Between life and death: exploring the sociocultural context of antenatal mental distress in rural Ethiopia

Towards person-centred maternal and newborn care in Ethiopia: a mixed method study of satisfaction and experiences of care

BACKGROUND

Person-centred maternal care is associated with positive experiences in high-income countries. Little is known about the transferability of this concept to non-Western, low-income settings. We aimed to explore women's experiences of care and investigate satisfaction with antenatal care (ANC) in relation to person-centred care and unmet psychosocial needs in rural Ethiopia.

METHODS

Design: facility-based, convergent mixed-method study. A cross-sectional survey included 2079 consecutive women attending ANC at eight health centres. Service satisfaction was measured using a 21-item validated measure.

INDEPENDENT VARIABLES

[1] person-centred care (1A: receipt of information; 1B: perceived adequacy of health worker responses) and [2] unmet psychosocial needs (2A: Patient Health Questionnaire for depressive symptoms; 2B: screening questionnaire for intimate partner violence (IPV)). Linear mixed effect regression assessed hypothesized associations between person-centred care/unmet psychosocial needs and service satisfaction, accounting for clustering at the health centre level. A linked qualitative study comprised eight in-depth interviews with women accessing ANC. Structured observations of ANC consultations rated health worker competencies (n = 65) and adherence to guidance promoting person-centred care (n = 53). Qualitative data were analysed thematically and triangulated with quantitative and observational data.

RESULTS

Women reported lowest satisfaction in relation to family involvement (71.5% dissatisfied) and continuity of care (65.7% dissatisfied). As hypothesised, satisfaction increased with more information received (adjusted regression coefficient (ARC) 0.96 95%CI 0.71,1.20) but reported adequacy of help from health workers did not show a dose-response relationship (test-for-trend p = 0.157). Undetected depressive symptoms (ARC - 0.21 95%CI -0.27,-0.15) and IPV (ARC - 1.52; 95%CI -2.43,-0.61) were associated with lower service satisfaction scores. Most observed consultations scored low on most indicators of person-centred care. In qualitative interviews, women valued respectful and responsive communication from health workers, which affected their willingness to disclose psychosocial problems. Triangulation of findings indicated a mismatch between what women valued about care, their reported satisfaction with care and the actual care they were observed to receive.

CONCLUSIONS

Systems strengthening interventions to support person-centred maternal care appear contextually relevant but need to increase women's expectations of care and agency to demand change. Prioritization of person-centred care could improve women's experience of maternal care and better address psychosocial needs.

Self-reported problems and functional difficulties in anxious pregnant women in Pakistan: The use of a patient-generated mental health outcome measure

Anxiety during pregnancy affects women worldwide and is highly prevalent in Pakistan. The Psychological Outcome Profiles (PSYCHLOPS) questionnaire is an instrument used in therapy to assess patient-generated problems and the consequent functional difficulties. Using the PSYCHLOPS, we aimed to describe the type of problems and the consequent functional difficulties faced by anxious pregnant women in Pakistan. Secondarily, we sought to explore if a cognitive behavioral therapy (CBT)-based intervention brought about changes in the severity score for certain problems or functional difficulties. Anxious pregnant women were recruited from the Obstetrics/Gynecology Department of a tertiary hospital in Rawalpindi, Pakistan. Of 600 pregnant women randomized to receive a psychosocial intervention for prenatal anxiety delivered by non-specialist providers, 450 received ≥1 intervention session and were administered the PSYCHLOPS. Eight types of problems were identified; worries about the unborn baby's health and development (23%), concerns about family members (13%), and financial constraints (12%) were the most frequently reported primary problems. Severity scores between baseline and the last available therapy session indicated the largest decrease for relationship problems (mean = 2.4) and for concerns about family members (mean = 2.2). For functional difficulties, 45% of the participants reported difficulties in performing household chores, but the intervention showed the greatest decrease in severity scores for mental or emotional functional difficulties. Focus on certain types of patient-generated problems, e.g., relationship problems, could anchor therapy delivery in order to have the greatest impact. Tailored CBT-based intervention sessions have the potential to address important but neglected problems and functional difficulties in anxious pregnant women.

Stress and resilience during pregnancy: A comparative study between pregnant and non-pregnant women in Ethiopia

BACKGROUND

Stress during pregnancy is associated with perturbances in maternal psychology and physiology, and results in adverse pregnancy and birth outcomes. However, little attention has been given to understand maternal stress and its potential negative consequences in many low- and middle-income countries. We aimed to investigate whether pregnancy is associated with greater stress and lower psychological resilience among women living in Jimma, Southwest Ethiopia.

METHOD

An institution-based comparative cross-sectional study design was implemented in Jimma University Medical Center and Jimma health centers from 15 September to 30 November 2021. Women attending antenatal care and family planning services were invited to participate in the study. Participants were interviewed using the Perceived Stress Scale (PSS-10), Brief Resilience Scale (BRS), distress questionnaire-5, and the Household Food Insecurity Access Scale (HFIAS). Linear regression analysis was used to test associations between pregnancy (exposure) and outcomes of interest (stress and resilience scores), while adjusting for potential confounders. Stress and resilience were mutually adjusted for one another in the final model.

RESULTS

A total of 166 pregnant and 154 non-pregnant women participated, with mean age of 27.0 SD 5.0 and 29.5 SD 5.3 years respectively. Pregnancy was associated with increased stress score by 4.1 points (β = 4.1; 95% CI: 3.0, 5.2), and with reduced resilience by 3.3 points (β = -3.3; 95% CI: -4.5, -2.2) in a fully adjusted model. In mutually-adjusted models, pregnancy was independently associated with greater stress (β = 2.9, 95% CI 1.8, 3.9) and lower resilience (β = -1.3, 95% CI: -2.5, -0.2) compared to non-pregnant women.

CONCLUSION

In this low income setting, pregnancy is associated with greater vulnerability in the mental health of women, characterized by greater perceived stress and diminished resilience. Context-relevant interventions to improve resilience and reduce stress could help improve the health and wellbeing of mothers, with potential benefits for their offspring.

Pregnant women and health workers' perspectives on perinatal mental health and intimate partner violence in rural Ethiopia: a qualitative interview study

BACKGROUND

Mental health conditions are common during the perinatal period and associated with maternal, foetal, and neonatal morbidity and mortality. There is an established bidirectional relationship between mental health conditions and intimate partner violence (IPV), including during and after pregnancy. Mean lifetime prevalence of physical, sexual or emotional IPV exposure among women in rural Ethiopia is estimated to be 61% and may be even higher during the perinatal period. We aimed to explore the perspectives of women and antenatal care (ANC) health workers on the relationship between all types of IPV and perinatal mental health, to inform the adaptation of a psychological intervention for pregnant women experiencing IPV in rural Ethiopia.

METHODS

We conducted in-depth qualitative interviews with 16 pregnant women and 12 health workers in the Gurage zone of the Southern Nations, Nationalities and People's Region of Ethiopia, between December 2018 and December 2019. We conducted thematic analysis of English-translated transcripts of audio-recorded Amharic-language interviews.

RESULTS

Participants contextualised IPV as the primary form of abusive treatment women experienced, connected by multiple pathways to emotional and bodily distress. Patriarchal norms explained how the actions of neighbours, family, community leaders, law enforcement, and government agents in response to IPV often reinforced women's experiences of abuse. This created a sense of powerlessness, exacerbated by the tension between high cultural expectations of reciprocal generosity and severe deprivation. Women and health workers advocated a psychological intervention to address women's powerlessness over the range of difficulties they faced in their daily lives.

CONCLUSIONS

Women and health workers in rural Ethiopia perceive multiple, interconnected pathways between IPV and perinatal emotional difficulties. Contrary to expectations of sensitivity, women and health workers were comfortable discussing the impact of IPV on perinatal mental health, and supported the need for brief mental health interventions integrated into ANC.

Multilevel analysis of quality of antenatal care and associated factors among pregnant women in Ethiopia: a community based cross-sectional study

OBJECTIVE

To determine the magnitude of quality of antenatal care and associated factors among pregnant women in Ethiopia.

DESIGN

A community-based cross-sectional study.

SETTING

Ethiopia.

PARTICIPANTS

A total of 4757 weighted sample of pregnant women from 18 January 2016 to 27 June 2016, were included for this analysis.

OUTCOME

Quality of antenatal care (ANC).

METHODS

Our analysis was based on secondary data using the 2016 Ethiopian Demographic and Health Survey. The quality of ANC was measured when all six essential components, such as blood pressure measurements, blood tests, urine tests, nutrition counselling, birth preparation advice during pregnancy and information on potential complications, were provided. Stata V.14 software was used for analysis. A multilevel mixed-effect logistic regression analysis was fitted. Adjusted OR (AOR) with 95% CIs was used to show the strength and direction of the association. Statistical significance was declared at a p value less than 0.05.

RESULTS

The magnitude of quality of ANC in Ethiopia was 22.48% (95% CI: 21.31% to 23.69%). Educational status; primary (AOR=1.34; 95% CI: 1.06 to 1.68) and secondary (AOR=2.46; 95% CI: 1.76 to 3.45), middle (AOR=1.31; 95% CI: 1.01 to 1.72) and rich (AOR=2.08; 95% CI: 1.59 to 2.72) wealth status, being married (AOR=2.34; 95% CI: 1.08 to 5.10) and four or more ANC (AOR=2.01; 95% CI: 1.67 to 2.40) were statistically significant associated factors of quality ANC in Ethiopia.

CONCLUSIONS

This study found that nearly only one in five pregnant women received quality ANC during pregnancy. To improve the quality of ANC in Ethiopia, Ministry of Health and health facilities are needed to increase financial support strategies that enable pregnant women from poor households to use health services and enhance pregnant women's understanding of the significance of quality of ANC through health education. Additionally, Community health workers should also be placed on supporting unmarried pregnant women to have quality ANC.

Depression remains a neglected public health problem among pregnant women in Northwest Ethiopia

BACKGROUND

Antenatal depression is highly prevalent but a neglected public health problem in low income countries. It has serious effects on the general health of women, birth outcomes and child health. However, there has been limited substantial evidence on the prevalence and predictors of antenatal depression in Ethiopia. This lack of evidence potentiates the consequences of the problem and can limit the attention to intervention. Thus, this study aimed to assess the prevalence and potential predictors of antenatal depression at Debre Tabor and Woreta towns, Northeast Ethiopia.

METHODS

A community-based cross-sectional study was employed on 548 pregnant women recruited by a cluster sampling method. Depressive symptoms were measured using the Edinburgh Postnatal Depression Scale (EPDS). The List of Threatening Experiences Questionnaire (LTE-Q), the Oslo-3 Social Support Scale (OSSS-3), Intimate Partner Violence (IPV) Scale and Fast Alcohol Screening Test (FAST) were also used to measure stressful events, social support, intimate partner violence (IPV) and hazardous alcohol use respectively. Bivariable and multivariable logistic regression analyses were carried out to identify factors associated with antenatal depression.

RESULTS

The prevalence of antenatal depression was found to be 24.45% (95% CI: 21.20, 28.30%). Being single (AOR =3.32, 95% CI = 1.36, 8.09); fear of pregnancy complication (AOR = 3.84, 95% CI = 1.53,9.62); history of chronic illness (AOR = 8.14, 95% CI = 2.14, 30.91); unplanned pregnancy (AOR = 2.99, 95% CI = 1.36,6.55); history of stillbirth (AOR = 3.56, 95% CI = 1.23, 10.29),one or more negative life events (AOR = 4.06, 95% CI = 1.71, 9.66) and intimate partner violence (AOR = 3.91, 95% CI = 1.65, 9.26) were factors significantly associated with antenatal depression.

CONCLUSION

Nearly a quarter of pregnant women suffer from depressive symptoms during pregnancy. Being single; fear of pregnancy complication; history of chronic illness; unplanned pregnancy; history of stillbirth; one or more negative life events and intimate partner violence were important predictors of antenatal depression in this study. Health care workers should consider addressing these risk factors during a routine antenatal care. Also, integrating early screening, detection, and treatment of antenatal depression into routine antenatal care is warranted to improve the quality of life of pregnant women and pregnancy outcomes as well.

A Narrative Review of Nutritional Malpractices, Motivational Drivers, and Consequences in Pregnant Women: Evidence from Recent Literature and Program Implications in Ethiopia

Maternal nutrition is very important for the wellbeing of pregnant women, childbirth, and lactating women, which are crucial and meant for the wellbeing of a mother and newborn baby. This narrative review discusses nutritional malpractices, motivational drivers, and their consequences typically from Ethiopian pregnant women's context. Different studies (regarding less of study design and type) done among pregnant women (aged 15-49 years) by considering pregnancy-related outcomes and timing of nutritional malpractices were included mostly. Accordingly, taboos of healthy diets, craving for unhealthy foods (sweet, fat, raw, and salty/spicy foods), and nonfood items (soil, coffee residue, stone, and ash) were practiced majorly by the women. The birth difficulty, fetal head plastering, fetus discoloration, fetus burns, abortion, and abdominal cramp are the primary drivers of taboos of healthy diets. Hormonal change and social and nutrient-seeking behavior are the most prevalent drivers to the consumption of unhealthy foods. Additionally, personal interest, flavor, and color of items are important motivators to practice pica. Such pica practice hurts nutrient intake, absorption of iron/zinc, abdominal health, and diarrhea occurrence. Food taboos are high predictors of health disorders, such as intrauterine growth restriction, infection, bleeding, preeclampsia, stillbirth, early birth, low birth weight, retarded development of cognitive, and anemia. Craving and eating unhealthy foods were interconnected with chronic disease development (hypertension, diabetes, heart disease, and cancer), discomforts, preterm labor, preeclampsia, and intrauterine growth restriction in women. Additionally, it is also associated with stillbirth, low birth weight, obesity, birth defect/deficit, hypertension, cancer, diabetes, metabolic syndrome, renal disease, decreased fetal growth, behavioral change, heart failure, and poor cognitive development in the infant. Overall, these nutritional malpractices are significantly associated with many argumentative pregnancies as well as developmental consequences leading to the direction of infant and maternal mortality and morbidity. Therefore, urgent implementation of health and nutrition education programs considering food misconceptions and beliefs regarding pregnancy and use of ground-breaking ways to play down the negative and maximize potential positive dietary effects designed by the government of Ethiopia could also serve as a long-term solution to the problem.

Changes in attitudes and behaviors supportive of maternal and newborn health in Ethiopia: an evaluative case study

Background

Ethiopia’s high neonatal mortality rate led to the government’s 2013 introduction of Community-Based Newborn Care (CBNC) to bring critical prevention and treatment interventions closer to communities in need. However, complex behaviors that are deeply embedded in social and cultural norms continue to prevent women and newborns from getting the care they need. A demand creation strategy was designed to create an enabling environment to support appropriate maternal, newborn, and child health (MNCH) behaviors and CBNC. We explored the extent to which attitudes and behaviors during the prenatal and perinatal periods varied by the implementation strength of the Demand Creation Strategy for MNCH-CBNC.

Methods

Using an embedded, multiple case study design, we purposively selected four kebeles (villages) from two districts with different levels of implementation strength of demand creation activities. We collected information from a total of 150 key stakeholders across kebeles using multiple qualitative methods including in-depth interviews, focus group discussions, and illness narratives; sessions were transcribed into English and coded using NVivo 10.0. We developed case reports for each kebele and a final cross-case report to compare results from high and low implementation strength kebeles.

Results

We found that five MNCH attitudes and behaviors varied by implementation strength. In high implementation strength kebeles women felt more comfortable disclosing their pregnancy early, women sought antenatal care (ANC) in the first trimester, families did not have fatalistic ideas about newborn survival, mothers sought care for sick newborns in a timely manner, and newborns received care at the health facility in less than an hour. We also found changes across all kebeles that did not vary by implementation strength, including male engagement during pregnancy and a preference for giving birth at a health facility.

Conclusions

Findings suggest that a demand creation approach—combining participatory approaches with community empowering strategies—can promote shifts in behaviors and attitudes to support the health of mothers and newborns, including use of MNCH services. Future studies need to consider the most efficient level of intervention intensity to make the greatest impact on MNCH attitudes and behaviors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03865-8.

Prevalence and Stigma of Postpartum Common Mental Disorders in the Gurage Region of Ethiopia: A Mixed-Methods Observational Cohort Study

Objectives: Mental disorders are vastly underdiagnosed in low-income countries that disproportionately affect women. We aimed to evaluate the prevalence of common mental disorders in newly postpartum women, and stigma associated with mental health reporting in an Ethiopian community using a validated World Health Organization survey.

Methods: The Self Reporting Questionnaire (SRQ) for psychological distress was administered in Amharic by nurses to 118 women aged 18–37 years who had given birth in the prior 3 months in the Glenn C. Olsen Memorial Primary Hospital in Yetebon. Mental health stigma among the four nursing staff was assessed using Link and Phelan's Components of Stigma.

Results: Among 118 women surveyed, 18% had a probable common mental disorder using the SRQ 4/5 cutoff and 2% admitted to suicidal thoughts. Presence of stigma in the healthcare staff was verified, including labeling, stereotyping, separating, and status loss and discrimination.

Conclusion: Postpartum mental health disorders as well as stigma against such diagnoses are common in the Yetebon community. There is an urgent need for increased availability of properly trained and supervised healthcare staff in the identification and referral of postpartum women with common mental disorders.

Validation of the Wijma delivery expectancy/experience questionnaire for pregnant women in Malawi: a descriptive, cross-sectional study

BACKGROUND

Fear of childbirth is a common health concern for women during pregnancy. The Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) is widely used to measure childbirth fear during pregnancy. However, this instrument is yet to be validated in Malawi, Africa. Our study aimed to assess the psychometric properties of the W-DEQ questionnaire in Malawi.

METHODS

Healthy pregnant women in the third trimester (N = 476) at a district hospital in Malawi were included. Fear of childbirth, depressive symptoms, and quality of life were assessed using the W-DEQ, the Edinburg Postnatal Depression Scale, and the World Health Organization Quality of Life scale, respectively. The construct validity, reliability, and convergent validity of the W-DEQ were examined using exploratory and confirmatory factor analyses, Cronbach's alpha, and Pearson correlations.

RESULTS

The mean age of participants was 28.2 (standard deviation = 6.8) years. Exploratory and confirmatory factor analysis of the Malawian version of the W-DEQ indicated a multidimensional structure with three factors: fear, negative appraisal, and a lack of self-efficacy, with acceptable goodness of model fit. The Malawian version of the W-DEQ showed a satisfactory internal consistency (α = 0.84) and was significantly correlated with depressive symptoms (r = 0.23, p < 0.001) and quality of life (r = - 0.17 ~ -0.26, ps < 0.05).

CONCLUSIONS

Our findings support the Malawian W-DEQ version being a reliable and valid instrument for measuring childbirth fear in African women.

Stakeholder perspectives on antenatal depression and the potential for psychological intervention in rural Ethiopia: a qualitative study

BACKGROUND

Psychological interventions for antenatal depression are an integral part of evidence-based care but need to be contextualised for respective sociocultural settings. In this study, we aimed to understand women and healthcare workers' (HCWs) perspectives of antenatal depression, their treatment preferences and potential acceptability and feasibility of psychological interventions in the rural Ethiopian context.

METHODS

In-depth interviews were conducted with women who had previously scored above the locally validated cut-off (five or more) on the Patient Health Questionnaire during pregnancy (n = 8), primary healthcare workers (HCWs; nurses, midwives and health officers) (n = 8) and community-based health extension workers (n = 7). Translated interview transcripts were analysed using thematic analysis.

RESULTS

Women expressed their distress largely through somatic complaints, such as a headache and feeling weak. Facility and community-based HCWs suspected antenatal depression when women reported reduced appetite, sleep problems, difficulty bonding with the baby, or if they refused to breast-feed or were poorly engaged with antenatal care. Both women and HCWs perceived depression as a reaction ("thinking too much") to social adversities such as poverty, marital conflict, perinatal complications and losses. Depressive symptoms and social adversities were often attributed to spiritual causes. Women awaited God's will in isolation at home or talked to neighbours as coping mechanisms. HCWs' motivation to provide help, the availability of integrated primary mental health care and a culture among women of seeking advice were potential facilitators for acceptability of a psychological intervention. Fears of being seen publicly during pregnancy, domestic and farm workload and staff shortages in primary healthcare were potential barriers to acceptability of the intervention. Antenatal care providers such as midwives were considered best placed to deliver interventions, given their close interaction with women during pregnancy.

CONCLUSIONS

Women and HCWs in rural Ethiopia linked depressive symptoms in pregnancy with social adversities, suggesting that interventions which help women cope with real-world difficulties may be acceptable. Intervention design should accommodate the identified facilitators and barriers to implementation.

Perinatal mental distress in a rural Ethiopian community: a critical examination of psychiatric labels

BACKGROUND

Perinatal mental distress poses a heavy burden in low- and middle-income countries (LMICs). This study investigated perceptions and experiences of perinatal mental distress among women in a rural Ethiopian community, in an effort to advance understanding of cross-cultural experiences of perinatal mental distress.

METHODS

We employed a sequential explanatory study design. From a population-based cohort study of 1065 perinatal women in the Butajira Health and Demographic Surveillance Site, we purposively selected 22 women according to their scores on a culturally validated assessment of perinatal mental distress (the Self-Reporting Questionnaire). We examined concordance and discordance between qualitative semi-structured interview data ('emic' perspective) and the layperson-administered fully-structured questionnaire data ('etic' perspective) of perinatal mental distress. We analysed the questionnaire data using summary statistics and we carried out a thematic analysis of the qualitative data.

RESULTS

Most women in this setting recognised the existence of perinatal mental distress states, but did not typically label such distress as a discrete illness. Instead, perinatal mental distress states were mostly seen as non-pathological reactions to difficult circumstances. The dominant explanatory model of perinatal mental distress was as a response to poverty, associated with inadequate food, isolation, and hopelessness. Support from family and friends, both emotional and instrumental support, was regarded as vital in protecting against mental distress. Although some women considered their distress amenable to biomedical solution, many thought medical help-seeking was inappropriate. Integration of perspectives from the questionnaire and semi-structured interviews highlighted the important role of somatic symptoms and nutritional status. It also demonstrated the differential likelihood of endorsement of symptoms when screening tools versus in-depth interviews are used.

CONCLUSIONS

This study highlights the importance of the wider social context within which mental health problems are situated, specificially the inseparability of mental health from gender disadvantage, physical health and poverty. This implies that public health prevention strategies, assessments and interventions for perinatal distress should be developed from the bottom-up, taking account of local contexts and explanatory frameworks.

Causal mechanisms of postnatal depression among women in Gondar town, Ethiopia: application of a stress-process model with generalized structural equation modeling

BACKGROUND

Postnatal depression (PND) is the second most common cause of disability and the most common complication after childbirth. Understanding the potential mechanisms by which the stress process can lead to PND is an important step for planning preventive interventions for PND. This study employed a stress process model to explore the possible pathways leading to PND in Gondar Town, Ethiopia.

METHODS

A community-based cohort study was conducted in 916 pregnant women, who were assessed for depression in their second or third trimester of pregnancy and re-assessed two to eight weeks after birth. Women with an Edinburgh Postnatal Depression Scale (EPDS) ≥6 were considered to be depressed. Modified Poisson regression was used to identify the independent predictors of PND. A Generalized Structural Equation Modeling (GSEM) was then used to explore the direct and indirect effects of stressors and their mediators on PND.

RESULTS

The prevalence and incidence proportion of PND were 9.27% (95%CI: 7.45, 11.36) and 7.77% (95%CI: 6.04, 9.79), respectively and 2.1% of the women demonstrated symptoms of depression within the study period. PND was independently predicted by having limited postnatal care services, Antenatal Depression (AND) and a Common Mental Disorders (CMD) before pregnancy, (IRR = 1.8; 95%CI: 1.0, 3.2), 1.6(95%CI: 1.4, 1.7), and 2.4 (95%CI: 1.4, 4.3) respectively). In SEM, AND (standardized total effect = 0.36) and a CMD before pregnancy (standardized total effect = 0.11) had both a direct and an indirect positive effect on PND scores. Low birth weight (standardized β = 0.32) and self-reported labor complications (standardized β = 0.09) had direct effects only on PND scores.

CONCLUSION

The observed incidence and prevalence of PND in Ethiopia were lower than in previous studies. A CMD before pregnancy and low birth weight (LBW) increased PND scores, and these effects were in part mediated via antenatal depression and labor complications. Early detection and treatment of depression before or during pregnancy could either directly or indirectly reduce the risk of labor complications and PND. Interventions that reduce LBW or improve the uptake of postnatal care might reduce PND incidence.

Perinatal mental health around the world: priorities for research and service development in Africa

Africa is a diverse and changing continent with a rapidly growing population, and the mental health of mothers is a key health priority. Recent studies have shown that: perinatal common mental disorders (depression and anxiety) are at least as prevalent in Africa as in high-income and other low- and middle-income regions; key risk factors include intimate partner violence, food insecurity and physical illness; and poor maternal mental health is associated with impairment of infant health and development. Psychological interventions can be integrated into routine maternal and child healthcare in the African context, although the optimal model and intensity of intervention remain unclear and are likely to vary across settings. Future priorities include: extension of research to include neglected psychiatric conditions; large-scale mixed-method studies of the causes and consequences of perinatal common mental disorders; scaling up of locally appropriate evidence-based interventions, including prevention; and advocacy for the right of all women in Africa to safe holistic maternity care.

Magnitude and Predictors of Antenatal Depression among Pregnant Women Attending Antenatal Care in Sodo Town, Southern Ethiopia: Facility-Based Cross-Sectional Study

BACKGROUND

Depression affects approximately 10 to 20% of pregnant women globally, and one in ten and two in five women in developed and developing countries develop depression during pregnancy, respectively. However, evidence regarding its magnitude and predictors in Southern Ethiopia is limited. The present study is aimed at assessing the magnitude and predictors of antenatal depression among pregnant women attending antenatal care in Sodo town.

METHODS

A facility-based cross-sectional study was conducted among 403 antenatal care attendants in Sodo town from November 2 to January 30, 2017. Systematic random sampling was used to select the study population, and data were collected by using a pretested and structured questionnaire. Data were entered using Epi-data 4.2 and then exported and analyzed using SPSS version 20. Bivariate and multivariable logistic regression analyses were used to assess the association between the dependent variable and independent variables. Variables with P value less than 0.05 were considered as statistically significant.

RESULTS

A total of 400 pregnant women were interviewed. The magnitude of antenatal depression was 16.3% (95% CI (12.8%, 19.9%)). Husband's educational status, at the college and above (AOR: 0.09; 95% CI (0.03, 0.34), regular exercise (AOR: 0.16; 95% CI (0.07, 0.36)), planned pregnancy (AOR: 0.16; 95% CI (0.06, 0.44)), use of family planning (AOR: 0.31; 95% CI (0.14, 0.66)), previous history of anxiety (AOR: 2.96; 95% CI (1.30, 6.74)), previous history of obstetric complications (AOR: 19.03; 95% CI (5.89, 61.47)), and current obstetric complications (AOR: 30.38; 95% CI (3.14, 294.19)) were significant predictors of antenatal depression.

CONCLUSION

Nearly one in six pregnant women had antenatal depression. The husband's educational status, regular exercise, planned pregnancy, use of family planning, previous history of anxiety, previous history of obstetric complications, and current history of obstetric complications were significant predictors of antenatal depression. Screening for depression during routine antenatal care could be essential and recommended to identify early and prevent further morbidities and mortalities due to antenatal depression.

Psychosocial distress among unpaid community health workers in rural Ethiopia: Comparing leaders in Ethiopia's Women's Development Army to their peers

There is a growing critical social science literature on volunteering in health programs in non-western, low-income countries, yet few have mixed quantitative and qualitative methods to examine the psychological and social wellbeing of unpaid community health workers in such contexts. We address this issue with data from unpaid community health workers (CHWs) and other women who comprise Ethiopia's state-organized Women's Development Army. We draw on qualitative and cross-sectional survey data collected between 2013 and 2016 to test links between various aspects of psychosocial and economic wellbeing and volunteer status in a rural context. We surveyed 422 adult women in Amhara state, 73 of whom were unpaid CHWs in the "Army". We also conducted interviews and focus group discussions with health officials, salaried Health Extension Workers, volunteer CHWs, and other adult women. Analyses of our qualitative and quantitative datasets show that volunteer CHWs are actually worse off than their peers in various psychosocial and economic respects, and that CHW recruitment processes are the most likely explanation for this difference. Additionally, the unpaid CHW position adds work to already burdened shoulders, and makes women-especially unmarried women-vulnerable to negative gossip and high levels of psychological distress. To a limited extent, the volunteer CHW position also bolsters married women's subjective socioeconomic status and confidence in achieving future gains in status. By showing that unpaid CHWs do not necessarily enjoy psychosocial benefits, and may experience harm as a result of their work, these findings reinforce the recommendation that CHWs in contexts of poverty be paid and better supported.

Prenatal stress and child development: A scoping review of research in low- and middle-income countries

INTRODUCTION

Past research has shown relationships between stress during pregnancy, and related psychosocial health measures such as anxiety and depressive symptoms, with infant, child, and adult outcomes. However, most research is from high-income countries. We conducted a scoping review to identify research studies on prenatal stress and outcomes of the pregnancy or offspring in low- and middle-income countries (LMICs), and to synthesize the stress measures and outcomes assessed, the findings observed, and directions for future research.

METHODS

We searched PubMed, Scopus, and PsycINFO for English-language abstracts published from Jan 1960-Jan 2017. Search terms were related to stress and psychosocial health; pregnancy; infant or child development; and LMICs.

RESULTS

48 articles were identified. Sixty percent of studies were in upper-middle, 25% in lower-middle, and 15% in low income countries. Most studies used questionnaires, either existing or tailor-made, to assess stress. Eight assessed cortisol. Most studies (n = 31) assessed infant outcomes at birth, particularly gestational age or preterm birth (n = 22, 12 showing significant relationships), and birthweight (n = 21, 14 showing significant relationships). Five studies analyzed outcomes later in infancy such as temperament and motor development, all showing significant results; and nine in childhood such as behavioral development, asthma, and physical growth, with eight showing significant results.

CONCLUSIONS

Results highlight the importance of prenatal stress on infant and child outcomes in LMICs. Methods used in high-income countries are successfully employed in LMICs, but tailored tools remain necessary. Careful assessment of covariates is needed to foster analyses of interactive effects and pathways. Studies including longer-term follow-up should be prioritized.

Postpartum depressive symptoms in the context of high social adversity and reproductive health threats: a population-based study

Background

Postpartum depression is an important but neglected public health issue in low- and middle-income countries. The aim of this study was to assess postpartum depressive (PPD) symptoms and associated factors in a rural Ethiopian setting characterized by high social adversity and reproductive health threats. We hypothesized that infant gender preference would be associated with PPD symptoms.

Methods

A cross-sectional, population-based study was conducted in Sodo district, southern Ethiopia, between March and June 2014. A total of 3147 postpartum women (one to 12 months after delivery) were recruited and interviewed in their homes. The questionnaire included demographic, reproductive health and psychosocial factors in addition to a culturally validated measure of depressive symptoms, the Patient Health Questionnaire. Scores of 5 or more were indicative of high levels of PPD symptoms.

Results

The prevalence of high PPD symptoms was 12.2%, with 95% confidence interval (CI) between 11.1 and 13.4. Of these, 12.0% of the study participants had suicidal ideation. Preference of the husband for a boy baby was associated with PPD symptoms in univariate analysis (crude odds ratio 1.43: 95% CI 1.04, 1.91) but became non-significant after adjusting for confounders. In the final multivariable analysis, rural residence [adjusted odds ratio (aOR) 2.56: 95% CI 2.56, 4.19], grand multiparity (aOR 2.00: 1.22, 3.26), perinatal complications (aOR: 2.55: 1.89, 3.44), a past history of abortion (aOR 1.50: 1.07, 2.11), experiencing hunger in the preceding 1 month (aOR 2.38: 1.75, 3.23), lower perceived wealth (aOR 2.11: 1.19, 3.76), poor marital relationship (aOR 2.47: 1.79, 3.42), and one or more stressful events in the preceding 6 months (aOR 2.36: 1.82, 3.06) were associated significantly with high PPD symptoms.

Conclusion

PPD symptoms affected more than one in 10 women in this Ethiopian community setting. Social adversity and reproductive health threats were associated with poorer mental health. Interventions focusing on poor rural women with low access to care are necessary. This research can serve as an entry point for the adaptation of a psychosocial intervention.

Process evaluations of task sharing interventions for perinatal depression in low and middle income countries (LMIC): a systematic review and qualitative meta-synthesis

BACKGROUND

Perinatal depression is common in low and middle income countries (LAMICs). Task sharing interventions have been implemented to treat perinatal depression in these settings, as a way of dealing with staff shortages. Task sharing allows lay health workers to provide services for less complex cases while being trained and supervised by specialists. Randomized controlled trials suggest that these interventions can be effective but there is limited qualitative information exploring barriers and facilitators to their implementation. This systematic review aims to systematically review current qualitative evidence of process evaluations of task sharing interventions for perinatal depression in LAMICs in relation to the United Kingdom (UK) Medical Research Council (MRC) framework for conducting process evaluations.

METHODS

We searched Medline/ PubMed, PsycINFO, Scopus, Cochrane Library and Web of science for studies from LAMICS using search terms under the broad categories of: (a) "maternal depression'" (b) "intervention" (c) "lay counsellor" OR "community health worker" OR "non-specialist" and (d) "LAMICs". Abstracts were independently reviewed for inclusion by two authors. Full text articles were screened and data for included articles were extracted using a standard data extraction sheet. Qualitative synthesis of qualitative evidence was conducted.

RESULTS

8420 articles were identified from initial searches. Of these, 26 full text articles were screened for eligibility with only three studies meeting the inclusion criteria. Main findings revealed that participants identified the following crucial factors: contextual factors included physical location, accessibility and cultural norms. Implementation factors included acceptability of the intervention and characteristics of the personnel. Mechanisms included counsellor factors such as motivating and facilitating trust; intervention factors such as use of stories and visual aids, and understandability of the content; and participant factors such as shared experience, meeting learning needs, and meeting expectations.

CONCLUSIONS

While task sharing has been suggested as an effective way of filling the treatment gap for perinatal depression, there is a paucity of qualitative research exploring barriers and facilitators to implementing these interventions. Qualitative process evaluations are crucial for the development of culturally relevant interventions.

Prenatal Maternal Anxiety in South Asia: A Rapid Best-Fit Framework Synthesis

Background: Most research efforts toward prenatal maternal anxiety has been situated in high-income countries. In contrast, research from low- and middle-income countries has focused on maternal depression and prenatal maternal anxiety in low- and middle-income countries remains poorly understood. Objectives: To examine whether dimensions and attributes of current maternal anxiety assessment tools appropriately capture South Asia women's experiences of perinatal distress during pregnancy. Design: We conducted a rapid review with best fit framework synthesis, as we wished to map study findings to an a priori framework of dimensions measured by prenatal maternal anxiety tools. Data Sources: We searched MEDLINE, PsycINFO, and CINAHL and gray literature in November 2016. Studies were included if published in English, used any study design, and focused on women's experiences of prenatal/antenatal anxiety in South Asia. Review Methods: Study quality was assessed using the Effective Public Health Practice Project Quality Assessment Tool and Critical Appraisal Skills Programme Qualitative Checklist. Study findings were extracted to an a priori framework derived from pregnancy-related anxiety tools. Results: From 4,177 citations, 9 studies with 19,251 women were included. Study findings mapped to the a priori framework apart from body image. A new theme, gender inequality, emerged from the studies and was overtly examined through gender disparity, gender preference of fetus, or domestic violence. Conclusions: Gender inequality and societal acceptability of domestic violence in South Asian women contextualizes the experience of prenatal maternal anxiety. Pregnancy-related anxiety tools should include domains related to gender inequality to better understand their influence on pregnancy outcomes.

A qualitative study of pregnancy-related anxiety among women in Tanzania

OBJECTIVES

To explore and understand the experiences and priorities of pregnant women living with fears and worries related to fetal/infant and maternal health, the birthing process and ability to parent the infant (ie, pregnancy-related anxiety (PRA)) in Mwanza, Tanzania.

DESIGN

Descriptive phenomenological approach.

SETTING

Two clinics in the Ilemela and Nyamagana districts of Mwanza.

PARTICIPANTS

Pregnant and postpartum women who obtained high scores on a PRA scale during pregnancy in a larger quantitative study were contacted to participate in an interview (10 women, aged 18-34 years; 3 HIV positive).

MEASURES

Semi-structured interviews were undertaken, with guiding questions related to the women's experience during pregnancy. The Colaizzi method was used with transcripts that had been translated and back translated from Swahili to English and then hand-coded by the interviewer, with independent review by another researcher to verify the analysis.

RESULTS

PRA, as experienced by women in Mwanza, was a state of worry and concern, often causing physical symptoms, and disrupting personal sense of peace. While some themes in the women's experiences reflected the domains examined in the PRA scale used to identify potential participants, others such as lack of knowledge, partner relationship, interactions with the healthcare system, spirituality and fear of HIV/AIDS were otherwise missing. Their prominence in the participants' stories broadens our understanding of PRA.

CONCLUSIONS

The realities and viewpoints of women in low-income and middle-income countries (LMIC) experiencing PRA are still relatively unknown. The findings from this study provided much-needed insight into the perspectives and priorities of women in Mwanza who have experienced PRA and further support the need to explore this phenomenon in other LMIC. The additional domains identified reinforce the need for a PRA tool that accurately and adequately capture the complexities of PRA for women in this region.

Antenatal depressive symptoms and utilisation of delivery and postnatal care: a prospective study in rural Ethiopia

BACKGROUND

Uptake of delivery and postnatal care remains low in Low and Middle-Income Countries (LMICs), where 99% of global maternal deaths take place. However, the potential impact of antenatal depression on use of institutional delivery and postnatal care has seldom been examined. This study aimed to examine whether antenatal depressive symptoms are associated with use of maternal health care services.

METHODS

A population-based prospective study was conducted in Sodo District, Southern Ethiopia. Depressive symptoms were assessed during pregnancy with a locally validated, Amharic version of the Patient Health Questionnaire (PHQ-9). A cut off score of five or more indicated possible depression. A total of 1251 women were interviewed at a median of 8 weeks (4-12 weeks) after delivery. Postnatal outcome variables were: institutional delivery care utilization, type of delivery, i.e. spontaneous or assisted, and postnatal care utilization. Multivariate logistic regression was used to examine the association between antenatal depressive symptoms and the outcome variables.

RESULTS

High levels of antenatal depressive symptoms (PHQ score 5 or higher) were found in 28.7% of participating women. Nearly two-thirds, 783 women (62.6%), delivered in healthcare institutions. After adjusting for potential confounders, women with antenatal depressive symptoms had increased odds of reporting institutional birth [adjusted Odds Ratio (aOR) =1.42, 95% Confidence Interval (CI): 1.06, 1.92] and increased odds of reporting having had an assisted delivery (aOR = 1.72, 95% CI: 1.10, 2.69) as compared to women without these symptoms. However, the increased odds of institutional delivery among women with antenatal depressive symptoms was associated with unplanned delivery care use mainly due to emergency reasons (aOR = 1.62, 95% CI: 1.09, 2.42) rather than planning to deliver in healthcare institutions.

CONCLUSION

Improved detection and treatment of antenatal depression has the potential to increase planned institutional delivery and reduce perinatal complications, thus contributing to a reduction in maternal morbidity and mortality.

Association of gender disadvantage factors and gender preference with antenatal depression in women: a cross-sectional study from rural Maharashtra

PURPOSE

Maternal depression is a major public health problem in low- and middle-income countries including India. Very few studies have assessed association of various risk factors with antenatal depression in rural Indian women, especially the effect of marital conflict, gender disadvantage and gender preference on antenatal depression. This paper describes the prevalence of probable antenatal depression in rural Maharashtra, a state in the western part of India and specifically assesses the association of marital and gender disadvantage factors and gender preference for a male child with antenatal depression.

METHODS

Primary Health Centre-based cross-sectional survey of antenatal women in rural Maharashtra was carried out. The outcome of interest was a probable diagnosis of depression in antenatal women which was measured using the Edinburgh postnatal depression scale (EPDS). Data were analyzed using simple and multiple logistic regression.

RESULTS

302 women in their antenatal period were included in this study. The outcome of antenatal depression (EPDS > 12) was found in 51 women (16.9%, 95% CI 12.6-21.1%). Feeling pressurized to deliver a male child was strongly associated with the outcome of antenatal depression (adjusted odds ratio (OR): 3.0; 95% CI 1.4-6.5). Unsatisfactory reaction of in-laws to dowry (adjusted OR 11.2; 95% CI 2.4-52.9) and difficult relationship with in-laws (adjusted OR 5.3; 95% CI 2.4-11.6) were also significantly associated with antenatal depression.

CONCLUSIONS

Our findings demonstrate that antenatal depression in rural women of Western Maharashtra is associated with gender disadvantage factors, especially related to preference for a male child. The agenda to improve maternal mental health should be ultimately linked to address the broader social development goals and gender empowerment.

Antenatal depressive symptoms and maternal health care utilisation: a population-based study of pregnant women in Ethiopia

BACKGROUND

Depressive symptoms during pregnancy can have multiple adverse effects on perinatal outcomes, including maternal morbidity and mortality. The potential impact of antenatal depressive symptoms on maternal health care use, however, has been little explored in low and middle-income countries (LMICs). This paper investigates whether maternal health care utilisation varies as a function of antenatal depressive symptoms.

METHODS

In a population-based cross-sectional survey, 1311 women in the second or third trimesters of pregnancy were recruited in Sodo district, Gurage Zone, southern Ethiopia. Depressive symptoms were measured using a locally validated version of the Patient Health Questionnaire (PHQ-9). The association between antenatal depressive symptoms and number of antenatal care (ANC) visits was examined using Poisson regression and the association of depression symptoms with emergency health care visits using negative binomial regression. Binary logistic regression was used to investigate the association of depressive symptoms with initiation, frequency and adequacy of antenatal care.

RESULTS

At PHQ-9 cut off of five or more, 29.5 % of participants had depressive symptoms. The majority (60.5 %) of women had attended for one or more ANC visits. Women with depressive symptoms had an increased risk of having more non-scheduled ANC visits (adjusted Risk Ratio (aRR) = 1.41, 95 % CI: 1.20, 1.65), as well as an increased number of emergency health care visits to both traditional providers (aRR = 1.64, 95 % CI: 1.17, 2.31) and biomedical providers (aRR = 1.31, 95 % CI: 1.04, 1.69) for pregnancy-related emergencies. However, antenatal depressive symptoms were not significantly associated with initiation of ANC.

CONCLUSIONS

Increased non-scheduled ANC and emergency health care visits may be indicators of undetected depression in antenatal women, and have the potential to overwhelm the capacity and resources of health care systems, particularly in LMICs. Establishment of a system for detection, referral and treatment of antenatal depression, integrated within existing antenatal care, may reduce antenatal morbidity and treatment costs and promote efficiency of the health care system.

Perinatal mental health care in a rural African district, Uganda: a qualitative study of barriers, facilitators and needs

BACKGROUND

Perinatal mental illness is a common and important public health problem, especially in low and middle-income countries (LMICs). This study aims to explore the barriers and facilitators, as well as perceptions about the feasibility and acceptability of plans to deliver perinatal mental health care in primary care settings in a low income, rural district in Uganda.

METHODS

Six focus group discussions comprising separate groups of pregnant and postpartum women and village health teams as well as eight key informant interviews were conducted in the local language using a topic guide. Transcribed data were translated into English, analyzed, and coded. Key themes were identified using a thematic analysis approach.

RESULTS

Participants perceived that there was an important unmet need for perinatal mental health care in the district. There was evidence of significant gaps in knowledge about mental health problems as well as negative attitudes amongst mothers and health care providers towards sufferers. Poverty and inability to afford transport to services, poor partner support and stigma were thought to add to the difficulties of perinatal women accessing care. There was an awareness of the need for interventions to respond to this neglected public health problem and a willingness of both community- and facility-based health care providers to provide care for mothers with mental health problems if equipped to do so by adequate training.

CONCLUSION

This study highlights the acceptability and relevance of perinatal mental health care in a rural, low-income country community. It also underscores some of the key barriers and potential facilitators to delivery of such care in primary care settings. The results of this study have implications for mental health service planning and development for perinatal populations in Uganda and will be useful in informing the development of integrated maternal mental health care in this rural district and in similar settings in other low and middle income countries.

Food taboos and nutrition-related pregnancy concerns among Ethiopian women

AIMS AND OBJECTIVES

To discuss Ethiopian food taboos during pregnancy and their relation to maternal nutritional status and pregnancy outcomes.

BACKGROUND

Recent waves of migration have seen large groups of Ethiopian refugees moving to countries around the globe. This is of concern as Ethiopian women are at risk of a number of medical and pregnancy complications. Health is further compromised by poor diet and adherence to cultural food beliefs and taboos. In refugee women, many of these factors correspond with significantly higher rates of pregnancy complications and poor birth outcomes.

DESIGN

This is a discussion paper informed by a literature review.

METHODS

A search of the Scopus, PubMed, Web of Science and Academic Search Premier databases for the keywords Ethiopian, pregnancy, food and taboos was conducted in the research literature published from 1998-2015. This time is contingent with Ethiopian migration trends.

RESULTS

Ethiopian migrant women are at risk of inadequate nutrition during pregnancy. Risks include cultural factors associated with food taboos as well as issues associated with low socioeconomic status. Consequently, Ethiopian women are more likely to have nutritional deficiencies such as anaemia which have been associated with a range of pregnancy complications.

CONCLUSIONS

There are many serious consequences of poor diet during pregnancy; however, most of these can be avoided by greater awareness about the role of nutrition during pregnancy and by adopting a balanced diet.

RELEVANCE TO CLINICAL PRACTICE

There is an urgent unmet need for nutrition education among Ethiopian women. Research indicates that Ethiopian women are receptive to nutritional advice during pregnancy and also that pregnant women are generally motivated to act in the baby's interest. These factors suggest that this high-risk group would be amenable to culturally appropriate nutrition education, which would provide much-needed meaningful support in pregnancy.

Mental and Physical Symptoms of Female Rural Workers: Relation between Household and Rural Work

This study aimed to investigate the relations among mental disorders, physical discomfort, household work and farm work among women. We conducted a cross-sectional study based on the administration of a structured questionnaire to 182 female farm workers. The data were analyzed by means of Poisson regression, where the significance level was set to 5%. Results indicated that 111 (61%) participants reported work-related mental disorders and physical discomfort was reported by 160 (87.9%). The participants with mental disorders and at least moderate levels of physical discomfort reported significantly higher levels of physical demand, time working (temporal demand), total effort and frustration with regard to farm work, in addition to significantly higher levels of frustration with regard to housework. Women with moderate or greater levels of both physical discomfort and frustration with farm work increased the chances of mental disorders. The results illustrate the complex challenge for health professionals in caring for women with mental disorders and physical discomforts related to their farm work, in the context of both the farm and domestic work demands these workers experience.

The Health Extension Program and Its Association with Change in Utilization of Selected Maternal Health Services in Tigray Region, Ethiopia: A Segmented Linear Regression Analysis

Background

In 2003, the Ethiopian Ministry of Health established the Health Extension Program (HEP), with the goal of improving access to health care and health promotion activities in rural areas of the country. This paper aims to assess the association of the HEP with improved utilization of maternal health services in Northern Ethiopia using institution-based retrospective data.

Methods

Average quarterly total attendances for antenatal care (ANC), delivery care (DC) and post-natal care (PNC) at health posts and health care centres were studied from 2002 to 2012. Regression analysis was applied to two models to assess whether trends were statistically significant. One model was used to estimate the level and trend changes associated with the immediate period of intervention, while changes related to the post-intervention period were estimated by the other.

Results

The total number of consultations for ANC, DC and PNC increased constantly, particularly after the late-intervention period. Increases were higher for ANC and PNC at health post level and for DC at health centres. A positive statistically significant upward trend was found for DC and PNC in all facilities (p<0.01). The positive trend was also present in ANC at health centres (p = 0.04), but not at health posts.

Conclusion

Our findings revealed an increase in the use of antenatal, delivery and post-natal care after the introduction of the HEP. We are aware that other factors, that we could not control for, might be explaining that increase. The figures for DC and PNC are however low and more needs to be done in order to increase the access to the health care system as well as the demand for these services by the population. Strengthening of the health information system in the region needs also to be prioritized.

Perinatal distress and depression in Malawi: an exploratory qualitative study of stressors, supports and symptoms

Quantitative studies have demonstrated that depression and anxiety in the perinatal period are common amongst women in low- and middle-income countries and are associated with a range of psychosocial and health-related stressors. In this exploratory qualitative study conducted in southern Malawi, we investigated the thoughts and emotions experienced by women in pregnancy and the postnatal period, their expectations of support from husband and others, problems and difficulties faced and the impact of these on psychological wellbeing. We conducted 11 focus group discussions with a total of 98 parous women. A thematic analysis approach was used. Three major themes were identified: pregnancy as a time of uncertainty, the husband (and others) as support and stressor, and the impact of stressors on mental health. Pregnancy was seen as bringing uncertainty about the survival and wellbeing of both mother and unborn child. Poverty, lack of support, HIV, witchcraft and child illness were identified as causes of worry in the perinatal period. Husbands were expected to provide emotional, financial and practical support, with wider family and friends having a lesser role. Infidelity, abuse and abandonment were seen as key stressors in the perinatal period. Exposure to stressors was understood to lead to altered mental states, the symptoms of which are consistent with the concept of common perinatal mental disorder. This study confirms and expands on evidence from quantitative studies and provides formative data for the development of a psychosocial intervention for common perinatal mental disorder in Malawi.

Prevalence and risk factors of depression in Ethiopia: a review

Background

Depression is the most common and disabling mental illness in the globe. It accounts for about 6.5% of the burden of diseases in Ethiopia. Regardless of its severity and relapse rate, there are no synthesized evidences about its prevalence and potential risk factors in Ethiopia. The aim of this review was thus to synthesize scientific information about the prevalence and potential risk factors of depression in Ethiopia.

Methods

Out of 37 papers, 31 were collected from PubMed, Medline and Google Scholar electronic databases, and the remaining six from Addis Ababa University, Department of Psychiatry. But, 13 articles were removed after reading the titles; five after reading the abstracts and two after reading the manuscripts and five of them were duplicates. Finally, 12 papers were reviewed and the pooled prevalence was also computed.

Results

The pooled prevalence of depression for the five studies, which had used Composite International Diagnostic Interview (CIDI), was 6.8% (95%, CI: 6.4–7.3); but, it increased to 11% (95% CI: 10.4–11.5) when three other studies that had used other screening tools were included. Demographic variables such as sex, age, marital status, violence, migration and substance use were associated with depression, but not with economic factors.

Conclusions

More attention should be given to socio-demographic risk factors and intimate partner violence, since they are potential risk factors of depression. The prevalence of depression in Ethiopia was also found comparable to that of some high-income countries.

Exploring women's fear of childbirth in a high maternal mortality setting on the Arabian Peninsula

BACKGROUND

Few studies from low-income countries have addressed women's fear of childbirth (FOC) although likely to affect women during both pregnancy and childbirth. The aim of this study was to explore FOC in a high maternal mortality setting in the Arab region, Yemen.

METHODS

A multi-stage (stratified-purposive-random) sampling process was used. We interviewed 220 women with childbirth experience in urban/rural Yemen. Answers to the question 'Were you afraid of giving birth?' were analyzed using qualitative content analysis.

RESULTS

Women perceived childbirth as a place of danger. Fear of death and childbirth complications stemming from previous traumatic childbirth and traumatic experience in the community was rampant. Husbands' and in-laws' disappointment in a girl infant constituted a strong sociocultural component of FOC. Women's perception of living in tension 'between worlds' of tradition and modernity reinforced fear of institutional childbirth. Women without FOC gave reasons of faith, social belonging and trust in either traditional or modern childbirth practice, past positive experience of childbirth and the desire for social status associated with children.

CONCLUSIONS

The numerous maternal and infant deaths have a strong impact on women's FOC. Antenatal care has an important role in reducing fear including that of institutional childbirth and in strengthening a couple in welcoming a female infant. Staff should be sensitized to the fears of both husband and wife and women be allowed support during childbirth. Within the scope of the Millennium Development Goals and strengthening of reproductive mental health programs, FOC urgently needs to be addressed.

Prevalence and determinants of antenatal depression among pregnant women in a predominantly rural population in Ghana: the DON population-based study

BACKGROUND

While depression during pregnancy is one of the strongest risk factors for postnatal depression, it has been comparatively little studied, particularly in sub-Saharan Africa.

METHODS

Cohort study nested within 4-weekly surveillance of all women of reproductive age to identify pregnancies and collect data on births and deaths in the Kintampo Health Research Centre study area of Ghana. Women were screened for depression during pregnancy using the Patient Health Questionnaire to ascertain DSM-IV major or minor depression. Information on demographic factors, indicators of social and economic disadvantage, and previous obstetric history were also collected which were examined using logistic regression; effect sizes reported as relative risks with 95% confidence intervals.

RESULTS

21,135 pregnant women were screened of whom 20,920 (98.9%) had complete data on potential determinants. 2086 (9.9%, 95% CI: 9.5%-10.3%) had AND. Determinants of AND were: maternal age 30+ years (relative risk [RR], 1.16 (1.06-1.27); never married ([RR] 1.34, (1.14-1.58); lower wealth quintile ([RR], 1.30 (1.13-1.50); unplanned pregnancy ([RR], 1.55 (1.43-1.69); previous pregnancy loss ([RR], 1.30 (1.18-1.43).

LIMITATIONS

We did not assess women for physical health during pregnancy, and lacked information on some potentially relevant psychosocial factors.

CONCLUSION

Prevalence of antenatal depression, applying clinical criteria, is similar to that seen in high income countries. Factors related to chronic social and economic disadvantage are among the most important co-determinants. Population-level interventions that address these problems among women of reproductive age may be the most effective strategy for reducing the prevalence and impact of depression in pregnancy.

The impact of antenatal mental distress on functioning and capabilities: views of health care providers and service users in Cape Town, South Africa

PURPOSE

Antenatal mental distress has disabling consequences. It affects functioning and participation in daily activities and can lead to postnatal depression. This study employs the International Classification of Functioning Disability and Health (ICF), to explore the experiences of pregnant women with mental distress attending the Perinatal Mental Health Project (PMHP). The analysis also adopts Amartya Sen's capabilities approach to provide suggestions for appropriate interventions.

METHODS

We conducted in-depth interviews with seven pregnant women experiencing antenatal mental distress, three postnatal women who had experienced antenatal mental distress and seven health care providers all affiliated with the PMHP. We used an open-ended interview guide employing domains from the ICF as well as from the capabilities approach.

FINDINGS

Participants attributed their antenatal mental distress to a range of environmental factors. Difficulties in functioning were reported by participants including difficulties at work and caring for children. Participants stated that services provided by the PMHP have a positive impact on functioning and capabilities.

CONCLUSION

The study suggests that the ICF is useful for exploring the impact of antenatal mental distress on functioning. It is well complemented by the capabilities approach to inform interventions. Implications for Rehabilitation Antenatal mental distress is a significant public health issue that impacts on women's functioning and participation exacerbated by social factors such as poverty and exposure to violence. This study explored restrictions in functioning and participation faced by women with antenatal mental distress including the ability to care for children, find meaningful employment and sustain relationships. Counselling services can play a role in restoring functioning and capabilities for women experiencing antenatal mental distress. Counselling services have the ability to discuss restrictions in functioning caused by antenatal mental distress with their clients and to offer support for creating capabilities once functioning has improved.

Determinants of antenatal and delivery care utilization in Tigray region, Ethiopia: a cross-sectional study

Introduction

Despite the international emphasis in the last few years on the need to address the unmet health needs of pregnant women and children, progress in reducing maternal mortality has been slow. This is particularly worrying in sub-Saharan Africa where over 162,000 women still die each year during pregnancy and childbirth, most of them because of the lack of access to skilled delivery attendance and emergency care. With a maternal mortality ratio of 673 per 100,000 live births and 19,000 maternal deaths annually, Ethiopia is a major contributor to the worldwide death toll of mothers. While some studies have looked at different risk factors for antenatal care (ANC) and delivery service utilisation in the country, information coming from community-based studies related to the Health Extension Programme (HEP) in rural areas is limited. This study aims to determine the prevalence of maternal health care utilisation and explore its determinants among rural women aged 15–49 years in Tigray, Ethiopia.

Methods

The study was a community-based cross-sectional survey using a structured questionnaire. A cluster sampling technique was used to select women who had given birth at least once in the five years prior to the survey period. Univariable and multivariable logistic regression analyses were carried out to elicit the impact of each factor on ANC and institutional delivery service utilisation.

Results

The response rate was 99% (n=1113). The mean age of the participants was 30.4 years. The proportion of women who received ANC for their recent births was 54%; only 46 (4.1%) of women gave birth at a health facility. Factors associated with ANC utilisation were marital status, education, proximity of health facility to the village, and husband’s occupation, while use of institutional delivery was mainly associated with parity, education, having received ANC advice, a history of difficult/prolonged labour, and husbands’ occupation.

Conclusions

A relatively acceptable utilisation of ANC services but extremely low institutional delivery was observed. Classical socio-demographic factors were associated with both ANC and institutional delivery attendance. ANC advice can contribute to increase institutional delivery use. Different aspects of HEP need to be strengthened to improve maternal health in Tigray.

Impact of perinatal somatic and common mental disorder symptoms on functioning in Ethiopian women: the P-MaMiE population-based cohort study

BACKGROUND

Little is known of the relationship between perinatal somatic and common mental disorder (CMD) symptoms and impaired functioning in women from settings where the burden of undernutrition and infectious disease morbidity is high.

METHODS

A population-based sample of 1065 women from Butajira, Ethiopia, was recruited in pregnancy (86.4% of those eligible) and reassessed two months postnatal (954 with singleton, live infants). At both time-points, women were administered a modified version of the Patient Health Questionnaire-15 and the Self-Reporting Questionnaire (locally-validated) to assess somatic and CMD symptoms, respectively. Negative binomial regression was used to investigate associations of CMD and somatic symptoms with functional impairment (World Health Organisation Disability Assessment Scale, version-II), after adjusting for maternal anthropometric measures, physical ill-health and sociodemographic factors.

RESULTS

In pregnancy, somatic and CMD symptoms were independently associated with worse maternal functional impairment after adjustment for confounders (WHODAS-II score multiplied by 1.09 (95%CI 1.06, 1.13) and 1.11 (95%CI 1.08, 1.14) respectively for each additional symptom). In the postnatal period, the size of association between somatic symptoms and functional impairment was diminished, but the association with CMD symptoms was virtually unchanged (multiplier value 1.04 (95%CI 1.00, 1.09) and 1.11 (95%CI 1.07, 1.16) respectively).

LIMITATIONS

Use of largely self-report measures.

CONCLUSIONS

Somatic and CMD symptoms were independently associated with functional impairment in both pregnancy and the postnatal period, with CMD symptoms showing a stronger and more consistent association. This emphasises the public health relevance of both CMD and somatic symptoms in the perinatal period.

Sociocultural practices in Ethiopia: association with onset and persistence of postnatal common mental disorders

BACKGROUND

Traditional perinatal practices may protect against postnatal common mental disorders (CMD) in non-Western societies.

AIMS

To evaluate the association between perinatal practices and postnatal CMD in rural Ethiopia.

METHOD

A population-based sample of 1065 women was followed up from pregnancy until 2 months postpartum. Qualitative investigation informed the development of scales measuring attitudes towards and adherence to perinatal practices. Postnatal CMD was measured using the Self-Reporting Questionnaire.

RESULTS

Endorsement of sociocultural perinatal practices was associated with lower odds of antenatal CMD persisting into the postnatal period (adjusted odds ratio (OR) = 0.66, 95% CI 0.45-0.95). Women who endorsed protective and celebratory perinatal practices but were unable to complete them had increased odds of incident (adjusted OR = 7.26, 95% CI 1.38-38.04) and persistent postnatal CMD (adjusted OR = 2.16, 95% CI 1.11-4.23) respectively.

CONCLUSIONS

There is evidence for an independent role of sociocultural practices in maintaining perinatal mental health in this Ethiopian community.