DOI: https://doi.org/10.21203/rs.2.14705/v2
Postpartum depression (PPD) refers to non-psychotic depressive episodes that begin in or extend into the postpartum period (1). According to The American psychiatric association (APA) postpartum depression is defined as the occurrence of a major depressive episode (MDE) within 4 weeks after delivery (2).
About 14% of the worldwide burden of disease has been attributed to neuropsychiatric disorders, including those disorders that can occur during the postpartum period. Such estimates have drawn attention to the importance of mental disorders for public health (3). The estimated lifetime prevalence of having one or more of the mental disorders varies widely across the world as shown by mental health surveys, from 12.1% in Nigeria to 47.4% in the United (4).
Postpartum depression is a non-psychotic depressive disorder that affects 13% to 19% of postpartum women and those women experience sign and symptoms like self-blaming thought, guilt about their inability to look after their new baby, low self-esteem, lack of interest in one’s environment, insecurity and suicidal thoughts. This condition begins in the postpartum period and persists up to a one-year duration after delivery. The treatment option for PPD women is behavioral counseling and anti-depressant therapy (2, 5-7).
World health organization (WHO) reported that for women of reproductive age group depression becomes the leading cause of disease burden (8). Postpartum nonpsychotic depression is a considerable public health problem and the most common complication of childbearing age that affect approximately 10 -15 % of postpartum women. In developing countries, the prevalence of postpartum depression almost doubled the developed world. The effect of postpartum depression on mother, her marital relationship and her children make it an important condition to diagnose, treat and prevent (9, 10). Untreated postpartum depression can have a prolonged adverse effect for the mother and her children. Pregnant mothers’ ongoing depression can contribute to the emotional, behavioral, cognitive and interpersonal problems (11).
Epidemiological studies conducted in China, Japan, India and New Dubai Hospital in Dubai, revealed that the overall prevalence of postpartum depression was 13.5%, 17%, 23% and 15.8% respectively (12-15). Another quasi-experimental study conducted among 420 consenting pregnant women on the title of postpartum depression in peri-urban communities of Karachi, Pakistan revealed that the overall prevalence of postpartum depression was 28.8% (16).
Having depression during the postnatal period affect the growth of the child due to the mothers care to the child could be decreased. Determining the prevalence of postpartum depression and identifying associated factors with it is important to show the magnitude of the problem. The result of the study could benefit policymakers, and the district health team in designing strategies to mitigate the problem. This study aimed to determine the prevalence of postpartum depression in the study area and to identify associated factors of postpartum depression.
Specific objectives:
The study area, design and period
The study was conducted in Debre Berhan town which found in North Shoa zone at Amhara regional state of Ethiopia. The study site had a total of one government-owned referral hospital, three health centers, five private clinics, and more than ten pharmacies. This town is found 130 kilometers away from the capital city of Ethiopia; Addis Ababa. Cross-sectional study design was employed from 1st May to June 30, 2018.
Population
Source Population: All women who came for postnatal care and vaccination services within 6 weeks after delivery in a referral hospital and health centers in Debre Berhan, Town Ethiopia.
Study Population: all women who came for postnatal care and vaccination service within 6 weeks after delivery during the data collection period.
Eligibility
Inclusion Criteria: All women who gave birth and who came for postnatal care and vaccination service within 6 weeks after delivery in health centers and referral hospital were included.
Exclusion Criteria: Women who had a verbal communication problem and complete loss of hearing were excluded.
Sample size calculation and sampling technique
The required sample size was determined by using a single population proportion formula with the following assumptions: (Z α/2) = value for the 95% CI, =1.96, the proportion of postpartum depression ; similar study at Gondar, Ethiopia (P= 24%), d = margin of error taken as 5%; by adding 10% of study subjects as nonresponse rate, the final sample size became 308. The study subjects were interviewed by using systematic random sampling after determining the sampling fraction (k=613/308= 2) and the first participant was selected by using lottery method. The total sample size (n=308) was allocated proportionally according to the total number of postpartum care and vaccination service attendees at each health center (Kebele 04, Kebele 07, Kebele 08) and Debre Berhan referral hospital.
Study variables
Dependent variable: Postpartum Depression (yes/no)
Independent variables
Socio-demographic factors: - (age, educational status, economic, marital status, employment, monthly income, current residence).
Social factors: - social and husband support, emotional violence, physical violence, sexual violence.
Substance use: use of any substance during perinatal period for a non-medical purpose (like Khat, alcohol, and cigarette).
Obstetrics factors: parity, pregnancy intention, hospitalized baby, mode of delivery, perinatal complication or illness, stressful life event during perinatal period and undesired fetal sex
Previous psychiatric history: A family history (first-degree relatives) of psychiatric problem.
Data collection tools and procedures
A structured interviewer-administered questionnaire was used to collecting information from study participants. Sociodemographic, clinical, and obstetric factors were assessed by predefined checklists. The social support level was assessed by using the Oslo social support scale, and Edinburgh postnatal depression scale (EPDS) was used to assess postpartum depression. Data were collected with an interviewer-administered questionnaire from mothers who came for postnatal care and vaccination service.
Data quality control and analysis
The data collection instrument was pre-tested on 5% of the sample size out of Debre Berhan town to improve language clarity, and appropriateness of data collection tools. The estimated time required, and necessary amendments were made after piloting of the questionnaire. Four fourth year undergraduate nursing students were collected the data. The data collectors were trained for one day on the techniques of data collection. The training also included the importance of disclosing the possible benefit and purpose of the study to the study participants before the start of data collection. The researcher checked completeness and consistency of questionnaires filled by the data collectors to ensure the quality of data and also visited the data collectors as many times as possible to check whether he/she collected the data appropriately. The collected data were entered into Epi-info version 7 and analysis was done after the data were imported to SPSS version 20. During bivariate analysis, variables with p-value < 0.05 were exported to multivariate analysis. Crude and adjusted odds ratios were analyzed using bivariate and multivariable binary logistic regression analysis and the level of significance of association was determined at P-value <0.05.
Socio-Demographic characteristics of postpartum mothers
A total of 308 mothers were included in the study, which was 100% response rate. Among the study subjects, two hundred eighty-six (86%) were aged 25-45 years and almost 85% were married. The majority of the participants, 206 (66.9%) were attended formal (modern) education. Regarding ethnicity, the majority of the study participants, 234 (76%) were Amhara and 62 (20.1%) were Oromo. Two hundred sixty-eight (87%) of the participants earn monthly income greater than 2500 Ethiopian Birr. Almost sixty percent of the participant's religion, 191 (62%) were orthodox Christian followers (Table 1).
Obstetric and clinical characteristic of postpartum mothers
From 308 study participants, the majority of respondents 254(82.5%) were multigravida (give birth > 1) and 54(17.5%) were primigravida (having first child). Almost 80% of participants had two or more living child during the study period. Regarding termination of pregnancy, 53(17.2%) had experienced termination and 39(12.7%) had experienced the death of their child. Forty-eight (15.6%) participants reported that the recent pregnancy was unplanned. Moreover, the sex of the last baby 189 (61.4%) were male and the rest were female. Regarding the desired sex of the last baby, 36(11.7%) of the respondents said that the sex of their infant was unwanted gender. Nearly 62% of participants, 190 (61.7%) mode of delivery were spontaneous vaginal delivery. Forty seven, 47 (15.3%) respondents had suffered from any diagnosed illness during their last pregnancy and 95(30.8%) study mothers reported their babies were admitted to hospital at least once before (Table 2).
Psychosocial factors (in last 6 months) of postpartum mothers
From the total study participants, 62(20.1%) responded that their family or close relative had died. 60(19.5%) reported there was serious diagnosed illness, Injury or assault happened to their close relative. Almost sixty, 59(19.2%) study participants had experienced parent or child death and 42 (13.6%) participant reported that they were separated due to marital difficulty. In addition, 41(13.7%) study participants were unemployed / not been able to work in the last six month of the study period. And also, 40(13%) reported physical violence during last pregnancy (Table 3).
Substance use among postpartum mothers
Overall, 31(10.1%) of study participants reported use of any substance before pregnancy and of these the majority of use was alcohol related; i.e. 21(67.7%). The remaining used only Khat at least once in lifetime. Regarding substance used during the last pregnancy, 18(5.8%) respondents used any kind of substance, and all of them used alcohol.
History of known illness among postpartum mothers
Of the total study participants, 31(10.1%) had known history of mental illness. In addition, 44(14.3%) study respondents had family history of known mental illness and 28(9.1%) had diagnosed diabetes mellitus and hypertension.
Social support among postpartum mothers
Social support status was assessed by using Oslo-3 social support scale. From the total study participants, the majority 137(44.5%) had moderate social support, 114(37%) had poor social support and the rest had strong social support. During pregnancy, 175 (56.8%), 111(36%) and 22(7.1%) had strong, moderate and poor husband support respectively. Thirty six percent, 112(36.4%) study participants had no practical support from family member during pregnancy (such as cooking, washing, cleaning or child-rearing), and during puerperium.
Prevalence of postpartum depression and its associated factors
According to Edinburgh postnatal depression scale (EDPS), study participants who scored ≥ 13 considered as having postpartum depression. Hence, the prevalence of postnatal depression among mothers who have postnatal care follow up was 15.6 %( 95% CI=11.7, 19.8).
Binary Logistic regression was performed to assess the association of each independent variable with the outcome variable (postpartum depression). The variables that showed a significance level (p <0.05) during bivariate analysis were added to the multivariate regression model. Twenty-two independent variables shown to be a significantly associated during the bivariate analysis. The result of the multivariate analysis showed that only four variables were statistically significant. Being widowed/widower, had a hospitalized child, had died family or close relative, had poor social support shown significant association with postpartum depression.
The results showed that study subjects who were widowed/widower had association with postpartum depression; having four times more likely to experience postpartum depression than who were married [AOR=4.17, 95% CI=1.14, 15.20]. In addition, respondents who had poor social support were five times more likely to be depressed than those who had strong social support [AOR=5.11, 95% CI= 1.00, 26.18]. Respondents who had a hospitalized child were nearly 3 times more likely to be depressed as compared with the respondents who had a hospitalized child [AOR=3.32, 95%CI= 1.39,7.93]. In similar dimension, participants who had died family or close relative in last six month were three times more likely to be depressed than those who did not experience this [AOR=2.92, 95%CI=1.01,8.50], (Table 4).
Prevalence of postpartum depression
The overall prevalence of postpartum depression was 15.6 %( 95%CI=11.7, 19.8). This was almost similar to other studies which were conducted in Delhi and adjacent states of northern India, 15.8 % (17), Egypt 17.9% (18), and Uganda 16.3 % (19).
The prevalence rate were higher in our study when compared with Canadian, Denmark, and Uganda (Kampala), and Egypt study which was 1.6 %, 5.5% and 6.1%, 7.14% respectively (20-23) . The higher rate might be due to use of different tools, assessment period, sociol support level and economic status of the mothers.
On the other hand, this figure was lower as compared with other similar studies done in Lebanon, 21% (24), Cameroon, 23.4% (25), Nigeria,23% (26). The lower prevalence rate in our study might be due to difference in residency, and sample size difference. For instance the study in Lebanon was conducted in rural area by using follow up study with the sample size of 396 mothers. In addition, the study conduct in Cameroon used case-control study design while our study used cross-sectional study design. Similar studies in Ethiopia, Bahir Dar, 22.1% (27), Benchi Maji Zone, 22.4%(28), Oromia region, 31.5% (29), of mothers were depressed respectively at their postnatal period. These studies had higher prevalence reports than our study. The higher prevalence report in these studies might be due to the screening tool, study design, and sample size. The study done in Oromia region used self-reporting questionnaire (SRQ) and community-based cross-sectional study.
Factors associated with postpartum depression
Among the sociodemographic factors, study subjects who were widowed/widower had association with postpartum depression: almost four times higher when compared with those who were married. This association was in agreement with the study done in Ethiopia (30). The agreement might be due to the fact that being married is important for mental health; especially during the postpartum period.
In the social support dimension, respondents who had poor social support were more likely to be depressed than those who had strong social support. The association in estimation was in line with studies done in Malaysian and Pakistan (31), Cameroon; Yaoundé (25) and Hiwot Fana specialized University Hospital in Ethiopia (10). In fact, having poor social support is one of the highest contributor for poor mental health (32).
The variables that were found to have an association with postpartum depression were having a hospitalized child during the postpartum period. Respondents who had a hospitalized child were almost three times more likely to be depressed as compared to the respondent who had a hospitalized child. In a similar dimension, participants who had died family or close relative in last six month were three times more likely to have postpartum depression than those who had no died family or close relative. The association was in agreement with the study done in Gobe/Robe town; Bale Zone, Ethiopia (29). The possible reason might be due to the fact that experiencing life-threatening events during the postpartum period became intolerable and may affect the mental wellness of the mothers.
Limitations: Postpartum women with persisting depression already acquired before/during pregnancy were not excluded and this may further increase the prevalence of postpartum depression. The study only included mothers who had postnatal care follow up in urban area.
Conclusion: Though significant proportions of postnatal mothers had depression, the prevalence of postpartum depression was lower than most studies in different areas. Major life events and trauma are associated with an increased risk of postpartum depression. Health professionals should aware of the mother’s circumstances during pregnancy. They should initiate support to reduce the risk of depression in the postpartum period. Health care professionals working in maternal and child health clinics should give special attention to pregnant mothers who were widowed/widower, had poor social support, had a hospitalized child, and had died family or close relative.
Recommendations: It would be advisable if midwife professionals routinely screen postpartum depressive symptoms and link them to mental health services just like other reproductive health problems for mothers attending hospitals and health centers after delivery.
Authors’ Contribution
AD: Analyze the data and write up the thesis report and the manuscript. KD: select the title and develop the proposal. All the authors read and approved the final manuscript and agreed to be accountable for all aspects of the work.
Availability of data and materials: All relevant materials and data supporting the findings of this study are contained within the manuscript.
Ethics Approval: Ethical clearance was obtained from the Debre Berhan University ethical review board (IRB). Permission letter to each study health institution was written and permission letter was taken.
Consent to participate: Written informed consent was taken from each study participants.
Consent for publication: the manuscript did not contain individuals’ person detailed data in any form.
Competing of Interest: The authors declare that they have no conflicts of interest.
Funding: This study was not supported by any grant. Funding for data collection, entry, analysis and write-ups were provided by the authors.
Acknowledgment: Our thanks dedicated to Debre Berhan University and AMARI project. Kefyalew Dagne was supported through AMARI (Africa mental health research initiative) which is funded through the DELTAS Africa initiative (DEL-15-01).
Table 1. Socio-demographic characteristics of mothers who have postnatal care at Debre Berhan health centers and referral hospital, 2018
|
Variables |
Category |
Frequency |
Percentage |
|
Age in years |
19-24 |
43 |
14.0 |
|
25-45 |
265 |
86.0 |
|
|
Marital status |
Single |
28 |
9.1 |
|
Widowed/widower |
19 |
6.2 |
|
|
Married |
261 |
84.7 |
|
|
Address |
Urban |
215 |
69.8 |
|
Rural |
93 |
30.2 |
|
|
Religion |
Orthodox |
191 |
62.0 |
|
Catholic |
15 |
4.9 |
|
|
Muslim |
47 |
15.3 |
|
|
Protestant |
55 |
17.9 |
|
|
Ethnicity |
Amhara |
234 |
76.0 |
|
Oromo |
62 |
20.1 |
|
|
Tigray |
12 |
3.9 |
|
|
Attended modern education |
Yes |
206 |
66.9 |
|
No |
102 |
33.1 |
|
|
Occupational status of mother |
Government employed |
84 |
27.2 |
|
House wife |
146 |
47.4 |
|
|
private employed |
58 |
18.8 |
|
|
Farmer |
8 |
2.6 |
|
|
Unemployed |
12 |
3.9 |
|
|
Monthly income
|
≤ 1200 |
5 |
1.6 |
|
1201-2500 |
35 |
11.4 |
|
|
≥2501 |
268 |
87.0 |
Table 2:- Obstetric and clinical characteristic among mothers who have postnatal care, Debre Berhan, Ethiopia, 2018
|
Variable |
Category |
Frequency |
Percent % |
|
Number of pregnancy |
1 |
54 |
17.5 |
|
≥ 2 |
254 |
82.5 |
|
|
Living child |
1 |
64 |
20.8 |
|
≥ 2 |
244 |
79.2 |
|
|
Sex of last baby |
Male |
189 |
61.4 |
|
Female |
119 |
38.6 |
|
|
Desired sex of the baby |
Desired |
271 |
71.3 |
|
Undesired |
109 |
28.7 |
|
|
Abortion |
Yes |
25 |
6.6 |
|
No |
355 |
93.4 |
|
|
Pattern of pregnancy termination |
Spontaneous |
47 |
15.3 |
|
Induced |
6 |
1.9 |
|
|
Number of termination of pregnancy |
1 |
49 |
15.9 |
|
≥ 2 |
4 |
1.3 |
|
|
Baby death |
Yes |
38 |
10.0 |
|
No |
342 |
90.0 |
|
|
Hospitalized baby |
Yes |
95 |
30.8 |
|
No |
213 |
69.2 |
|
|
Mode of delivery |
Vaginal |
190 |
61.7 |
|
Cesarean section |
87 |
28.2 |
|
|
Vacuum/forceps |
31 |
10.1 |
|
|
Planed pregnancy |
Yes |
260 |
84.4 |
|
No |
48 |
15.6 |
|
|
Illness/complication in last pregnancy |
Yes |
47 |
12.4 |
|
No |
333 |
87.6 |
Table 3:- psychosocial characteristic (in last 6 months) among mothers who have postnatal care, Debre Berhan, Ethiopia, 2018.
|
Variable |
Category |
Frequency |
Percent (%) |
|
Serious illness injury or assault during pregnancy |
Yes |
42 |
13.6 |
|
No |
266 |
86.4 |
|
|
Close relative serious illness, injury or assault |
Yes |
60 |
19.5 |
|
No |
248 |
80.5 |
|
|
Died spouse, parent or child |
Yes |
59 |
19.2 |
|
No |
249 |
80.8 |
|
|
Died Family or close relative |
Yes |
62 |
20.1 |
|
No |
246 |
79.9 |
|
|
Major financial crisis |
Yes |
37 |
12.0 |
|
No |
271 |
88.0 |
|
|
Sacked from job |
Yes |
12 |
3.9 |
|
No |
296 |
96.1 |
|
|
Unemployed/not able to work |
Yes |
41 |
13.3 |
|
No |
267 |
86.7 |
|
|
Separation due to marital difficulty |
Yes |
42 |
13.6 |
|
No |
266 |
86.4 |
|
|
Broken off a steady relationship |
Yes |
33 |
10.7 |
|
No |
275 |
89.3 |
|
|
Serious problem with close friend, neighbor /relative |
Yes |
37 |
12 |
|
No |
271 |
88 |
|
|
Lost / stolen property which mattered a lot |
Yes |
30 |
9.7 |
|
No |
278 |
90.3 |
|
|
Any problems with police/court |
Yes |
18 |
5.8 |
|
No |
290 |
94.2 |
|
|
Emotional violence |
Yes |
26 |
8.4 |
|
No |
282 |
91.6 |
|
|
Physical violence |
Yes |
40 |
13 |
|
No |
268 |
87 |
|
|
Who physically violate you |
Boy friend |
21 |
52.5 |
|
Family member |
8 |
20 |
|
|
Stranger |
11 |
27.5 |
|
|
Forced sexual activity |
Yes |
35 |
11.4 |
|
No |
273 |
88.6 |
|
|
Who forced you for sexual activity |
Boy friend |
15 |
37.5 |
|
Family member |
2 |
5 |
|
|
Stranger |
18 |
45 |
Table 4. Bivariate and multivariate analysis of factors associated postpartum depression among mothers who have postnatal care, Debre Berhan, Ethiopia, 2018
|
Variables |
Postpartum Depression |
COR (95%CI) |
AOR(95%CI) |
||
|
Yes |
No |
||||
|
Marital status |
Single |
10 |
18 |
4.28(1.81,10.13) |
2.70 (0.72,10.21) |
|
Widowed/widower |
8 |
11 |
5.60(2.09,15.03) |
4.17(1.14,15.20)* |
|
|
Married |
30 |
231 |
1.00 |
1.00 |
|
|
Attend modern school |
Yes |
24 |
182 |
1.00 |
1.00 |
|
No |
24 |
78 |
2.33(1.25,4.36) |
0.76(0.34,1.71 |
|
|
Social support |
Poor |
34 |
80 |
11.69(2.70,50.67) |
5.11(1.00,26.18)* |
|
Moderate |
12 |
125 |
2.64(0.57,12.19) |
1.93(0.36,10.36) |
|
|
Strong |
2 |
55 |
1.00 |
1.00 |
|
|
Husband support |
Poor |
8 |
14 |
4.43(1.65,11.8) |
0.70(0.14,3.57) |
|
Moderate |
20 |
91 |
1.70 (0.870,3.33) |
1.02(0.42,2.47 |
|
|
Strong |
20 |
155 |
1.00 |
1.00 |
|
|
Serious illness, injury or assault to a close relative |
Yes |
17 |
43 |
2.77(1.41,5.44) |
0.28(0.08,10.96) |
|
No |
31 |
217 |
1.00 |
1.00 |
|
|
Died spouse, parent or child |
Yes |
20 |
39 |
4.05(2.08,7.89 |
0.56(0.17,1.85 |
|
No |
28 |
221 |
1.00 |
1.00 |
|
|
Died close family or relative |
Yes |
21 |
41 |
4.15(2.15,8.04) |
2.92(1.01,8.50)* |
|
No |
27 |
219 |
1.00 |
1.00 |
|
|
Has major financial crisis |
Yes |
14 |
23 |
4.24(1.99,9.03) |
1.74(0.55,5.49 |
|
No |
34 |
237 |
1.00 |
1.00 |
|
|
Have sacked from job |
Yes |
5 |
7 |
4.20(1.28,13.85 |
0.67(0.21,2.11) |
|
No |
43 |
253 |
1.00 |
1.00 |
|
|
Unemployed/not able to work |
Yes |
15 |
26 |
4.09(1.97,8.51) |
3.21(0.68,15.12) |
|
No |
33 |
234 |
1.00 |
1.00 |
|
|
Separation due to marital difficulty |
Yes |
13 |
29 |
2.96(1.40,6.23) |
0.72(0.22,2.40) |
|
No |
35 |
231 |
1.00 |
1.00 |
|
|
broken off steady friendship/relationship |
Yes |
14 |
19 |
5.22(2.40,11.37) |
0.75(0.22,2.50) |
|
No |
34 |
241 |
1.00 |
1.00 |
|
|
Serious problem with close friend, neighbor /relative |
Yes |
13 |
24 |
3.65(1.70,7.83) |
1.86(0.51,6.81) |
|
No |
35 |
236 |
1.00 |
1.00 |
|
|
Any problems with police/court |
Yes |
6 |
12 |
2.95(1.05,8.30) |
0.62(0.19,2.05) |
|
No |
42 |
248 |
1.00 |
1.00 |
|
|
Emotional/physical abused by parents |
Yes |
9 |
17 |
3.30(1.37,7.92) |
1.51(0.47,4.90) |
|
No |
39 |
243 |
1.00 |
1.00 |
|
|
Had Hospitalized baby |
Yes |
27 |
68 |
3.63(1.926,6.84) |
3.32(1.39,7.93)* |
|
No |
21 |
192 |
1.00 |
1.00 |
|
|
Pregnancy intention |
Planned |
35 |
225 |
1.00 |
1.00 |
|
Unplanned |
13 |
35 |
2.39(1.15,4.95) |
0.75(0.25,2.21) |
|
|
Forced sexual activity |
Suffered |
13 |
22 |
4.02(1.86,8.69 ) |
2.00(0.68,5.93) |
|
Not suffered |
35 |
238 |
1.00 |
1.00 |
|
|
Family diagnosed mental illness |
Yes |
15 |
29 |
3.62(1.76,7.46 |
2.04(0.68,6.14) |
|
No |
33 |
231 |
1.00 |
1.00 |
|
|
Diabetic mellitus |
Yes |
12 |
16 |
5.08(2.23,11.6) |
2.40(0.69,8.35) |
|
No |
36 |
244 |
1.00 |
1.00 |
|
Key: *= p-value less than 0.05; COR= crude odds ratio; AOR= adjusted odds ratio; CI= confidence interval.