Prevalence And Factors Associated With Psychological Distress Among Pregnant Women Attending The Antenatal Clinic At A National Referral Hospital In Uganda.

Background: Psychological distress (PD) among pregnant women has a bearing both on the mother and the outcome of the pregnancy and is thus a public health problem. It is a precursor for other severe mental health conditions that include anxiety, depression, bipolar disorder and so if screened and diagnosed early it can prevent progress to severe mental illness. PD has however not been screened among pregnant women and thus no available data in Uganda. The objective of this study was to determine the prevalence and factors associated with PD among pregnant women at Kawempe hospital Uganda. Methods: A cross sectional study was conducted among 530 pregnant women attending antenatal care at Kawempe hospital Uganda. The SRQ-20 tool was used to screen for PD and data on socio-demographic and clinical factors was collected using a. socio-demographic questionnaire and medical records respectively. Descriptive statistics were applied to determine the prevalence of PD and multivariable logistic regression analysis was used to assess for factors associated with PD among pregnant women. Results: The prevalence of PD was 19.1% , while having a fair/bad relationship with the spouse (P-value =0.007), a low monthly income (p-value = 0.013), and having less than two meals a day (P-value =0.022). therefore


Background
Psychological distress (PD) among pregnant women is a public health problem because of its impact on the mother and the outcome of the pregnancy (1). Pregnant women experience very signi cant life changes and these include; psychological, physiological, emotional, and these do not come without PD (2). It's a time of new responsibility for the woman, and there are a lot of expectations both from the family and the community. At the same time a woman has to deal with the day today burdens of life and these predisposes her to PD (3).
Globally one in every four people suffer from poor mental health, this makes mental health one of the leading causes of morbidity (4).It has been noted worldwide that about 10% of pregnant women and 13% of women who have just given birth experience a mental disorder. The predicament is even higher in developing countries estimating the prevalence at about 15.6% during pregnancy and about 19.8% after child birth (5). Similarly available literature from low and middle income countries shows the prevalence of PD ranging from 18 % to 38.6% (6)(7)(8)(9)(10)(11) .
Maternal mental illness is associated with poor obstetric outcomes, and poor compliance to the antenatal care visits, which impacts on the government's challenge of bringing down maternal morbidity (12).
Speci cally, several studies have associated maternal PD with preterm births, increased susceptibility to infections, low birth weight, increased cesarean delivery, behavioral problems during childhood, high baseline levels of stress related hormones, and poor cognitive development (4,12,13). In addition, maternal PD has also been shown to affect intra uterine lung development, and as such babies born to mothers with PD in pregnancy have increased odds of developing wheezing and asthma in their rst six years of life (14). Because of the effect of maternal PD on the birth outcomes, the American college of obstetricians and gynecologists (ACOG) recommends screening for psychosocial stressors among all women prenatally and in all trimesters regardless of social status, education level, race or ethnicity (15). The burden of PD among pregnant women in Uganda is not documented and it is not a routine in our setting to screen for it in pregnancy.We set this study to document the prevalence of PD and the factors associated with it among pregnant women Methods From 1 st January 2020 to 30 th March 2020, the study team approached women attending the antenatal clinic at Kawempe National Referral Hospital and requested for their participation. Kawempe National referral hospital is located in Kampala, the capital city of Uganda. Apart from being a referral center, the hospital doubles as a teaching site for Makerere University medical students offering obstetrics and gynaecology, and pediatrics. The hospital serves mainly women of low socio-economic status.
The design was a cross-sectional description study. The study population was pregnant women who were attending the ANC at Kawempe national referral hospital. We excluded women who were too ill, in active labor or those actively bleeding. We conducted systematic random sampling using ANC register to identify the mothers to approach, then we explained to them the purpose of study. Eligible participants were consented/assented. Study participants were then interviewed face to face in the spacious well ventilated room while observing the Ministry of Health COVID-19 protective measures. The Interview was conducted by trained research assistants Outcome measures: We used the SRQ20 tool together with a pretested interviewer administered questionnaire to collect data. The SRQ 20 tool is one of the instruments developed in a collaborative study on strategies for extending mental health care coordinated by WHO (16). It was found appropriate for use in different kinds of settings and countries. It is a self-reporting questionnaire with 20 symptoms which are scored on a dichotomous scale (16). It is a well validated questionnaire for measuring PD or the degree of global mental health (16), and in Uganda Nakigude et al 2005, validated the SRQ 20 tool and, they reported cut off between 5 and 6 to have 80% sensitivity and 74% speci city in detecting psychiatric comorbidity among general out patients. The negative predictive value was 53% and the positive predictive value was 87%. A score of 6 or more was diagnostic of PD (17).
We collected the following information; maternal age, marital status, residence, level of education and occupation, level of income, number of meals consumed per day. The study also inquired about, the history of previous pregnancy and mode of delivery, history of abuse, past medical history, drug abuse, and any current medical condition.
Data management and statistical analysis: The questionnaires were coded and entered into EpiData using double entry procedure to ensure validation. The data was then exported to STATA 14 for further analysis. The prevalence of PD among pregnant women in Kawempe referral hospital was obtained by dividing the number of women diagnosed with PD by the total number of women recruited. To assess for factors associated with PD among pregnant women, variables that had p value of <0.2 were entered into multivariate logistic regression analysis. The variables that were included in multivariate model were; age, duration of marriage/cohabiting, education level, monthly income, status of relationship with spouse/partner, being a victim of abuse, number of major meals in a day, being happy about current pregnancy, presence of chronic illness, presence of fever, parity, trimester, current pregnancy planned, number of children who are alive and mode of delivery in previous pregnancies. Factors that had p-values of less than 0.05 were considered independently associated with PD. Signi cant variables were tested for interaction and dropped variables tested for confounding.
Ethical considerations: Ethical approval to conduct the study was granted by the school of medicine research and ethics committee (SOMREC) at Makerere University, Kampala #REC number 2019-144, Uganda. Permission to conduct the study was obtained from the Kawempe Hospital administration. All participants were consented/assented before participating in the study. Mothers less than 18 years were treated as emancipated minors. All participants were given unique identi ers. Those found with PD were linked to care at Mulago mental health clinic. All methods were carried out in accordance with relevant guidelines and rregulations.

Results
A total of 530 participants were recruited over a period of three months. In table 1 (demographic characteristics), 238 (44.9%) were prime gravidas. The participants ages ranged from 15 to 43 years with a mean age of 25.35 (SD=5.42) years. Majority of the participants were married 374 (70.0 %), lived within Kampala city 348(66%), and had attained secondary level of education 324 (61.25%). Approximately half of the women did not earn an income 275 (51.89%), and majority did not know how much their husbands earned 381(72.43%).
As shown in table 2, most of the participants described the status of the relationship with their spouses/partners as good (86.3%). None of the women smoke cigarettes and among those who drink alcohol (53 women), 52.83% consume beer and 39 (76.47%) consume not more than one liter of alcohol. There were 309 (58.97%) women in their third trimester of the pregnancy, 202(38.55%) in their second trimester, and 13(2.48%) in their rst trimester. The women were assessed for their medical history and about 7 (1.3%) had history of mental illness with only 2 taking medication. Twenty (3.77%) of the participants had a family history of mental illness.
In table 4, about 41 (14.8%) women faced complications during previous/past pregnancy while 42 (15.2%) got complications after delivery. Among the pregnant women, 331(64.02%) had planned the current pregnancy however there are some women who had been forced or raped.
Tables 5, 6 and 7 show factors at bivariate analysis with psychological distress.

Psychological distress among pregnant women
The prevalence of PD was 191 cases of PD in every 1000 pregnant women which is about 19.1%.
The factors at multivariate analysis that were found to be independently associated with PD, were having a fair/bad relationship with the spouse (p =0.007), a low monthly income below 100,000 (p=0.013) and having less or equal to one meal (p=0.022). The details of the multivariate analysis are shown in Table 8.

Discussion
Prevalence of psychological distress among pregnant women.
One in ve pregnant women receiving antenatal services at Kawempe national referral hospital has psychological distress (PD). This magnitude is similar to ndings from studies done in low and middle income countries, including Nigeria, Pakistan, Ethiopia, where the prevalence ranged from 18% to 38.5% (6)(7)(8)(9)(10)(11) . However in high income countries, the prevalence of PD, among pregnant women is much lower than what we found. In the USA, the prevalence of PD among pregnant women was 6.4% in the rst trimester and 3.9% in the third trimester (18). This may be because ACOG recommends screening for psychological stressors among pregnant women and thus a low prevalence (15,18). In France the prevalence of PD was found at 12.7% (19). This high magnitude in our setting justi es the need to introduce screening for PD among pregnant women.
Factors associated with psychological distress among pregnant women in Kawempe hospital.
In this study the factors that were independently associated with PD, were having a fair/bad relationship with spouse, low monthly income and having less than two meals a day.
These results were similar to a study by Karmaliani et al, carried out among 1368 participants which found that PD was associated with low household wealth (6). Also a study by Busari, et al found that low household wealth and verbal/physical abuse were strongly associated with PD this may be because, different contributing factors, as the pregnant woman may not be able to access the basic needs, or the essential needs, or even this may affect their health seeking behavior, due to inability to reach the health centers (3). Some of these factors are also interdependent as low household wealth is likely to result in food insecurity, especially in city suburbs among which this study was conducted. It has also been noted from several studies that families with low household wealth are likely to have increased levels of gender based violence(20). Among the 664 pregnant women who reported to antenatal care in 11 midwife centers and obstetric units in South Africa, Cape Town 38.6% had psychological distress. This study too had low social economic status as one of the major factors that were signi cantly associated with PD(21).
In a study by Jebena et al, looking at household food security and its relationship with psychological distress, it was found that pregnant women living in households experiencing food insecurity were 4.15 times more likely to develop psychological distress than their counter parts. The way these women developed PD, involved the worry to access food, which caused them to sacri ce the of quality diets for what is available (9).In our study, the women who had less than two meals a day were 3.31 times more likely to develop PD as compared to those who had three meals a day.

Strengths of the study:
This was a cross sectional study, and therefore we were able to assess, many variables and their strength of association with psychological distress. Data from our study can be used in other types of research methods, for example, these mothers could be followed up in a cohort study, to know the likely impact of psychological distress, on their pregnancies, or can be used as a case control study to ascertain the strength of association with different factors. This study had also not been conducted before in Uganda and as such, the prevalence of psychological distress among pregnant women had not been known.

Limitations:
The results of this study may have the following limitations. Psychological distress was measured at one point in time, and thus may not give a full picture of the strength of association, with the different variables. This was however minimized by doing both bivariate and multivariate logistics regression on the data, to determine the strength of association.

Conclusion
From this study, one in every ve pregnant women attending the antenatal clinic at Kawempe National referral hospital was diagnosed with psychological distress, and this is similar to studies in low and middle income countries. The independent factors associated with PD were a fair/bad relationship with spouse, low household income and food insecurity, which are also more common in the low and middle income countries, like Uganda. This therefore supports the notion to screen pregnant women for psychological distress, during their antenatal care.

ACOG :
American college of obstetricians and gynecologists. Written informed consent was obtained from all study participants and their willingness to participate was emphasized and they were free to withdraw from the study at any time. All data collected was kept securely in a password protected computer, and the physical data under lock and key. Con dentiality was maintained by restricting access to study data to only the investigators, and not using speci c name identi ers in the data sets.

Consent for publication
Not applicable Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests
The authors declare that they have no competing interests.