Postpartum depression and physical activity amongst women attending immunization and postnatal clinic in a tertiary hospital in Ibadan

Depressive disorders are listed as one important public health issue among women of reproductive age. Postpartum depression is a mental health disorder occurring after childbirth and has disabling effect on mother and child. Amongst other alternative treatment methods, physical activity has been proposed as benecial especially for mild postpartum depression. Therefore, this study sought to determine the prevalence of postpartum depression, and the association between postpartum depression and physical activity among women in a tertiary hospital in Ibadan. Methods The cross-sectional study was conducted among 401 women attending immunisation and postnatal clinics at the University College Hospital Ibadan. The data was collected using a self-administered questionnaire containing; a self-developed socio-demographic section, Edinburgh postnatal depression scale to measure postpartum depression and International physical activity questionnaire (short type) to assess physical activity. Analysis was done using chi square and a multivariate analysis to determine independent factors. Signicance was set at 0.05.


Introduction
Among all common mental health disorders depression is the most common illness affecting people and by the year 2020 is expected to be second most prevalent health problem in general 1 . In 2004, the World Health Organisation estimated that 10% of the over 150 million people living with depressive disorders were in Africa. Among women of reproductive age depressive disorders lead universally 2 . Due to the greater prevalence of depression among females as compared to males, maternal mental health has become a vital public health issue and poses a challenge across the globe. The most common mental health challenge post childbirth is postpartum depression, an overwhelming illness that impairs maternal behavior 3 . Postpartum depression (PPD) is classi ed as a major depressive episode that begins within 4 or 6 weeks of childbirth by the Diagnostic and Statistical Manual of Mental Disorders and 10th edition of the International Classi cation of Diseases respectively 4 . Although onset must be within 4-6 weeks, it is believed that women remain exposed to the risk of PPD even up to 14 months after delivery 5,6 .
Reported as affecting around 1 in 10 women at some time in the rst year 7 , studies have shown a diverse range of prevalence. Halbreich & Karkun (2006) in a review of literature reports a prevalence of about 0% to almost 60% from one continent to another 8 . A literature review on lower-middle-income countries have placed the prevalence of PPD at approximately 20% 9 . According to studies conducted in Nigeria, about 10-30% of women attending primary care have PPD 10 while Abiodun (2006) in similar population reported a prevalence of 18.6% in developing society 11 . Several factors; psychological, biological, and social have been ngered in the etiology of PPD and have shown positive association. Psychosocial risk factors such as history of depression, poor relationship with spouse, weak social support, stressful periods/events prior to birth, poor social status, stress of childcare and complications during birth have been strongly associated with postpartum depression 3,4,12 .
General treatment of PPD includes medication and psychotherapy. Side effects of these drugs however are relatively unknown especially as it relates to its effects in breast milk 13,14 coupled with reports on relapses and other adverse effects 15 hence non-pharmacologic approaches have come highly recommended. Conversely, studies have shown that participation in some form of physical activities (leisure time activity or moderate to vigorous activity) improves PPD symptom [16][17][18][19] . Seeing as postpartum depression has proven negative effect on both the woman, infant and family, any effective treatment should therefore explore all available options of treatment including physical activity. To the best of my knowledge, no study has explored the relationship between physical activity and postpartum depression in Nigeria hence prompting this study whose main aim was to determine the prevalence of postpartum depression and the relationship between physical activity and postpartum depression. Other objectives included determining other risk factors in postpartum depression.

Participants
The cross-section study was carried out at the University College Hospital which is a multidisciplinary tertiary hospital in Ibadan attending to a mix of patients from all over. The target population for the study were infant nursing mothers that came for immunization at the child welfare clinic of the Institute of child health and postnatal clinic at the University College Hospital, Ibadan. Mothers who had a delivery within the 12months preceding this study, who were at least four weeks post-delivery were included. Women who were pregnant were excluded.

Study design
Total sampling method was employed for this study. This was due to the number of women attending the child welfare and postnatal clinics which was about 300 women per month and the study duration which was scheduled for six weeks. All consenting respondent available during the six weeks' duration of this study were surveyed until the required study size was achieved. The study size was determined using the Leslie Kish formula, Where P=30.6%; q=69.4%; Zα= = standard normal deviate corresponding to 95% con dence interval, critical value of 1.96; d=0.05 Using a previously reported prevalence of 30.6% in a Nigerian study 20 , the sample size was calculated to be 326. Using a 10% anticipated non-response rate, sample size was rounded up to 400. In totality 401 women participated in the study

Data collection
The questionnaire which was lled by the respondents was in English language and consisted of three sections.
A-Socio-demographic section containing personal information (age, religion, tribe, educational status, marital status, family type, employment status, occupation), family and social history (number of children, ever lost a child, help with child, relationship satisfaction, agreement with partner on nance, decision making and nance), Child and obstetric history (age of present child, illness during pregnancy, mode of delivery, desired gender, complications during pregnancy, history of depression) B-The Edinburgh Postnatal Depression Scale (EPDS): The scale, which consists of 10 questions, asks the respondent how they have been feeling over the last one week. Responses are ranked from 0 to 3, according to severity, with an overall score of 30. This study used a score of 10 as it's cut off for PPD. This score has been suggested for the detection of mild depression 21 . As reported by Adewuya et al, (2005), "At cut-off score of 10 the EPDS was found to be the best for screening for both major and minor depression (sensitivity = 0.867, speci city = 0. The types of activity assessed were walking, moderately intense activities and vigorous activities. Categorical scoring method classi es physical activity into low, moderate or high according to the number of hours and days spent in moderate or vigorous physical activities and walking. The examples of physical activities given in the IPAQ was ne-tuned to re ect activities that are common to this environment and was validated by a content expert (physiotherapy department). The activities were chosen from the compendium of physical activities and had the same Metabolic Equivalent of Task as the original activities given. Categorical scoring was graded as, Low-No activity OR Some activity is reported but not enough to meet Categories 2 or 3.
Moderate-any of the following 3 criteria: 3 or more days of vigorous activity of at least 20 minutes per day OR 5 or more days of moderate-intensity activity and/or walking of at least 30 minutes per day OR 5 or more days of any combination of walking, moderate-intensity or vigorous intensity activities achieving a minimum of at least 600 MET-minutes/week.
High: any one of the following 2 criteria: Vigorous-intensity activity on at least 3 days and accumulating at least 1500 MET-minutes/week OR 7 or more days of any combination of walking, moderate-or vigorous-intensity activities accumulating at least 3000 MET-minutes/week" (http://www.ipaq.ki.se).
IPAQ has shown to be appropriate for use in developed or developing countries and has good evidence of test-retest reliability 22 .

Data Analysis
Data were analyzed using SPSS version 20. Data collected at the end of each day was checked for errors and cleaned. Questionnaires with missing data were discarded. A research assistant was present to help with any di culties the respondents encountered. Data was categorised into women with EPDS scores above 10 as having symptoms of depression and below 10 as not having depressive symptoms. Physical activity was categorised as low, moderate or high. Descriptive statistics such as frequencies and percentages were used to summarize and present qualitative data. Relationship satisfaction was determined from three questions which were picked from the couple satisfaction index; in general, how often do you think things are going on well between you and your partner, do you feel like a team with your partner, does your partner meet your needs. Responses were ranked on a likert scale of 0-5 and summed up to 15. Relationship satisfaction was categorised as; poor (0-5), moderate (6-10) and good (11)(12)(13)(14)(15). Chi square test was used to determine the association between postpartum depression (dependent variable) and physical activity (independent variable). Bivariate analysis was also performed to explore the independent variables that were signi cantly associated with PPD at a signi cance level of 10%. Logistic regression was performed for all signi cant variables from the bivariate analysis to determine the odd ratio and 95%CI at a signi cance level of 5%.

Results
From a total of 600 women proposed to participate, 401 women willingly participated. Almost half of the women (43.1%) were within the age range of 30-34 while about 27% were above 35years. The mean age of respondents was 31.8± 4.1, with the age range of 20-50 years. Most were Yoruba (88%), the dominant ethnic tribe of south west, Christian (84%) and tertiary education (79.6%). Three quarter of the respondents had less than two children (76.5%) while 32.9% were between three months to six months.
Half had some sort of support for childcare and almost all had their desired gender at birth (86.3%) and were in monogamous marriages (83.3%). Most of the respondents agreed with their partners on major decisions (87.3%), issues concerning nances (88%) and in-laws (79.8%). Most also reported having good relationship satisfaction with their partners (85.8%). Two-third of the respondents were healthy during pregnancy (78.6%) while almost all had no complications at birth (92.5%). About 59.7% of respondents had normal delivery and less than 10% had medical history of depression ( Table 1).

Prevalence of Postpartum depression and physical activity
Prevalence of PPD was 37.8%. Mean postpartum depression score was 8.15 (± 4.7) with scores ranging from 0-26. Suicidal ideation was reported by 31 women (7.7%) who answered above 1 in the 10 th question of the EPDS scale.
Physical activity (PA) was generally high. Among the women, 41.2% had moderate levels of physical activity and 30.9% had higher levels of physical activity. In general, 72.1% of respondents were physically active while 27.9% had low physical activity.

Postpartum depression and physical activity
There was no statistically signi cant association between PPD and physical activity (p=0.327), but those with higher physical activity had an increased risk of having PPD (OR=1.255, 95% CI=0.797-0.977) ( Table   2).

Postpartum depression and other variables
Family type (p<0.001), age of child (p=0.025), number of children living (p=0.019) and desired gender (p=0.026) were statistically associated with postpartum depression. Maternal age (p=0.912), support for childcare (p=0.220), previously lost a child (p=0.413) and marital status (p=0.156) were not statistically associated with postpartum depression ( Table 2). Medical history of depression pre-pregnancy was signi cantly associated with postpartum depression (p=0.086). Agreement with partner on family nances (p=0.026), ways to deal with in-laws (p=0.008), decision making (p=0.008) and relationship satisfaction (p<0.001) were also signi cantly associated with postpartum depression (Table 3)

Multiple regression
Age of child was statistically associated with postpartum depression. Mothers with child between 6weeks-3months were independently associated with postpartum depression (OR=0.24; 95%CI=0.06-0.89). Women with children between 6weeks-3months are at less risk to have PPD than women with children above 9months. Family type had a statistically independent signi cant association with postpartum depression. Women who were in polygamous marriages were three times more likely to have postpartum depression than those that were in monogamous family (OR==3.49; 95%CI=1.83-6.65) and single parents were less likely (OR=0.66; 95%CI=0.14-3.06). Women who reported having the desired gender were also less likely (OR=0.47; 95%CI=0.24-0.93) to report postpartum depression symptoms than those who did not have their desired gender. Relationship satisfaction was independently associated with postpartum depression (OR= 2.664; 95%CI=1.317-5.390). Those with poor/ moderate relationship satisfaction were twice as likely to have postpartum depression than those in a good relationship with partner (Table 4).

Discussion
This study showed a high prevalence of 37.8% which is comparable to some other Nigerian studies done in similar hospital setting 20, 23 . In Nigeria varying rates from 10-44% has been reported from different regions of the country 21,24−26 . This wide range prevalence is also re ected in Africa as well as other continents 27 . However, majority of developing countries have estimated prevalence rates higher than that those found in high-income countries 27,28,29 . This variability from country to country could be due to study design (diagnostic tool, cut off scores, period of assessment), cross cultural differences, socioeconomic terrain, and perception of PPD/ mental health. This further indicates that a woman's susceptibility to postpartum depression is not based on geographical location but on social, economic, psychological and biological factors that thrive in enabling environments.
With three quarter of the women reporting moderate to high physical activity (PA), prevalence of physical activity was quite high (72.1%). Although there was no exact study measuring PA in postpartum women in Nigeria, however two Nigerian studies report 79% and 52.2% postnatal exercises engagement 30,31 with activity participation differing from this study. Other foreign studies have shown lower physical activity levels 16,32 . Though High PA in this study could be due to the economic terrain which necessitates a woman getting back to work shortly after whilst joggling home care, the high levels of PA could be because a one-year range was used. Physical activity was found to be lesser in the immediate postpartum period and increased constantly throughout the postpartum period. This may also have in uenced the high rate reported. The increasing levels of PA down the postpartum period may re ect the reduction in help and support earlier received and more women being comfortable participating in PA. These studies were either experimental or a review of literature. Although there was no signi cant association, high PA increased the chances of developing PPD symptoms as compared to lower PA. This nding is buttressed by Demissie et al. (2011) who reported women who had high levels of PA had twice the risk of developing elevated depressive symptoms 17 . High PA in this study involved vigorous exercises which were household activities and walking than activities performed for leisure. It has been reported that leisure/outdoor physical activity reduces PPD as compared to activities due to childcare or household work 17,39 Age

Conclusion
Postpartum depression is prevalent here in Nigeria and is generally higher than the speculated 10-15%. It is a global health issue that should be taken seriously as it cuts across both low-and high-income countries and associated factors are dependent upon cultural and socio-economic terrain. It is no longer a myth that can be swept under the carpet but should be openly addressed and necessary systems put in place, especially in tertiary hospitals that attends to a mix of mothers in the society, in other to enable healthier, happier families. This study hopes to encourage further research in this direction.

Limitations
A standard scale was not used to assess relationship satisfaction therefore the result should be interpreted with caution. Also, as a cross sectional study I could not determine temporal association between postpartum depression and physical activity. In as much as the study population was a mix of people, the sample population may not re ect this diversity as most were educated, consequently a generalization must be carefully made. Declarations male cence of the study. Con dentiality was maintained in the questionnaire by keeping them anonymous.

Consent for publication: Not applicable
Availability of data and material: The datasets used and/or analysed during the current study are available on reasonable request.