Introducing depression and developmental screenings into the national programme on immunization (NPI) in southeast Nigeria: an experimental cross-sectional assessment

Associations between self-reported ADHD symptoms and depression and anxiety in mothers and fathers during the postpartum period: A Canadian nationwide longitudinal study

BACKGROUND

Attention-deficit hyperactivity disorder (ADHD) may be a risk factor for intra- and inter-parental affective disorders in the perinatal period, placing families at risk for negative outcomes.

METHODS

A large prospective cohort of Canadian women and their male partners (N = 2544 couples) were recruited in the postpartum period. Repeated measures data were collected at baseline and six timepoints over 24-months postpartum. Self-reported ADHD symptoms were measured at baseline, and depression/anxiety were measured at all timepoints. Generalized estimating equations examined associations between possible ADHD and ADHD symptoms with new depression, anxiety, and comorbidity. Cross-parental associations were explored.

RESULTS

Compared to mothers without, those with possible ADHD had higher odds of depression (adjusted odds ratio [aOR] = 1.70, 95 % CI [1.13-2.56]), anxiety (aOR = 1.74 [1.30-2.34]), and comorbidity (aOR = 1.66, [1.06-2.60]), at 3-24 months postpartum. Maternal ADHD symptoms were associated with anxiety in fathers (aOR = 1.03 [1.01-1.06] for 1-unit increase in symptoms) at 3-24-months. When compared to fathers without, those with possible ADHD had higher odds of depression (aOR = 2.33 [1.78-3.05]), anxiety (aOR = 2.02, [1.60-2.55]), and comorbidity (aOR = 2.05, [1.51-2.79]), as well as paternal ADHD symptoms associated with depression (aOR = 1.05, [1.01-1.08] for 1-unit increase in symptoms) and comorbidity (aOR = 1.04 [1.00-1.08] for 1-unit increase in symptoms) in mothers at 3-24-months.

LIMITATIONS

Self-reported measures.

CONCLUSIONS

Parental ADHD in the postpartum period is associated with depression and anxiety among mothers and fathers. Paternal ADHD was a risk for maternal mental health problems in the early postpartum period, and maternal ADHD was a risk for paternal mental health problems in the late postpartum period.

Integrated Approaches for the Delivery of Maternal and Child Health Services with Childhood Immunization Programs in Low- and Middle-Income Countries: Systematic Review Update 2011-2020

Background: The integration of maternal and child health services (MCH) with routine immunization is an important global health strategy, particularly in low- and middle-income countries (LMICs). However, evidence is lacking regarding the best practices for service integration and the effect of integration on immunization and linked health service outcomes. Methods: We searched publication databases and gray literature for articles published between 2011 and 2020 that include approaches to integrating MCH services with immunizations during the first two years of life in LMICs. Abstracts and full-text articles were screened for eligibility. For the included articles, data extraction and analysis examined the descriptive characteristics of studies, outcomes, and implementation considerations. Results: Among the 16,578 articles screened, 44 met the criteria for inclusion, representing 34 studies, of which 29 were from Africa. The commonly linked MCH services were family planning (24%), human immunodeficiency virus (HIV) diagnosis or care (21%), and malaria prevention or control (21%). Multiple integration strategies were typically used; the co-location of linked services (65%), the provision of extra services by immunization staff (41%), and/or the provision of extra information by immunization staff (41%) were the most common. In general, integration improved MCH service outcomes (76%) and was either beneficial (55%) or neutral for immunization (35%), with some examples in family planning, malaria, and HIV where integrated services were not beneficial. Important implementation considerations included the careful matching of target populations in service re-design, ensuring support from policy, logistics, and information systems, the provision of adequate training and support of staff to avoid overload, clear client communication regarding service integration, and the need to address community concerns. Conclusions: Integrating MCH services with routine immunization can expand linked services and improve immunization coverage. This study has identified key implementation considerations relevant to both childhood and adult vaccination programs. More research is needed regarding costs and client preferences.

Maternal mental health and nutritional status of infants aged under 6 months: A secondary analysis of a cross-sectional survey

Maternal/caregivers' mental health (MMH) and child nutrition are both poor in low- and middle-income countries. Links between the two are plausible but poorly researched. Our aim was to inform future malnutrition management programmes by better understanding associations between MMH and nutritional status of infants aged under six month (u6m). We conducted a health facility-based cross-sectional survey of 1060 infants in rural Ethiopia, between October 2020 and January 2021. We collected data on: MMH status (main exposure) measured using the Patient Health Questionnaire (PHQ-9) and infant anthropometry indicators (outcome); length for age Z-score (LAZ), weight for age Z-score (WAZ), weight for length Z-score (WLZ), mid upper arm circumference (MUAC), head circumference for age Z-score (HCAZ) and lower leg length (LLL). Analysis of secondary data using linear regression was employed to determine associations between the main exposure and outcome variables. The result showed infants' mean (SD) age was 13.4 (6.2) weeks. The median score for MMH problem was 0 (inter quartile range 0-2) points, and 29.5% and 11.2% reported minimal and mild to severe depression score of 1-4 and 5-27 points, respectively. Mean (SD) LAZ was -0.4 (1.4), WAZ -0.7 (1.3), WLZ -0.5 (1.2), MUAC 12.4 (1.3) cm, HCAZ 0.4 (1.3) and LLL 148 (13.9) mm. In adjusted linear regression analysis, minimal MMH problem was negatively associated with infant LAZ marginally (β = -0.2; 95% CI: -0.4, 0.00; p = 0.05) and LLL (β = -2.0; 95% CI: -3.8, -0.1; p = 0.04), but not with other anthropometric indicators. Statistically significant associations were not found between mild to severe depressive symptoms and infant anthropometric outcomes. In conclusion, only minimal, but not mild, moderate or severe, maternal/caregivers' depressive symptoms are associated with infant anthropometry outcomes in this data set. Whilst there is a plausible relationship between maternal mental health problems and offspring nutritional status, we did not observed this. Possible reasons include: PHQ-9 not suited to our population; and only a small number of participants reporting moderate to severe level of depression. Further research to investigate and understand the relationship and pathways between maternal mental health and offspring nutritional status is required.

Prevalence and determinants of postpartum depression among adolescent and adult mothers in Northwest Ethiopia

Postpartum depression (PPD) is a common mental health issue in resource-limited settings that negatively affects the well-being of mothers and children. However, PPD often remains untreated, leading to long-term consequences for families. Therefore, we examined the prevalence and determinants of PPD among adolescent and adult mothers in northwest Ethiopia. Data were collected from 374 adolescent (10-19 years) and 760 adult (20-34 years) mothers 6 weeks after childbirth. Data were analyzed using binary and multiple logistic regression. Adolescent mothers had a significantly higher proportion of PPD (37.4%) than adult mothers (20.1%) and were more likely to report low self-esteem (13.1% vs. 8.2%) and low social support (28.3% vs. 23.3%). Factors associated with PPD differed between adolescent and adult mothers. Adolescent mothers with PPD were more likely to report household food insecurity, low self-esteem, low knowledge of postpartum complications, and working in agriculture or professional/technical occupations. For adult mothers, factors associated with PPD included distance to the nearest health facility, medium social support, inadequate dietary diversity, and food insecurity. Results suggest that targeted interventions by age group are needed to reduce the burden of PPD in Ethiopia.

Association between maternal postpartum depression and children's physical growth in early childhood: a birth cohort study

Background

Untreated maternal postpartum depression (PPD) has consequences for children's physical growth, but no published study has evaluated changes in this effect over time. Here we therefore aimed to evaluate the dynamic effects of PPD on the physical growth of children in a prospective birth cohort.

Methods

Between 2015 and 2019, 960 mother-child pairs in Changsha, China were followed up when the child was aged 1-48 months. Data were obtained through household surveys. The mothers' depressive symptoms were measured using the Edinburgh Postpartum Depression Scale (EPDS) at 1 month postpartum. Linear mixed models were used to examine the changes in the association of PPD and EPDS scores with physical growth in six different age groups of children between 1 and 48 months.

Results

A total of 604 mother-child pairs completed the follow-up, and 3.3% of mothers reported PPD. No associations were found between PPD and weight or height growth at any age. While EPDS scores were associated with weight gain (β = -0.014, 95% CI (-0.025, -0.002), P = 0.024) and height growth (β = -0.044, 95% CI (-0.084, -0.004), P = 0.030) rates at 1-3 months, no associations were found in older children.

Limitations

The number of mothers who reported PPD was relatively small, and the measurement of PPD was not continuously taken.

Conclusions

After adjustments for confounders, no dynamic association was found between PPD and children's weight and height growth. EPDS scores, in contrast, did negatively affect children's weight and height growth at age 1-3 months, but this effect was not long-lasting.

Selective cutoff reporting in studies of the accuracy of the Patient Health Questionnaire-9 and Edinburgh Postnatal Depression Scale: Comparison of results based on published cutoffs versus all cutoffs using individual participant data meta-analysis

OBJECTIVES

Selectively reported results from only well-performing cutoffs in diagnostic accuracy studies may bias estimates in meta-analyses. We investigated cutoff reporting patterns for the Patient Health Questionnaire-9 (PHQ-9; standard cutoff 10) and Edinburgh Postnatal Depression Scale (EPDS; no standard cutoff, commonly used 10-13) and compared accuracy estimates based on published cutoffs versus all cutoffs.

METHODS

We conducted bivariate random effects meta-analyses using individual participant data to compare accuracy from published versus all cutoffs.

RESULTS

For the PHQ-9 (30 studies, N = 11,773), published results underestimated sensitivity for cutoffs below 10 (median difference: -0.06) and overestimated for cutoffs above 10 (median difference: 0.07). EPDS (19 studies, N = 3637) sensitivity estimates from published results were similar for cutoffs below 10 (median difference: 0.00) but higher for cutoffs above 13 (median difference: 0.14). Specificity estimates from published and all cutoffs were similar for both tools. The mean cutoff of all reported cutoffs in PHQ-9 studies with optimal cutoff below 10 was 8.8 compared to 11.8 for those with optimal cutoffs above 10. Mean for EPDS studies with optimal cutoffs below 10 was 9.9 compared to 11.8 for those with optimal cutoffs greater than 10.

CONCLUSION

Selective cutoff reporting was more pronounced for the PHQ-9 than EPDS.

Maternal mental health and child well-being in Nigeria: A systematic review

Maternal mental health distress has a disease burden of severe adverse effects for both mother and child. This review identified maternal mental health concerns, their impact on child growth and the current practice of maternal healthcare for both mothers and their children in Nigeria. The Population, phenomenon of Interest and Context (PICo) model was adopted to formulate the review strategy, and five databases were searched for published articles between 1999 and 2019. Databases include Scopus, PubMed, ProQuest, Applied Social Science Index and Abstracts and Web of Science. Boolean operators (AND/OR/NOT) helped to ensure rigorous use of search terms which include 'maternal', 'pre/peri/postnatal', 'mental health', 'mental illness', 'disorders', 'intervention,' 'Nigeria', 'child', 'infant growth', and 'wellbeing'. Thirty-four studies met the inclusion criteria, and extracted data were qualitatively synthesised and analysed thematically. Five themes emerged. These include (i) marital difficulties, (ii) relationship status of the mother, (iii) child's gender, (iv) mode of child delivery and (v) child growth and development. The review showed a significant paucity of literature on the impact of specific maternal mental health problems on child physical growth and cognitive development. We concluded that culturally appropriate and evidence-based psychological interventions for maternal mental health problems would benefit Nigerian indigenous mothers. Therefore, the study recommends randomised controlled trials that are culturally appropriate and cost-effective for distressed mothers with children.

Association of antepartum depression, generalized anxiety, and posttraumatic stress disorder with infant birth weight and gestational age at delivery

BACKGROUND

Low- and middle-income countries bear a disproportionate burden of preterm birth (PTB) and low infant birth weight (LBW) complications where affective and anxiety disorders are more common in the antepartum period than in industrialized countries.

OBJECTIVE

To evaluate the extent to which early pregnancy antepartum depression, generalized anxiety disorder, and posttraumatic stress disorder (PTSD) are associated with infant birth weight and gestational age at delivery among a cohort of pregnant women in Peru.

METHODS

Our prospective cohort study consisted of 4408 pregnant women. Antepartum depression, generalized anxiety, and PTSD were assessed in early pregnancy using the Patient Health Questionnaire-9, Generalized Anxiety Disorder Scale-7 and PTSD Checklist - Civilian Version, respectively. Pregnancy outcome data were obtained from medical records. Multivariable linear and logistic regression procedures were used to estimate adjusted measures of association (β coefficients and odds ratios) and 95% confidence intervals (CI).

RESULTS

After adjusting for confounders, women with antepartum generalized anxiety (32.6% prevalence) had higher odds of LBW (adjusted odds ratio (OR)=1.47; 95%CI: 1.10-1.95) and were more likely to deliver small for gestational age (OR = 1.39; 95%CI: 1.01-1.92) infants compared to those without anxiety. Compared to those without PTSD, women with PTSD (34.5%) had higher odds of delivering preterm (OR = 1.28; 95%CI: 1.00-1.65) yet PTSD was not associated with LBW nor gestational age at delivery. Women with antepartum depression (26.2%) were at no increased risk of delivering a preterm, low-birth-weight or small-for-gestational-age infant.

LIMITATIONS

Our ability to make casual inferences from this observational study is limited; however, these findings are consistent with prior studies.

CONCLUSION

Generalized anxiety disorder during pregnancy appeared to increase odds of delivering a low-birth-weight or small-for-gestational-age infant, while PTSD was associated with increased odds of delivering preterm. Our findings, and those of others, suggest antenatal care should be tailored to screen for and provide additional mental health services to patients.

Consequences of maternal postpartum depression: A systematic review of maternal and infant outcomes

Introduction:

The postpartum period represents the time of risk for the emergence of maternal postpartum depression. There are no systematic reviews of the overall maternal outcomes of maternal postpartum depression. The aim of this study was to evaluate both the infant and the maternal consequences of untreated maternal postpartum depression.

Methods:

We searched for studies published between 1 January 2005 and 17 August 2016, using the following databases: MEDLINE via Ovid, PsycINFO, and the Cochrane Pregnancy and Childbirth Group trials registry.

Results:

A total of 122 studies (out of 3712 references retrieved from bibliographic databases) were included in this systematic review. The results of the studies were synthetized into three categories: (a) the maternal consequences of postpartum depression, including physical health, psychological health, relationship, and risky behaviors; (b) the infant consequences of postpartum depression, including anthropometry, physical health, sleep, and motor, cognitive, language, emotional, social, and behavioral development; and (c) mother–child interactions, including bonding, breastfeeding, and the maternal role.

Discussion:

The results suggest that postpartum depression creates an environment that is not conducive to the personal development of mothers or the optimal development of a child. It therefore seems important to detect and treat depression during the postnatal period as early as possible to avoid harmful consequences.

Prevalence and incidence of postpartum depression among healthy mothers: A systematic review and meta-analysis

This review aims to examine the prevalence and incidence of postpartum depression among healthy mothers without prior history of depression including postpartum depression and who gave birth to healthy full-term infants. A systematic search of ClinicalTrials.gov, CINAHL, EMBASE, PsycINFO, and PubMed was performed for English articles from the inception of the database to November 2017, as well as a manual search of the reference lists of the included articles, and an expert panel was consulted. Across 15,895 articles, 58 articles (N = 37,294 women) were included in the review. The incidence of postpartum depression was 12% [95% CI 0.04-0.20] while the overall prevalence of depression was 17% [95% CI 0.15-0.20] among healthy mothers without a prior history of depression. Prevalence was similar regardless of the type of diagnostic tool used; however, there were statistical differences in the prevalence between different geographical regions, with the Middle-East having the highest prevalence (26%, 95% CI 0.13-0.39) and Europe having the lowest (8%, 95% CI 0.05-0.11). There was no statistical difference in prevalence between different screening time points, but an increasing prevalence was observed beyond six months postpartum. Intervention studies often neglect healthy mothers. This review reports a similar prevalence rate of postpartum depression among mothers without history of depression when compared to mothers with history of depression. Thus, future studies should place equal emphasis on this neglected group of mothers so that targeted interventions and follow-ups can be introduced at appropriate time points.

Intimate Partner Violence, Depression, and Child Growth and Development

BACKGROUND

Evidence on the relationship between maternal depression and exposure to intimate partner violence (IPV) with child physical growth and development is equivocal. Our aim in the current study is to examine these relationships among women and their children in Tanzania.

METHODS

The Bayley Scales of Infant Development and anthropometric measures were used to assess children 18 to 36 months of age (n = 1031). Maternal exposure to IPV and depression were assessed using the Tanzania Demographic and Health Survey questionnaire and the Patient Health Questionnaire-9, respectively. We used linear regression models to calculate standardized mean differences (SMDs) for developmental outcomes and generalized linear models to estimate the associations with nutritional status.

RESULTS

Mild depressive symptoms in mothers (Patient Health Questionnaire-9 ≥5) and exposure to physical and sexual IPV were associated with lower SMDs for motor skills (-0.14 [P = .023] and -0.23 [P < .01], respectively), expressive communication (-0.13 [P = .187] and -0.23 [P < .01], respectively), receptive communication (-0.19 [P < .009] and -0.16 [P = .03], respectively), and cognitive development (-0.08 [P = .245] and -0.12 [P = .07], respectively). Exposure to physical and sexual IPV was associated with higher risk for stunting (relative risk = 1.6; P < .001).

CONCLUSIONS

This study reveals that maternal depressive symptoms and IPV are associated with adverse child nutritional and developmental outcomes. Further research is needed to develop programs to address IPV and depression among women and enhance the growth and development of their children.

Economic and Health Predictors of National Postpartum Depression Prevalence: A Systematic Review, Meta-analysis, and Meta-Regression of 291 Studies from 56 Countries

BACKGROUND

Postpartum depression (PPD) poses a major global public health challenge. PPD is the most common complication associated with childbirth and exerts harmful effects on children. Although hundreds of PPD studies have been published, we lack accurate global or national PPD prevalence estimates and have no clear account of why PPD appears to vary so dramatically between nations. Accordingly, we conducted a meta-analysis to estimate the global and national prevalence of PPD and a meta-regression to identify economic, health, social, or policy factors associated with national PPD prevalence.

METHODS

We conducted a systematic review of all papers reporting PPD prevalence using the Edinburgh Postnatal Depression Scale. PPD prevalence and methods were extracted from each study. Random effects meta-analysis was used to estimate global and national PPD prevalence. To test for country level predictors, we drew on data from UNICEF, WHO, and the World Bank. Random effects meta-regression was used to test national predictors of PPD prevalence.

FINDINGS

291 studies of 296284 women from 56 countries were identified. The global pooled prevalence of PPD was 17.7% (95% confidence interval: 16.6-18.8%), with significant heterogeneity across nations (Q = 16,823, p = 0.000, I2 = 98%), ranging from 3% (2-5%) in Singapore to 38% (35-41%) in Chile. Nations with significantly higher rates of income inequality (R2 = 41%), maternal mortality (R2 = 19%), infant mortality (R2 = 16%), or women of childbearing age working ≥40 h a week (R2 = 31%) have higher rates of PPD. Together, these factors explain 73% of the national variation in PPD prevalence.

INTERPRETATION

The global prevalence of PPD is greater than previously thought and varies dramatically by nation. Disparities in wealth inequality and maternal-child-health factors explain much of the national variation in PPD prevalence.

Epidemiology of maternal depression, risk factors, and child outcomes in low-income and middle-income countries

Maternal depression, a non-psychotic depressive episode of mild to major severity, is one of the major contributors of pregnancy-related morbidity and mortality. Maternal depression (antepartum or post partum) has been linked to negative health-related behaviours and adverse outcomes, including psychological and developmental disturbances in infants, children, and adolescents. Despite its enormous burden, maternal depression in low-income and middle-income countries remains under-recognised and undertreated. In this Series paper, we systematically review studies that focus on the epidemiology of perinatal depression (ie, during antepartum and post-partum periods) among women residing in low-income and middle-income countries. We also summarise evidence for the association of perinatal depression with infant and childhood outcomes. This review is intended to summarise findings from the existing literature, identify important knowledge gaps, and set the research agenda for creating new generalisable knowledge pertinent to increasing our understanding of the prevalence, determinants, and infant and childhood health outcomes associated with perinatal depression. This review is also intended to set the stage for subsequent work aimed at reinforcing and accelerating investments toward providing services to manage maternal depression in low-income and middle-income countries.