ethiopia.

Determinants of antenatal depression
Different studies conducted so far in different area reported Risk factors can be mentioned like sociodemographic characteristics, social support, obstetrics factors, previous psychiatric history and substances use for depression among pregnant mothers such as being young age was associated with AD in Rawalpindi, Pakistan (11), low income associated with AD in Jamaica (12), lower educational attainment and obstetric factors in Rawalpindi, Pakistan (11) history of depression (11)(12)(13), history of miscarriage and pregnancy termination (7), concomitant high anxiety in pregnancy (38), low self-esteem (27) and low social support (37,39,40).
Women from a developing country like Ethiopia are usually exposed to risk factors for the development of AD like poor socioeconomic status, unintended pregnancy, and gender-based violence and history of childhood sexual abuse in Ethiopia (28,41).
Socio-demographic characteristics, Pregnancy planning, social support, previous psychiatric history, obstetric factors and marital con ict were signi cantly associated with AD, a cross sectional study conducted in Northern Ethiopia at Dubti Hospital (37).
Bivariable logistic regression analysis showed that maternal education, average family monthly income, history of complication in previous pregnancy, and previous history of depression were statistically associated with antenatal depression in Northern Ethiopia Dubti Hospital (37).
In multivariable logistic regression analysis marital con ict, pregnancy planning, and social support were found to be signi cantly associated with AD. Those women who had marital con ict were about six times more likely to have AD as compared to those who had no marital con ict (37). Women who had planned their current pregnancy were 96% less likely to have antenatal depression as compared to women who had no planned pregnancy compared to women who had low social support, women who had medium social support less likely to have antenatal depression (37).

Sociodemographic characters tics of antenatal depression
The incidence of AD is affected by different contributing factors among these socio demographic characteristics is one of the leading factors for AD. This has been revealed by different studies.
Firstly, when we see age, Young mothers were found to be at increased risk of AD than mothers of older age in British(14) (35).In contrast, a cross sectional study which was conducted in Turkish women revealed that the prevalence of AD was higher in older women than younger (14). Beside a study in China tells the absence of association between AD and maternal age (5). But in Ethiopia it has been revealed by different studies that Young mothers were found to be at increased risk of AD than mothers of older age (27) .
Secondly, there is also evidence on the difference in the incidence of AD between educated and noneducated mothers with the higher prevalence of AD in uneducated in developed country like Harvard University (27). But this result is in opposite with other ndings where educational status of the mother did not associate with AD in the Rural developing world (5). Another cross sectional study in Qatar tells women who are educated are more vulnerable for the problem (22).In Ethiopia speci cally Northern part in Dubti hospital reveled that Non-educated women have higher prevalence than educated women in a cross sectional study (37).
Thirdly, single mothers appear to have greater risk of AD in one study in rural South Africa (21).But in Ethiopia majority of participants were married and the prevalence is higher in married than women who does not married in a cross sectional study in Northern Ethiopia particularly Dubti Hospital (37).
Fourthly women who are in low economic status are also at high risk for AD in one cross sectional study in Harvard University (27) and in South Africa (25). Another study conducted in middle and low income countries in North East Africa with a systemic review study showed similar nding that women who are in low economic status have higher prevalence (15,22,37,39) and a study conducted in Ethiopia revealed similar nding that women with low income status were found to have higher prevalence of AD. Almost 90 percent of study participants had reported that they earn an average family monthly income of more than500 Ethiopian Birr (the minimum Ethiopian wage during that time and Young mothers were found to be at increased risk of AD than mothers of older age (37).
Fifthly, a Socio cultural factor ritual is among the list of factor which contributed for the incidence of AD in one cross sectional study in British (14) but there is no conducted result about socio cultural factor in Ethiopia.
Sixthly, In different researches it has been mentioned that mothers who are working are also affected with the problem a cohort study in South Africa (25,39), comparatively mothers who are unemployed are more at risk to develop AD than employed in a cross sectional study in Ethiopia (15,29).

Social support
This was evident in different studies. On the study in developed countries which was conducted in 2010-2011 on 285 women by BDI I who gave birth in the Department of Obstetrics, Gynecology and Gynecologic Oncology at the University Hospital in Bydgoszcz has been mentioned that the child birth without the presence of any relatives was mentioned as a factor for AD but another study concluded that there was no association between AD and lack of social support in Jamaica (12,38,39).
The incidence of AD Women who have poor husband support were found to be at increased risk of AD in a cohort study in rural population in a developing country worldwide (5), But in one cross sectional study conducted in Northern Ethiopia reveled that marital problem was a contributing factor for maternal depression in which (27.2%) had encountered a con ict with their husbands in the last 12 months preceding the study.
For instance, in Ethiopia at least one in ve women reported intimate partner violence (42) and women having history of intimate partner violence are 3 to 5 times likely to develop AD (19,20,43,44). Despite extensive variations in the prevalence and associated factors of AD across different communities of Ethiopia, there is no pooled evidence regarding the overall prevalence and potential associated factors of perinatal depression.
Social support loss and marital con ict had higher prevalence of AD than women who had no con ict with their husband and women who had no social support in a study conducted in Ethiopia (37) .
History of substance use Substance use particularly alcohol or khat, are not uncommon before or during pregnancy. Multiple addictions are also common, in particular alcohol with tobacco and alcohol with cannabis. A research conducted in University Hospital in Bydgoszcz has been mentioned that women using substance like khat and alcohol are associated with AD (27). On a systematic review of the prevalence of antenatal depression among Women with Substance use, an abuse history, or Chronic illness by including seventeen papers on patient health questionnaire 9 assessing depression between 3 and 36 weeks of antenatal period there were high rates of AD among substance-using women of khat and alcohol and those with current or past experiences of abuse in Southwest Ethiopia (39,45).
Again another study in Ethiopia revealed that Prevalence of major depression was 12.4% for past-year pregnant women, of these women's 35.4% had nicotine dependence. Twenty-one (5.9%) of the study participants had used alcohol at least once in the last 30 days but none of the participants had reported current khat chewing (37).

Obstetric factors of antenatal depression
A study conducted in Iran indicated that unwanted pregnancy is not a risk factor for AD (40). A research done on risk factor of depression in rural area of Isfahan province, Iran prime-paresis women were at higher risk for antenatal depression compared with multipara, prime-gravidia, multigravida (29). In one cohort study conducted in Southwest Ethiopia (26,29,39,46) More than three-fourth (76.2%) of pregnant women were in either the second or third trimester during the time of the study. A national survey in Ethiopia conducted in 2013 showed an overall unplanned pregnancy rate of 24%.
Due to the associated higher risk women are at increased risk of having obstetric complications such as preterm labor, preeclampsia, fetal growth restriction, abruption placenta, and associated fetal and maternal complications (18). Women having such problems are usually less likely to seek and get care for themselves as well as their child, which intern leads to pre-term birth, low birth weight, and growth restriction (24,(47)(48)(49).
Another research conducted in Northern Ethiopia speci c place of Maichew, two hundred eighty-four (79.6%)of the women had planned their current pregnancy, of 221 women who had a history of pregnancy, 55(24.9%) had a history of complication during previous pregnancy among 388 the participants in the study.
Previous psychiatric history PPD has been found to elevate the risk of AD. A research conducted in developed countries, for example in Brazil there was a cross sectional study on the assessment of prevalence and associated of previous psychiatric disorder with bio-social-demographic factors, family history of psychological disorders was mentioned as a contributing factor for AD (17).
There are also other studies which tell that women with PPD found to be at increased risk of AD, a cohort study conducted in developing countries throughout the world (5).
There are plenty of studies which tell that women with previous history of depression found to be at increased risk of AD, a cohort study conducted on different part of Ethiopia (32,37). In general the study revealed that women who had PPD especially depression had higher prevalence than women who had no previous psychiatry history and About 97 (27.2%) of the study participants reported a previous history of depression (37).

Methodology Study area
The study was conducted at Ayder Comprehensive Specialized Hospital Mekelle speci cally at Michu clinic is the capital city of the Tigray Region and located at 783 kilometers to the north of Addis Ababa, the capital city of Ethiopia. Mekelle University, College of Health Sciences/Ayder Comprehensive Specialized Hospital commenced rendering its referral and non-referral services in 2008, 9 million populations in its catchment areas of the Tigray, Afar and South-eastern parts of the Amhara Regional States. It provides a broad range of medical services to both in and out patients of all age groups.
As such, the Hospital can be designated as the most advanced medical facility, by all accounts, in the Northern part of the country and that it stands as the second largest hospital in the nation with the total capacity of about 500 inpatient beds in all departments and other specialty units. From the 500 inpatient bed 18 beds are in psychiatry department use for any disorders like psychotic or depression etc.
The Hospital is also used as a teaching hospital and research center for the College of Health Sciences, Mekelle University Ayder Comprehensive Specialized Hospital, and College of Health Science has above 80 specialists, in various areas of medical specializations and fairly adequate numbers of all the other health professionals constituting the health care team. It has about 50 international relations, over 2,165 staff and about 4,000 students.
Currently the institution has 61 programs with 21 under graduate, 30 post graduates including 10 specialty and three PhD programs generally the study was be conducted in ACSH speci c place of Michu clinic which is established 2 years ago from now and is speci c center for antenatal care and for family planning and other related purposes.
The climate condition of this area is sunny and cloudy and we preferred this area to conduct this research basically based on feasibility and because we can easily access women who follow antenatal care other than other centers since there is adequate number of women who follow ANC compared to other health centers. Age greater than or equals to 18.

Exclusion criteria
Women who were unable to hear and speak Women who were seriously sick.

Sample size determination
The minimum number of sample required for this study was determined by using Single population proportion formula considering the following assumptions Where Ni = minimum sample size required for the study Z= standard normal distribution (Z=1.96) with con dence interval of 95 %) D2 = margin of error (5%) P =population proportion =17.9% (37), We preferred this population proportion since we were studying the magnitude and associated factors and this study conducted in Dubti hospital showed the associated factors better than the other studies conducted before. Then we used the correction formula since the target population is less than 10,000 that is the total number of women visiting antenatal care was 981. That is K=N/n, Where n-is the sampling women included in the study N -is the target population/women following ANC during the data collection period K=981/203 =4.8, approximated to 4, this is the K interval.
Then we selected participant women every 4 interval of women for this the rst women was selected by lottery method among women triage of rst woman to 4 woman, the rst woman selected and was the rst mother of the triage and selected based on (1,5,10......).

Sampling procedure and techniques
We used a probability sampling technique (systemic random sampling) among 203 pregnant women who was following antenatal care at Michu clinic based on their triage order from the clinic during their appointment.
We faced with non -voluntary, non-communicable, seriously sick and other situations which make uctuation women; we jumped and took the next mother. Social support loss like husband support loss, community support loss.
History of substance use like khat, alcohol, cigarette and others.

Previous psychiatric histories like depression and family history of depression
Operational de nition Antenatal depression: a depression occurred during the pregnancy period.
According to Beck's Depression inventory II(50) form a score of 14 or more is considered having depressive symptoms and can be classi ed as follow, Minimal depression considered as the score of 0-13 of beck depression scale.
Mild depression with a score of 14-19 of beck depression scale.
Moderate depression with a score of 20-28.
Severe depression with score of 29-63 A score of greater or equals to 17 is a cutoff point to detect depression in the study conducted in Ethiopia speci c place of Dubti Hospital, for BDI II (37).
Antenatal care: a care in which health professionals give support and follow the pregnancy status of women until give birth.
Gestation period: Development of the fetus from the rst day of the last period until birth, 40 weeks.
Multigravida: Woman who has had more than one pregnancy. Multipara: Woman who has given birth to more than one viable child.
Primeparasis: A woman pregnant with her rst child.
Primgravidia: A woman who is pregnant for the rst time.
Low income level: Women with monthly income of <500 ETB (37).
Substance user: women who uses at least one of the speci ed substances starting from being pregnant (37).
Social support loss: individuals who score >=9, either moderate or strong on Oslo 3-items social support scale (51).

Data collection tools
We used self-administered standard questionnaire composed of closed ended and some open ended questions.
Beck depression scale (BDI) II was used to assess individual's depression status which contains 4point scale values of 0 up to 3.
(BDI) II is a standardized questionnaire for depression which contains 21 items basically of depression symptoms (50).

Data collection procedures
The data collection instrument was pretested for accuracy of responses, language clarity, appropriateness of data collection tools, estimate the time required and the necessary amendments was consider based on the pretest.
We pretested the questionnaire outside of Michu clinic; It was carried out two week proceeding to the actual data collection period in ve percent of non -study participants of women in Mekelle hospital.
Maintaining con dentiality of the participants throughout the whole process of data collection was also discussed and ascertained during this period.
We also had appraised the data during the data analysis stage to verify the completeness of the collected.

Data quality control
To ensure data quality data was collected only by the investigators.
The English version of questionnaire was translated to local language (Amharic, Tigrigna) and back translation to English to maintain its consistency by language experts.
Based on the nding from the pretest, the questioner was revised and adopted.
Data analysis procedure First we checked for completeness and consistency.
Data was coded in order to enter in to computer.
We used descriptive statistics to determine the prevalence of antenatal depression AOR with 95% CI was used to measure the association between depression and associated factors and bivariate and multivariate were also used to assess the relationship between each independent variable and showed strong association if p-value < or equals to 0.05. Data was Analyses by SPSS version 22 software package.
Generally bivariate was used and for the result is less than 0.25 then we transferred to multivariate and for the result is equals or <0.05, there was strong association.
For all statistical testes in this study, the signi cant level set at p-value equals or< 0.05.
Then data presented with graphs, percentage and frequency tables.

Dissemination of results
The result of this study will be disseminated or communicated to Mekelle University, the central library for documentation, all campus administrative o ce of Mekelle University, College of Health Science Department of Nursing, and Psychiatric Nursing Staff for approval. Regional health bureaus and other concerned bodies through reports and publication on an appropriate journal and for any concerned body.

Results
Totally 203 ANC following women requested to participate in a study out of which all of them (100%) Participants responded fully to all the questions.

Sociodemographic characteristics of pregnant women
The mean age of respondents were 27.57(SD=3.951), the median age was 28 years (range; 18-34years), the modal age of participants were 30 years. Most of participants 176 (86.7%) were Orthodox followers. Among the participants 150(73.9%) were educated Diploma and above and majority of participant 99(99%) were living in urban. most of participants 148(72.9%) had monthly income greater than 1000 and 88(45.3%) were Government workers (Table 1).

Social support among pregnant mothers
From the 203 participants 108 (53.2%) had 1-2 close persons during great di culty and 79(38.9%) got some interest and concern about what they did. 54(26.6%) had di culty of getting practical help from their neighbors whenever they need help from them (Table 1).
Based on Oslo's scale from 203 participant women 148(72.9%) had social support who scored greater or equals to 9, whereas 55(17.1%) of them had social support loss (Fig.2).

History of substance use among pregnant
Among 203 participants 188(92.6%) of them did not used substance during pregnancy on the other hand 15(7.4%) of the participants used substance after being pregnant out of 18(8.9%) ever used substance. Among substance users during pregnancy 15(7.4%) of them used alcohol (Table 3) Table 4).

Previous psychiatric history among pregnant women
Among 203 participants only 2 of (1%) only reports previous history of depression and other mental illness and only 7 out of 203(3.4%) reports history of depression and other mental illness among relatives (Table 5).
Beck Depression Inventory II responses among pregnant women BDI (II) is composed of 21 questions which indicate how mothers felt in the past two weeks and each question scored from 0 to 3. From all respondents 127(62.6%) of them reported they didn't felt sad, 163(80.3%) didn't discouraged about their future workout, 115(56.7) of them didn't felt like a failure 48(23.6) of them did not enjoy as much they enjoyed in the past, 117(57.6%) of participants didn't feel particularly guilty, 143(70.4%) didn't feel of being punished, 150(73.9%) of them didn't criticize themselves more than the usual, 163(80.3%) didn't have thought of killing themselves, 141(69.5%) of them didn't cry any more than the usual , 89(43.8%) of them had feeling of more restlessness/wound up than the usual, 118(58.1%) of them had no problem of decision making problem, 97(47.8%) of them had no loss of interest in daily living activities, 102(50.2%) of them didn't feel that they were worthlessness, 80(39.14%) had less energy than usual, 45(22.2%) of participants sleep a lot more than day, 118(58.1%) of the respondents were not irritable, 68(33.5%) of them had somewhat less than the usual, 130(64.0%) of the respondents concentrated well as ever, 110(54.2% had get more tired/fatigue than the usual and 82(40.4%) had less interest in sex (Table 6).
Bivariate and multivariate regression of AD Bivariate regression Binary Logistic regression was performed to assess the association of each independent variable with the outcome variable (antenatal depression) .The variables that showed a signi cant level (p <0.25) and COR with CI 95% were added to multivariate regression model (Table 7).
Multivariate regression P value <0.25 of the statically analysis were entered into multinomial logistic and p value <0.05 in multinomial logistic is strong relationship with antenatal depression such as middle income; history of antenatal follow up and educational status of pregnant women had signi cance (Table 8).

Discussion
The study indicated that the prevalence of Antenatal Depression is 31.5% with 95% CI (24.7, 37.9) respondents were depressed during their Antenatal period. The prevalence of antenatal depression varies across different countries and current study indicating that its prevalence is increasing from time to time.
The prevalence of this study is higher when compared to high income countries throughout the world 7%-15 %(22),in Ethiopia country wide ranges from 4.4%-12% (28,30),in Goa China and Tamil Nadu in India 23% and 19% respectively (25,26)and in Dubti (17.9%) among 363 pregnant women with BDI (II) (52) this might be due to different questionnaire, sample size, economical status, cultural difference, women's response towards the standard questionnaire and living status of women difference.
In this study the middle monthly income level of pregnant women is associated with antenatal depression with AOR of 95% CI 0.1999(0.066, 0.597) in which women who had middle income level had 80% less likely to develop antenatal depression when compared to high monthly income women and this result is similar with a research conducted in Harvard University(52) , in South Africa (25), in North East Africa (39) and in Northern Ethiopia at Dubti Hospital (37) and this might be due to women with middle income had less stress than higher income women.
The educational status of the participants in this study showed an association with antenatal depression in which high school students were associated when compared to illiterate women with AOR of 95% CI 6.755(1.761, 25.908) that is women with high school level educational status had 6.8 times more risk for antenatal depression and this is similar with a study conducted In Qatar women who are educated had higher prevalence of antenatal depression (22).Butnone educated were highly associated in rural developing world(5), in Harvard University (52) and in Ethiopia Dubti Hospital (37) showed that higher prevalence in non-educated women. In this study the high school level students had strong association with antenatal depression and this might be due to becoming of busy with work, less time to meet with their family members and their husband due to shortage of time.
History of antenatal follow up in the past showed association with antenatal depression in this study that is women who had no antenatal follow up were associated with antenatal depression with AOR of 95% CI 0.038(0.04, 0.341) in which they had 96.2% less likely to develop antenatal depression and this might be related to culture in which some women might consider antenatal follow up as a deviation from their culture.

Conclusion
Antenatal depression is a common mental health problem at the pregnancy period and its prevalence continues in a signi cant proportion. This study found that 31.5% of respondents had antenatal depression which is signi cant high value.
It also identi es the presumed risk factors like socio-demographic factors like monthly income and educational status and similarly, women who had no antenatal follow up in the past had association with antenatal depression. 2. Government should enable women to work in collaboration to be self-su cient and Financially stable.

Abbreviations
3. Further research should be done on antenatal depression using different study design, set up and sample size in order to investigate future some of the risk factors that were found to be associated with antenatal depression.

Declarations
Authors' contributions BG, a principal investigator, analyzed and interpreted the patient data regarding Antenatal Depression. GB and AT are major contributor in writing the manuscript. All authors read and approved the nal manuscript.
All participants have individual rights that are not to be infringed. Individual participants in studies have, for example, the right to decide what happens to the (identi able) personal data gathered, to what they have said during a study or an interview, as well as to any photograph that was taken.

Funding
Not applicable for this section but the assumption source of funding is Mekelle University, College of Health Science.
Availability of data and materials Not applicable.
Ethics approval and consent to participate Ethical clearance was obtained from Mekelle University of Ayder Comprehensive Special Hospital, School of Nursing Department of Psychiatry Nursing. We were clearly explaining the aims of the study for study participant and collect the information after obtaining verbal consent from each participant. Respondents were also informed that they can refuse or discontinue participation at any time. They want and they had informed that they can ask anything about the study. Information was recorded anonymously and con dentiality was assured throughout the study period.