Prevalence and associated factors of maternal depression among mothers of children with undernutrition at comprehensive specialized hospitals in northwest, Ethiopia, 2023: a cross‑sectional study

doi:10.21203/rs.3.rs-3785410/v1

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Prevalence and associated factors of maternal depression among mothers of children with undernutrition at comprehensive specialized hospitals in northwest, Ethiopia, 2023: a cross‑sectional study

https://doi.org/10.21203/rs.3.rs-3785410/v1

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Background

Malnutrition remains one of the most significant child health problems in developing countries, accounting for an estimated 53% of child deaths per year. Depression is the leading cause of disease-related disability in women and adversely affects the health and well-being of mothers and their children. Studies have shown that maternal depression has an impact on infant growth and nutritional status. Evidence is scarce regarding the relationship between maternal depression and child malnutrition.

Objectives

To assess the prevalence and associated factors of maternal depression among mothers of children with undernutrition in Comprehensive Specialized hospitals in Northwest Ethiopia, 2023.

Methods

An institutional-based cross-sectional study was conducted among a total of 465 mothers in the hospital. Data were collected by reviewing the patient chart and using an interviewer-administered questionnaire. Outcome variables were assessed by using a patient health questionnaire (PHQ-9). Then it was entered into Epi-data version 4.6 and analyzed using SPSS version 25 computer software. Bi-variable and multi-variable logistic regression analyses were performed to identify factors associated with maternal depression. The presence of an association was presented by an adjusted odds ratio considering a 95% confidence interval and a p-value < 0.05.

Result

The prevalence of maternal depression among mothers of children with undernutrition was found to be 36.4% (95% CI: 32–41%). In the multivariable analysis, Lack of maternal education (AOR = 2.872, 95% CI = 1.502–5.492), being unemployed (AOR = 2.581, 95% CI = 1.497–4.451), poor social support (AOR = 2.209, 95% = 1.314–3.713), perceived stigma (AOR = 2.243, 95% CI = 1.414–3.560), and stunting (AOR = 1.913, 95% CI = 1.129–3.241) were factors significantly associated with maternal depression.

Conclusion

The overall prevalence of maternal depression among mothers of children with undernutrition was high which was associated with a lack of education, being unemployed, having poor social support, high perceived stigma, and stunting physical growth in children with undernutrition. Therefore, to control the high magnitude of maternal depression among mothers of children with undernutration interventions like increasing the level of maternal education and employment status, strengthening social support, and reduction of stigma are required.

prevalence

maternal depression

malnutrition

Ethiopia

Maternal depression refers to depressive disorders experienced by pregnant women and mothers up to 12 months after giving birth. Prenatal, postpartum, and psychotic disorders are all possible manifestations of maternal depressive illness(1). Maternal depressive symptoms include distress, depressed mood, and loss of interest and enjoyment, which are the result of decreased maternal sensitivity and responsiveness to her child's needs as a result of depression (2–4). Malnutrition is defined as a person's intake of energy and/or nutrients being deficient, excessive, or unbalanced. under-nutrition is a category of malnutrition”-which includes stunting (low height for age), wasting (low weight for height) and underweight (low weight for age)(5). Since feeding and caring for the young is primarily the mother’s responsibility, poor maternal physical or mental health can adversely affect the nutrition, health, and psychological well-being of children (6).

Malnutrition is one of the most significant child health issues in developing countries with approximately 19.4% and 29.9% of children aged under 5 years having underweight and stunting respectively (7). Maternal depression affects 15.6% and 19.8% of women during antenatal and postnatal periods respectively in low- and middle-income countries (LMIC)(2). In sub-Saharan African countries, rates of maternal depression range from 6–30%. Approximately 20% of women experience clinically relevant depressive symptoms during pregnancy; in over 40% of them, the symptoms continue postpartum, and 80% of women with Postpartum Depression (PPD) have subsequent depressive episodes(8). Maternal depression is common during the postpartum period, with an estimated 14% of new mothers experiencing depression in the first 6 months after delivery(9). Studies from different countries showed that the prevalence of depression among mothers of children with undernutrition was higher than among mothers of children with normal nutritional status; the reported evidence from Uganda indicates that the prevalence of depression among mothers of malnourished children was 42% compared to 13% among mothers of controls(10), Kenyan about 64.1% mother with malnourished children has depression higher than mothers of normal weight children (5.1%)(6).

Despite rates of child malnutrition in many regions of the world have declined in recent years, remains one of the most significant child health problems with an estimated 53% of child deaths per year(11, 12).

Malnutrition impairs physical growth, increases morbidity and mortality and reduces cognitive development and physical work capacity(13). Malnutrition is an underlying risk factor that increases the morbidity and mortality of many diseases in children and adults (14). Research in developing countries indicates that maternal depression is a risk factor for poor child growth in young infants (15).

In addition, the combination of women’s vulnerability to depression, their responsibility for childcare and the high prevalence of maternal depression in developing countries have a substantial influence on growth during childhood (16). Moreover, psychosocial factors including maternal mental health status affect breastfeeding in both high- and low-income countries (17–19). Mothers with depression symptoms also stop exclusive breastfeeding earlier than mothers without symptoms(18, 20).

Maternal mental health significantly impacts children's nutritional status, interfering mother’s responsibility for child care(21, 22). Evidence suggests a link between maternal mental health and child undernutrition in low-income countries, with more than 40% increased risk of stunting for children of mothers with depression symptoms(10, 23, 24). Risk factors for maternal depression include low income, education level, lack of financial support, child age, residence region, mothers' education, household wealth index, sex, and family size (25–28).

Even though the impact of maternal mental health on children's emotional, cognitive, and behavioral problems in high-income countries has been well studied, but less studied in low and middle-income countries where malnutrition is a major issue(29, 30).

Although there is a dearth of evidence on child factors and maternal depression, that addresses the relationship between maternal depression and child-related factors, such as malnutrition, childhood illness, is scarce. As a result, the purpose of this study was to assess the magnitude and associated factors of maternal depression among mothers with malnourished children in comprehensive specialized hospitals in Northwest, Ethiopia.

2.1 General Objective

The general objective of this study is to assess the prevalence and associated factors of maternal depression among mothers of children with undernutrition in Comprehensive Specialized Hospitals of Northwest Ethiopia, 2023.

2.2 specific objectives

To determine the prevalence of maternal depression among children with undernutrition in Comprehensive Specialized Hospitals of Northwest Ethiopia, 2023

To identify the associated factors of maternal depression among children with undernutrition in Comprehensive Specialized Hospitals of, Northwest Ethiopia, 2023

4.1 Study design and Study Area

An institution-based cross-sectional study design was conducted from March to April 2023 in three comprehensive specialized hospitals of which the University of Gondar Comprehensive Specialized Hospital (UoG CSH)) is located in Gondar which is located 750 km Northwest of Addis Ababa, the capital city of Ethiopia. whereas the two namely: Tibebe Ghion Comprehensive Specialized Hospital (TGCSH)and Felege Hiwot Comprehensive Specialized Hospitals (FHCSH)are located in Bahir Dar City, Northwest part of Ethiopia. Bahir Dar is the town of Amhara Regional State, located at a distance of 565 km from Addis Ababa. These hospitals have separate rooms for treatment of under malnourished children and approximately 1042 under malnourished children are being treated each month both in the Pediatric ward and outpatient department (OPD).

4.2 Source Population

All women having children with malnutrition attending child care and treatment at Comprehensive Specialized Hospitals in Northwest Ethiopia

4.3 Study Population

All women having children with undernutrition attending child care and treatment at Comprehensive Specialized Hospitals in Northwest Ethiopia who were admitted and avails at the time of the study period

4.4 Eligibility Criteria

4.4.1 Inclusion and Exclusion Criteria

Mothers of malnourished children attending pediatric wards and OPD during the data collection period were included in the study. Participants were excluded from the study, who were critically ill and difficulty communicating.

4.5 Sampling

The sample size was determined by using a single population proportion formula with a 95% confidence level, 4% margin of error and considering the prevalence of maternal depression 22.8%(proportion = 0.228) from a study conducted in Ethiopia(31).

$$\frac{{\left(\frac{Z\alpha }{2}\right)}^{2 }p(1-P)}{{d}^{2}}$$

Where, n = minimum sample size

Z critical value = 1.96

p = 22.8%.

95% Confidence level and 4% margin of error

After adding 10% for the likelihood of non-response (with a calculated non-respondent rate is 42). Then the final sample size was 423 + 42 = 465 participants. Systematic random sampling technique was used to select samples after proportionally allocating for three Comprehensive Specialized hospitals. (Fig. 1)

4.7 Variables

4.7.1 Dependent variable

Maternal Depression yes/no

4.7.2 Independent variables

Socio-demographic factors

Age, residence, marital status, level of education, occupation and family size assessed by a structured questionnaire.

Clinical factors for mothers

history of chronic medical illness, family history of mental illness.

Substance use factors: current substance use: (Alcohol, Khat)

Children-related factors

age of children, sex of children, children's medical illness, weight of children, height of children.

Obstetric factors

Pregnancy complication or illness, unplanned pregnancy, Mode of delivery, Stressful life event during pregnancy, undesired fetal sex, history of abortion.

Psychosocial factors

Social support (Husband support, Domestic violence (intimate partner violence), unsatisfactory relationship with Mother-in-law, unsatisfactory relationship with husband), Perceived Stigma.

Child-related factors (age of children, children's medical illness and undernutrition (low height, low weight).

4.8. Data collection instrument and procedure

Data was collected by reviewing the patient chart as well as using an interviewer-administered questionnaire, which was adapted to the local contexts employed as a tool for this study.

Socio-demographic characteristics like residence, age at the time of interview, marital status, ethnicity, religion, education, occupational status.

Maternal depression

Patient Health Questionnaire-9 (PHQ-9) was used to measure maternal depression. (PHQ-9) is a screening tool created in 2001 by Dr Robert Land and his colleagues at Columbia University in the United States to screen adult patients for the presence and severity of depression in a primary care setting (32). The PHQ-9 is a self-rated depression scale with nine items that asks about the past two weeks with response options ranging from “not at all” to “nearly every day.” The items reflect the nine criteria on which the diagnosis of DSM-5 major depressive disorder is based(32). The PHQ-9 score ranges from 0 to 27. Each of the 9 items scored from 0 (not at all) to 3 (nearly every day) (32). PHQ-9 is used to grade depressive symptom severity as none (score of 0–4), mild (5–9), moderate (10–14), Moderately severe depression 15–19 and Severe depression 20–27 as recommended by the scale developers(32). PHQ-9 has validity and usefulness in East Africa, which is widely used in Kenya for screening maternal depression(33) and in rural settings in Ghana for screening postpartum depression(34). The PHQ-9 items showed good internal consistency (Cronbach's alpha = 0.85)(35).

PHQ-9 is validated in Ethiopia, in urban and rural areas with a cut-off point ≥ 10 in urban and ≥ 5 in rural settings respectively and in urban settings with specificity and sensitivity of 67% and 86%, respectively for rural settings sensitivity is 83.5% and specificity is 74.7% (35, 36).

Social support

was measured using the Oslo Social Support Scale (OSSS-3)(37). The Oslo 3 Social Support Scale is a quick and affordable tool for determining the extent of social support. Without considerably increasing the workload for researchers or participants, it can be incorporated into bigger research initiatives like population-based studies. Oslo-3, which consists of 3 questions on one's family, friends, and neighborhood. The Oslo-3 scale consists of three items, the sum of which ranges from 3 to 14 (38). The Oslo 3-item social support scale (OSSS-3), is poor social support (a score of 3–8), intermediate social support (a score of 9–11), and strong social support (a score of 12–14). In African countries, it is validated in Nigeria among the population of clinical students and in general adult depression. Oslo-3 commonly used to assess level of social support in different Ethiopian studies, in particular with related psychiatric conditions. The internal consistency of the Oslo-3 of tools (Cronbach’s alpha = 0.91) in Nigeria(39).

Perceived stigma

was assessed by a three-item stigma scale. In the European population, a simple three-question tool for determining the extent of patients' perceived stigma has been developed and validated (40).In African countries three-item stigma scale which is validated in Zambia for epilepsy patients and comprised of dichotomous questions in which a positive response is indicative of perceived stigma with an overall possible score ranging from 0 (no perceived stigma) to 3 (maximally perceived stigma)(41).

Intimate partner violence

An intimate partner is defined as a present or former partner, husband, boyfriend, or ex-partner. Regardless of the legality of the relationship with the current or past intimate partner, women were deemed to have suffered intimate partner violence (IPV) if they answered "yes" to any one of the ranges of sexual, psychological, and physical coercive acts or any combination of the three(42).

Clinical factors of mothers: was assessed by structured questioners: family history of mental illness, and history of medical illness.

Child-related factors (age of children, children's medical illness) and undernutrition

Anthropometric measurement:

Children’s ages were recorded, and mid-upper arm circumference (MUAC, weight and height were taken following standard anthropometric procedures(43).

Undernutrition in the present study was characterized by the following indexes: stunted, underweight, and wasted. For children who were newly admitted, standard anthropometric procedures were used to measure their weight, height, and mid-upper arm circumference (MUAC), whereas for those who had been hospitalized for a long time and had established nutritional support, the data was retrieved from medical charts. The age of the child was determined from the mother's report. Anthropometric measures were converted into height for age, weight for height and weight for age. Finally, cases were considered if their Z scores were below minus three standard deviations (− 3SD) and a MUAC less than 115 mm according to WHO growth standard measurements (44).

Using standard cut-off points, operational definitions of malnutrition in all its manifestations are as follows: Children who had WAZ, HAZ and WHZ Z-scores are more than or equal to minus two standard deviations (≥ -2SD) were classified as normal underweight, stunted and wasted respectively. Children who had WAZ, HAZ and WHZ Z scores below − 2SD were classified as mild underweight, stunted and wasted respectively and Those with WAZ, HAZ and WHZ Z- scores below − 3SD were classified as moderate/severe underweight, stunted and wasted respectively(45, 46).

Obstetric factors

like unplanned pregnancy, mode of delivery, history of abortion, birth complication, child hospitalization, desired sex of the child, and child death were assessed by structured questioners.

Substance-related factors

like current use, and every use of substance.

Current substance use

according to alcohol, smoking, and substance involvement screening test (ASSIST) using at least one of a specific substance (Alcohol, Khat) for nonmedical purposes within the last 3 months (47).

Ever use of substance

according to alcohol, smoking, and substance involvement screening test (ASSIST) using at least one of any specific substance (Alcohol, Khat ) for the nonmedical purpose at least once in a lifetime(47).

4.9 Operational definitions

Maternal Depression

Those who were found to score ≥ 10 from PHQ-9 were considered as having depression (32).

Social support- using the OSLO scale categorized into poor ‘3–8’, moderate “9–11”, and strong “12–14”.

Perceived stigma

Perceived stigma was assessed by a three-item stigma scale with an overall possible score ranging from 0 (no felt stigma) to 3 (maximally felt stigma) (41).

Intimate partner violence

The current or past intimate partner, women were deemed to have suffered intimate partner violence (IPV) if they answered "yes" to any one of the ranges of sexual, psychological, and physical coercive acts or any combination of the three(42).

Child anthropometry

Children were classified as under-nutrition if their weight-for-age, height-for-age and weight-for-height Z- scores, fell below − 3SD the median WHO growth criteria (Z score), and if their MUAC was less than 115 mm. Those with WAZ, HAZ and WHZ Z- scores below − 3SD were classified as underweight, stunted and wasted respectively(45, 46).

Ever use of substance

refers to the use of at least one of any specific substance for a non-medical purpose at least once in a lifetime (alcohol, khat).

Current substance use denotes using at least one of any specific substance for non-medical purposes within the last 3 months (alcohol, khat).

Chronic medical illness: refers to previous experiences of any physical illness whose information was collected using the following question: “Have you ever been faced with any known chronic medical illness? “ If their response was yes, it was being considered as having a chronic medical illness.

Family history of mental illness: the previous history of mothers ‘mental health problems. The information was based on a guiding question “Do you have family members who have ever known mental illness and answers?” If their response was “yes”, the respondent was considered as having a family history of mental illness.

4.10 Data collection process and Data quality assurance

Data were collected by both face to face interviews and reviewing the children’s medical charts by using Amharic version of a pretest was conducted about 5%( n = 23) of the total sample size in Debre Tabor University referral hospital with Cronbach's alpha of 0.76 for (PHQ-9).Two days of training were given before data collection for data collectors and supervisors on the objective of the study, sampling procedures, structured questionnaires and how to handle ethical issues and confidentiality. Regular supervision and control were made for data collectors by the supervisor and principal investigator. The collected data was properly handled, reviewed and checked for completeness and consistency. Mothers who were highly depressed during data collection were advised to consult mental health professionals at nearby hospitals.

4.11 Data Processing and Analysis

First, the data was checked for completeness and consistency. The collected data was coded, edited, entered, and checked into the computer using EPI data version 4.6 and analyzed using SPSS version 25. Data was presented by using numbers, frequencies, tables, charts and figures. To determine the association between dependent and independent variables adjusted odds ratio was used using logistic regression and the significance level was determined using a confidence interval of 95%. Bivariate and multivariable logistic regression analyses were undertaken to identify the independent predictors of maternal depression. This was done by entering each independent variable separately into bivariate analysis. Then variables with a p-value of less than 0.2 on bivariate analysis were entered into multivariate logistic regression. Then, variables which were showed a statistically significant association with a p-value less than 0.05 on logistic regressions were considered as predictors of maternal depression. The model's fitness was checked, and a Hosmer and Lemeshow Test value of 0.65 was found. Tolerance and variance inflation factors (VIF) were checked to test multicollinearity and showed that tolerance was ≥ 0.253 while VIF was ≤ 4.924.

5.1 Socio-demographic Characteristics of the Study Participants

A total of 465 mothers of children with undernutrition participated in this study out of which 456 (98%) participants completed the interview. The remaining 9 participants were excluded due to the incomplete data they provided. The participants were aged between 19 and 42 years. The mean age of respondents was found to be 30.22 (SD: ±5.292). Nearly two-thirds (65.4%) of the study participants were in the age range of 25–34 years, over three-fourths, specifically 361(79.2%) of the respondents were married. About 83(18.2%) of the participants had not attended formal education. About 177(38.8%) of the mothers were housewives and the majority of mothers 256(56.1%) were urban residents (Table 1).

Table 1

Socio-demographic characteristics of participants among mothers of children with undernutrition in Northwestern Ethiopia, (n = 456), 2023
Variables	Categories	Frequency	Per cent
Age	16–24	35	7.7
	25–34	298	65.4
	> 34	123	27
Mothers Marital status	Married	361	79.2
	Divorced	85	18.7
	Widowed	10	2.2
Mother Educational Status	Not educated	83	18.2
	Primary	183	40.1
	secondary and above	190	41.7
Mothers’ Occupation	Employed	151	33.1
	Housewife	177	38.8
	Unemployed	128	28.1
Residence	Urban	256	56.1
Residence	Rural	200	43.9

5.2 Psychosocial and clinical characteristics of the participants

Regarding psycho-social factors of mothers having children with undernutrition, the majority 192 (42.1%) of the respondents reported having poor social support. Nearly half (48.9%) of the mother participants indicated that they have experienced perceived stigma due to their being mothers of malnourished children. The majority (44.7%) of mothers reported they had experienced intimate partner violence. Nearly one-fifth (18.4%) of mothers had physical and verbal abuse. Over two-fifths (43.2%) of mothers had no satisfaction with their marital relationship.

Out of the total participants, 46(10.1%) of mothers have a family history of mental illness, and 35 (7.7%) of mothers have a known chronic medical illness. (Table-2)and (Fig. 2)

Table 2

Psychosocial and clinical characteristics of the participants among mothers of children with undernutrition in Northwestern Ethiopia, (n = 456), 2023
Variables	Categories	Frequency	Per cent
Social support	Poor social support	192	42.1
	Moderate social support	144	31.6
	Good Social Support	120	26.3
Perceived Stigma	Yes	223	48.9
Perceived Stigma	No	233	51.1
Intimate partner violence	Yes	204	44.7
	No	252	55.3
	Verbal and Physical	84	18.4
	Physical	32	7.0
	Verbal	70	15.4
	No abuse	270	59.2
Satisfaction with marital relationship	Yes	259	56.8
Satisfaction with marital relationship	No	197	43.2
Family mental illness	Yes	46	10.1
Family mental illness	No	410	89.9
chronic medical illness	Yes	35	7.7
	No	421	92.3
	DM	26	5.7
	HIV AIDS	9	2.0

5.3 Substance-related Characteristics of Participants

From the study participants, nearly one-third (32.5%) of participant mothers used substances at least once in their lifetime; whereas nearly one-third (31.4%) of mothers were found to have an experience of drinking alcohol. Among the study participants, one-fourth (25.9%) of mothers used substances in the past 3 months. 84(18.4%) of mothers were drinking alcohol (Table 3).

Table 3

Substance-related characteristics of the participants among mothers of children with under nutrition in Northwestern Ethiopia, (n = 456), 2023
Variables	Categories	Frequency	Percentage
Every substance used in life	Yes	148	32.5
Every substance used in life	No	308	67.5
Alcohol	Yes	143	31.4
Alcohol	No	313	68.6
Khat	Yes	17	3.7
Khat	No	439	96.3
Alcohol and Khat	Yes	7	1.5
Alcohol and Khat	No	449	98.5
Current substance used	Yes	118	25.9
Current substance used	No	331	72.6
Alcohol	Yes	84	18.4
Alcohol	No	372	81.6
Khat	Yes	29	6.4
Khat	No	427	93.6
Alcohol and khat	Yes	11	2.5
Alcohol and khat	No	445	97.5

5.4 Obstetric factors

Of all the respondents, about four-fifths (81.1%) had their 2–4 pregnancy and nearly one-fifth (17.1%) women had hospitalized their babies. about 58(12.7%) of the women had a history of abortion. about 42(9.2%) of the women delivered by operation. Nearly three-fourths (77.4%) had unintended pregnancy. about 44(9.6%) of mothers had complications during the last delivery (Table 4).

Table 4

Obstetric factors of the participants among mothers of children with undernutrition in Northwestern Ethiopia, (n = 456), 2023
Variable	Categories	frequency	Percentage
Number of pregnant	1	67	14.9
	2–4	370	81.1
	> 4	18	4
Number of abortions	Yes	58	12.7
Number of abortions	No	398	87.3
Hospitalization of baby	Yes	78	17.1
Hospitalization of baby	No	378	82.9
Death of children	Yes	46	10.1
Death of children	No	410	89.9
Mode of delivery	Vaginally	357	78.3
	Operation	42	9.2
	Instrumental or C/section	57	12.5
Planned pregnancy	Yes	103	22.6
Planned pregnancy	No	353	77.4
Sex of the last child	Male	297	65.1
Sex of the last child	Female	159	34.9
Desired sex for the last child	Yes	385	84.4
Desired sex for the last child	No	71	15.6
Complications during last pregnancy	Yes	44	9.6
Complications during last pregnancy	No	412	90.4

5.5 Anthropometric measurements of children

About 75.7% of under-malnourished children were underweight (low weight for age), 62.1% were stunted (low height for age), and 50.7% were wasted (low weight for height). 26(5.7%) of Children with malnutrition had known chronic medical diseases (Diabetic Mellitus (DM), Human Immune Virus (HIV) and Congestive heart failure (Table 5).

Table 5

Anthropometric measurements and child clinical characteristics of children of the participants among mothers of children with undernutrition in Northwestern Ethiopia, (n = 456), 2023
Variables	Categories	Frequency	Valid Percent
Age of child	0–5	56	12.3
	6–23	185	40.6
	24–59	215	47.1
WAZ(weight to age) (underweight)	Yes	345	75.7
WAZ(weight to age) (underweight)	No	111	24.3
HAZ(height to age) (stunting)	Yes	283	62.1
HAZ(height to age) (stunting)	No	173	37.9
WHZ(weight to height) (Wasting)	Yes	231	50.7
WHZ(weight to height) (Wasting)	No	225	49.3
			Percentage (%) or mean (SD)
Underweight			-4.78 ± 2.42
Stunting			-4.49 ± 5.29
Wasted			-2.83 ± 4.49
Child chronic medical Illness (DM, HIV, CHF)	Yes	26	5.7
Child chronic medical Illness (DM, HIV, CHF)	No	430	94.3

5.6 Prevalence and associated factors of maternal depression

The overall prevalence of maternal depression among mothers of children with undernutrition was 166 (36.4%) with (95% CI: 32–41%).

Mother's educational status, marital status, mother's occupational status, history of known chronic medical illness, family history of mental illness, alcohol use, social support, Perceived Stigma, intimate partner violence (physical and verbal abuse, physical abuse), Last pregnancy planned, stunting, wasting, underweight, chronic medical illness of the child, and hospitalization were factors associated with maternal depression at a p-value less than 0.2 in binary logistic regression.

Finally, multivariate logistic regression analysis indicated that the mother's educational status, mother's occupational status; poor social support, perceived stigma and stunting were found to be significantly associated with maternal depression with 95% CI and a p-value less than 0.05. Lack of maternal education made mothers 2.9 times more likely to develop maternal depression as compared with mothers educated in secondary school level and above (AOR = 2.872,95%CI = 1.502–5.492). Mothers with unemployment were 2.6 times more likely to develop maternal depression as compared with mothers with employed (AOR = 2.581,95%CI = 1.497–4.451). Mothers who had poor social support were about 2.2 times more likely to develop maternal depression when compared to those who had strong social support (AOR = 2.209,95%=1.314–3.713). Mothers who had perceived stigma were about 2.24 times more likely to develop maternal depression when compared to those who did not (AOR = 2.243,95%CI = 1.414–3.560). Regarding child malnutrition, mothers of children who were stunted were 1.9 times more likely to develop maternal depression when compared to those mothers of children who were not stunted (AOR = 1.913,95%CI = 1.129–3.241) (Table 6).

Table 6

bivariate and multivariable logistic analysis of factors associated with maternal depression among mothers of children with undernutrition at a comprehensive specialized hospital in North West, Ethiopia (n = 456), 2023
Variables	Categories	Maternal Depression		COR and 95% CI	AOR and 95% CI
Variables	Categories	Yes	No	COR and 95% CI	AOR and 95% CI
Mothers Marital status	Married	117	244	1	1
	Separated	17	22	1.611(.824, 3.150)	.996 (.435, 2.283)
	Divorced/widowed	32	24	2.781 (1.567, 4.933)	1.837 (.925, 3.647)
Mother Educational Status	Not educated	52	31	3.302 (1.930, 5.650)	2.872 (1.502, 5.492) ***
	Primary School	50	133	.740 (.475, 1.153)	.824 (.490, 1.385)
	secondary and above	64	126	1	1
Mother Occupation	Employed	41	110	1	1
	Housewife	89	88	1.058(.620, 1.777)	.928 (.503, 1.712)
	Unemployed/No occupation	36	92	2.713(1.706, 4.316)	2.581 (1.497, 4.451) **
Social Support	Poor social support	94	98	2.427 (1.571, 3.751)	2.209 (1.314, 3.713) ***
	Moderate social support	23	68	.597 (.485, 1.524)	.715 (.358, 1.428)
	Good Social Support	49	124	1	1
Perceived Stigma	Yes	110	113	3.077 (2.064, 4.586)	2.243(1.414, 3.560) ***
Perceived Stigma	No	56	177	1	1
Intimate partner violence	Yes	105	99	1.382(.939, 2.034)	1.380( .700, 2.720)
Intimate partner violence	No	190	61	1	1
What kind of abuse	Verbal and physical	35	49	1.429(.865,2.360)	1.295 (.715, 2.345)
	Physical	13	19	1.368(.647, 2.895)	1.204(.487, 2.979)
	Verbal	28	42	1.333(.776, 2.290)	1.339(.680, 2.635)
	No abuse	90	180	1	1
Current substance used	Yes	50	68	1.407(.917, 2.160)	3.666(.777, 17.297)
Current substance used	No	116	222	1	1
Current Alcohol use	Yes	30	54	1.267(.642, 1.745)	1.378 (.748, 2.536)
Current Alcohol use	No	64	146	1	1
Family History of Mental illness	Yes	22	24	1.693(.917, 3.126)	1.792 (.849, 3.783)
Family History of Mental illness	No	144	266	1	1
Chronic medical history of mothers(DM, HIV)	Yes	16	19	1.521 (.760, 3.046)	1.660 (.690, 3.990)
Chronic medical history of mothers(DM, HIV)	No	150	271	1	1
WAZ(under weigh)	Yes	140	205	2.233 (1.369, 3.641)	2.837 (.996, 3.387)
WAZ(under weigh)	No	26	85	.051	.996
HAZ(stunting)	Yes	119	164	1.945(1.291,2.931)	1.913 (1.129, 3.241) *
HAZ(stunting)	No	47	126	1
WHZ(wasting)	Yes	95	136	1.515 (1.032, 2.225)	1.401 (.852, 2.304)
WHZ(wasting)	No	71	154		1
Child chronic medical illness	Yes	15	11	2.520(1.129, 5.623)	.383 (.142, 1.033)
Child chronic medical illness	No	151	279	1	1
The child had hx of hospitalized	Yes	34	44	1.440(.878, 2.362)	1.380 (.768, 2.481)
The child had hx of hospitalized	No	132	246	1
Last pregnancy planned	Yes	29	74	1.618 (1.002, 2.615)	1.785 (.999, 3.192)
Last pregnancy planned	No	137	216	1	1
𝑃 Value < 0.05, 𝑃 value < 0.01, and **𝑃 value < 0.001, Hosmer and Lemeshow test = 0.65

Maternal depression might contribute to undernutrition in children by having a negative impact on interpersonal behaviour and impairments in social functioning and tend to be less responsive towards their children. Maternal depression can reduce maternal interest in a child which impairs a woman’s ability to cope with the responsibilities of being a mother and reduces a mother’s involvement in maternal care, which impairs the physical growth of the child.

In this study, the prevalence of maternal depression and its possible associated factors was assessed. The findings indicated that a high number of mothers suffered from maternal depression.

From the total of 456 respondents, the prevalence of maternal depression among mothers’ children with undernutrition was 36.4% (95% CI: 32–41%). The finding of the current study was consistent with the findings of other studies done in Botswana which reported that the prevalence of maternal depression for a similar population was 33.3%(48).

However, the prevalence of maternal depression in this study was higher than previous research findings done in North Ethiopia, among the Meket district (22.8%)(31). The variation could be due to the different types of study settings. The previous study was a community-based study, and the current study was a hospital-based institution, where severely malnourished children are receiving care and maternal depression is expected to be higher. It is possible that the hospital-based study setting causes emotional distress. The other possible reason could be the different screening tools used in both the previous and current studies; the previous study used the Edinburgh Postnatal Depression Scale (EPDS), while the current study used the PHQ-9)(31). In addition, another plausible explanation accountable for the difference could be the sample size difference between the current and previous studies.

The current prevalence finding of maternal depression was also higher in studies done outside Ethiopia in a study among mothers of children with malnutrition that involved a comparative study between African countries; specifically Northern Ghana, Kenya for which the prevalence rate was reported at 27.8% and 27.1% respectively (49, 50), Similarly in the current study the prevalence of maternal depression was also higher than a study done at Brazil which reported 17.9% (51). The possible reason for those variations may be due to differences in the socioeconomic status of participants, maternal educational status, screening tools and cut-off points, study setting and availability of health facilities between those countries. People who live in low-income countries like Ethiopia could have poor healthcare infrastructure and be vulnerable to developing stress, which is directly or indirectly responsible for the onset of maternal depression (52). The screening tools used in Northern Ghana, Kenya and Brazil were different from the screening tools used in the current study. Centre for Epidemiological Studies Depression Screening Scale (CES-D), Beck‘s Depression Inventory (BDI) and EPDS were used in Northern Ghana, Kenya and Brazil respectively, Whereas the current study used PHQ-9 which has more sensitivity compared to tools employed in previous studies in Africa and Brazil (49–51) In this regard, the use of PHQ-9 may overestimate the prevalence of maternal depression among mothers of children with undernutrition. The other plausible explanation for the discrepancy in the prevalence rate between our current study and the previous study in Brazil may be attributable to the type of research design employed, specifically the cohort used in Brazil (51). In this regard, this study design was performed for a long study period which may lead participants to develop resilience to adverse conditions of child malnutrition in the longer course of the study period. However, the current study was based on cross cross-sectional study design which lasted for a shorter time and gave little or no opportunity to measure the effect of coping and resilience across time on their current state of depression hence a single shot survey may overestimate the prevalence rate.

In contrast, the current study finding is lower than the previous study done in Kenya, Uganda and Sudan 64.1%, 42% and 41.5% respectively (8, 53, 54). The possible reason for those variations may be due to differences in the screening tool and its cut-off points employed for the current and the previous study. The previous study screening tool in Uganda was the Mini International Neuropsychiatric Interview (M.I.N.I.) while Kenyan and Sudanese studies employed PHQ-9 similar to the current study but with different cut-off points, PHQ-9 ≥ 5 in Kenya(53). But in the current study PHQ-9 ≥ 10.

Regarding factors affecting maternal depression; Mothers of children who did not attend formal education were 2.9 times more likely to have maternal depression as compared with mothers who were educated. This finding was supported by previous studies done in Ethiopia, Saudi Arabia, Iran and Japan (55–57). The emotional and behavioural problems that poor readers experience may make them more prone to depression as well as being difficult to control(58). Mothers with a lack of literacy suffer from low self-esteem, low level of confidence and inability to make independent decisions and are held responsible for every unfavorable event, this creates a negative feeling among the mothers. The level of education a person has is one of the most important indicators of their economic situation; a lower socioeconomic position is linked to more stressors and a higher risk of developing depressive symptoms (59).

Mothers of children who were unemployed were 2.6 times more likely to develop maternal depression as compared with mothers who had been employed. This finding was in line with the results done in Sudan, Kenya and Saudi Arabia (57, 60, 61). The possible reason may be Unemployed mothers are stressed, psychologically distressed and anxious about their future work prospects and current and future financial situations or lack of adequate income among unemployed mothers leads to stressors. It was further asserted that unemployment may contribute to depression due to losses in social contact and status or stress related to financial losses. Following postpartum periods are known as stressful times, and unemployment is the main trigger for past stress and increases the risk of maternal depression(62).

Mothers of children with poor social support were 2.2 times more likely to have maternal depression as compared with mothers who had strong social support. This finding was in line with previous studies done in Ethiopia (63–65) and in Sudan, Pakistan and Japan (66–68). The possible reason may be due to lack of social support mothers may be more susceptible to stress, loneliness, hopelessness, low self-esteem and psychological distress(69). The mother who has good asocial support throughout the postpartum period will be able to handle their responsibilities at home, be able to deal with challenges and problems and minimize the risk that major stressor may case depression.

Mothers who had perceived stigma due to being mothers of undernourished children were about 2.24 times more likely to develop maternal depression when compared to those who did not. The main emphasis of the previous study was how perceived stigma impacts mothers’ help-seeking behaviour, which in turn may lead to clinical maternal depression. To the best of the researcher’s knowledge, there are no studies that examine whether perceived stigma influences self-reported maternal depression and the association between the two. Experienced perceived stigma is a person's perception of being stigmatized by others because of their children being undernourished (which may or may not accurately reflect network member’s behaviour and feelings) while internalized perceived stigma is a person's negative feelings (such as shame and deviance) about their malnourished children(70). The possible justification may be perceived stigma as a belief that people will devalue and discriminate against other individuals whose mothers are having children who are malnourished. The main reason for the findings of the current study is nicely articulated in previous studies which asserted that perceived stigma impacts social support and may cause self-isolation, low self-esteem and more vulnerability to stress (71, 72). Mothers of children with undernutrition are easily vulnerable to shame, ignorance, feelings of isolation from social situations and guilty feelings because their Neighbors typically hold them accountable for their undernourished children(73).

Mothers having stunted children were over two times more likely to have maternal depression as compared to mothers whose children were not stunted. This finding was supported by previous studies done in Kenya, Uganda, Botswana; India and Pakistan (25, 53, 74–76). Mothers of stunted children are more vulnerable to stressor related to their child's health and physical status feels helplessness, and sadness and has low self-esteem.

The symptoms of depression data were evaluated using maternal recall of the two weeks before the survey; this may have contributed to under- or over-reporting of depression symptoms and may lead to recall bias.

Data was collected through face to face interview, which leads social desirability bias.

In this study, the overall prevalence of maternal depression among mothers of children with under-nutrition was found to be higher compared to most previous studies reviewed and hence maternal depression is a significant burden for mothers who are malnutrition children. The distribution of maternal depression among malnutrition children was high among mothers with a lack of education, unemployment, poor social support, and perceived stigma and stunting in children with undernutrition. Therefore, early screening and detection of maternal depression is necessary and Provides educational opportunities, reduces unemployment, strengthens social support and suppresses perceived stigma on the part of mothers having under-malnourished children. Researchers are advised to conduct longitudinal studies to identify the cause-and-effect relationship of maternal depression among mothers of children with undernutrition.

AOR

Adjusted odds ratio

Confidence interval

COR

Crude odds ratio

EPDS

Edinburgh Postnatal Depression Scale

Epi-Data

Epidemiological Data

LMIC

Low- and middle-income countries

PHQ

Patient Health Questionnaire

Acknowledgement

The authors of this study would like to acknowledge the participants of the study, data collectors, supervisors, and staff members of the pediatric Department.

Author’s contribution:

BY: conceived the idea, developed the proposal and participated in data collection, Analysis and wrote the final paper. BG, GNa, and GN participated in data analysis and revised subsequent drafts of the paper and were involved in writing up and final review of the manuscript. All authors read and approved the final manuscript.

Availability of data and materials

The data included in the manuscript can be obtained from the corresponding author through the email address "[email protected]" with a rational request.

Fund: University of Gondar provided the entire funding for the materials and humanitarian assistance needed for this research study.

Ethics approval and consent to participate

The study was approved by the Institutional Review Board (IRB) of the University of Gondar, and it was to be conducted following the Declaration of Ethical Guidelines. A formal letter of permission was obtained from the Department of Psychiatry. Written informed consent and assent form was obtained from each study participant and/ or their legal guardians or parents, after detailed explanations before the interviews. The privacy of study participants and the confidentiality of the information were maintained during the data collection process. The collected data were used only for the objective of this study.

Conflict of interest

There is no competing of interest declared by the authors

Consent for publication: Not applicable

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No competing interests reported.

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Prevalence and associated factors of maternal depression among mothers of children with undernutrition at comprehensive specialized hospitals in northwest, Ethiopia, 2023: a cross‑sectional study

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Abstract

Background

Objectives

Methods

Result

Conclusion

Figures

1. Introduction

2. OBJECTIVE

2.1 General Objective

2.2 specific objectives

4. METHODOLOGY

4.1 Study design and Study Area

4.2 Source Population

4.3 Study Population

4.4 Eligibility Criteria

4.4.1 Inclusion and Exclusion Criteria

4.5 Sampling

95% Confidence level and 4% margin of error

4.7 Variables

4.7.1 Dependent variable

4.7.2 Independent variables

4.8. Data collection instrument and procedure

4.9 Operational definitions

4.10 Data collection process and Data quality assurance

4.11 Data Processing and Analysis

5. Results

5.1 Socio-demographic Characteristics of the Study Participants

5.2 Psychosocial and clinical characteristics of the participants

5.3 Substance-related Characteristics of Participants

5.4 Obstetric factors

5.5 Anthropometric measurements of children

5.6 Prevalence and associated factors of maternal depression

6. DISCUSSION

7. Limitations

8. Conclusion and recommendation

Abbreviations

Declarations

References

Additional Declarations

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