Perinatal depression: Epidemiology and associated adverse birth and infant health outcomes in Ethiopia: A mixed method study

Author: Abel Dadi

Dadi, Abel, 2020 Perinatal depression: Epidemiology and associated adverse birth and infant health outcomes in Ethiopia: A mixed method study, Flinders University, College of Medicine and Public Health

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Introduction: Depression occurring during the perinatal period (from pregnancy through the postnatal period to 12 months postpartum is one of the most common complications of the perinatal period in high- and low-income countries. Perinatal depression has been reported to affect pregnancy, maternal, newborn and child health outcomes. Although several studies have been conducted on perinatal depression in Ethiopia, the mechanisms underlying the relationship between this disorder and risk factors, and the links between the condition and adverse birth and infant health outcomes remain unexplored. Furthermore, there have been no studies conducted to explore how the healthcare system addresses perinatal depression issues in Ethiopia. This PhD thesis has investigated the burden and potential causal mechanisms of perinatal depression and its association with the risk of adverse birth and infant health outcomes in Gondar town, Ethiopia. Health system related barriers and enablers of accessing perinatal depression services in Ethiopia were also explored.

Methods: A mixed-methods study was employed to address research questions as follows: (i) to understand what previous studies had found and to assess any gaps in literature, systematic reviews and primary observational studies published between 2007 and 2018 were systematically searched from relevant databases. The quality of the systematic reviews and primary studies were appraised using the Assessment of Multiple Systematic Reviews (AMSTAR) checklist and the Newcastle–Ottawa scale, respectively. (ii) To assess the epidemiology of perinatal depression (using Edinburgh Postnatal Depression Scale (EPDS)), risk factors and effects of perinatal depression on birth and infant health outcomes, a prospective cohort study was conducted. In total, 916 pregnant women were interviewed from six randomly selected urban districts in Gondar town between June 2018 and March 2019. Face-to-face questionnaires were administered using the online Open Data collection Kit (ODK). Enrolled women were followed from pregnancy to up to six months after birth. Using Stata (release 12) software, a mixed effect linear regression and Structural Equation Modelling (SEM) were used to explore antenatal and postnatal depression risk factors and their potential causal mechanisms. Modified Poisson regression and Generalized SEM were used to estimate the risk of adverse birth outcomes and potential mechanisms. Targeted Maximum Likelihood Estimation (TMLE) was applied to investigate the causal association between perinatal depression and the risk of adverse infant health outcomes. (iii)To explore barriers to and facilitators of access to services that address perinatal depression, a qualitative study was conducted with 13 health service administrators from different levels of the Ethiopian health system. A thematic content analysis was conducted to analyse the qualitative data aided by NVivo 12 software.

Results: The systematic review findings highlighted the following: (i) The global prevalence of antenatal depression (AND) ranged from 7% to 65% and was highest in low-income countries. (ii) Globally, the risk of LBW and preterm birth was 1.49 (95%CI: 1.32, 1.68) and 1.40 (95%CI: 1.16, 1.69) times higher in women with AND relative to those with no depression. (iii) Nearly one in three pregnant women in low-income and one in five in middle-income countries had depression symptoms. (iv) The risk of low birth weight (LBW) and preterm birth was found to be 1.66 (95%CI: 1.06, 2.61) and 2.41 (95%CI: 1.47, 3.56) times higher in women with AND in low- and middle-income countries (LMICs) relative to those with no depression. (iii) One in four postnatal women in low-income and one in five in middle-income countries had depression symptoms. (iv) The risk of malnutrition (RR=1.39; 95%CI: 1.21, 1.61), non-exclusive breastfeeding (RR=1.55; 95%CI: 1.39, 1.74), and common infant illnesses (RR=2.55; 95%CI: 1.41, 4.61) were found to be high in the infants of postnatally depressed women. (v) Perinatal women with depression were more likely to experience abuse or violence, poor social and/or partner support, a history of common mental disorders (CMDs), economic difficulties, and poor obstetric history relative to those without depression. The review found that there was a lack of information on the potential causal links of antenatal and postnatal depression and their effects on birth and infant health outcomes in Ethiopia.

Findings from the preliminary analysis of cohort study indicated that the prevalence of AND was 6.9% (95%CI: 5.3, 8.7). Unplanned pregnancy (standardised β=0.15), having a history of CMDs (standardised β=0.18), fear of giving birth (standardised β=0.29), and adequate food access for the last three months (standardised β=–0.11) were correlated with depression score. Social support (β=–0.21), marital agreement (β=–0.28), and partner support (β=–0.18) appeared to partially mediate the link between the identified stressors and the risk of AND. Findings from the cohort study (sample 916) showed that the cumulative incidence of stillbirth, LBW, and preterm birth was 1.90% (95%CI: 1.11, 3.02), 5.25% (95%CI: 3.88, 6.92), and 16.42% (95%CI: 14.05, 19.01), respectively. Depression had no direct effect on birth outcomes but indirectly affected preterm birth via partner support. Partner support moderated the association between AND, preterm birth, and LBW. The risk of stillbirth was 3.22 (95%CI: 1.04, 9.98) times higher in women with AND, and 73% (RR: 0.27; 95%CI: 0.07, 0.99) lower in women with higher coping abilities, but this association was attenuated in path analysis.

The analysis of the cohort study (sample 895) indicated the prevalence and incidence proportion of postnatal depression (PND) to be 9.27% (95%: 7.45, 11.36) and 7.77% (95%CI: 6.04, 9.79), respectively. More than two percent of the women showed depression symptoms both in pregnancy and the postnatal period. Postnatal depression was associated with limited postnatal care services (IRR=1.8; 95%CI: 1.0, 3.2), and was predicted by AND (IRR=1.6; 95%CI: 1.4, 1.7) and CMDs before pregnancy (IRR=2.4; 95%CI: 1.4, 4.3). Antenatal depression (standardised total effect=0.36) and history of CMDs before pregnancy (standardised total effect=0.11) had both a direct and an indirect positive effect on PND scores. Low birth weight (standardised β=0.32) and self-reported labour complications (standardised β=0.09) had only direct effects on PND scores. The cumulative incidence of diarrhea, acute respiratory infection (ARI) and malnutrition during the 6-month follow-up (sample 878) was 17.0% (95%CI: 14.5, 19.6), 21.6% (95%CI: 18.89, 24.49), and 14.4% (95%CI: 12.2, 16.9), respectively. Antenatal depression was not causally associated with the risk of ARI (RD=–1.3%; 95%CI: –21.0, 18.5), diarrhea (RD=0.8%; 95%CI: –9.2, 10.9), or malnutrition (RD=–7.3%; 95%CI: –22.0, 21.8). Similarly, there was no evidence of causal association between PND and the risk of diarrhea (RD=–2.4%; 95%CI: –9.6, 4.9), ARI (RD=–3.2%; 95%CI: –12.4, 5.9), or malnutrition (RD=0.9%; 95%CI: –7.6, 9.5).

The qualitative inquiry identified the following barriers to the delivery of perinatal mental health services: (i) low awareness of perinatal depression among health administrators and community members, and (ii) the absence of policies and/or programs that addressed perinatal depression in Ethiopia. However, the introduction of the new mental health gap action program (MhGap), the simplicity of available screening programs and health worker motivation were identified as potential opportunities that could be used to address perinatal depression by the health system in Ethiopia.

Discussion: The cohort study findings estimated a lower prevalence of antenatal and postnatal depression estimates than those found in systematic reviews. Higher incidence of adverse birth and infant health outcomes were observed in the current study than in previously conducted studies in Ethiopia. Partner support during pregnancy mediated the link between depression, LBW and preterm births.

Keywords: Antental depression, Postnatal depression, Structural equation modeling, adverse birth outcomes, adverse infant health outcomes, Generalized structural equation modeling, Targeted maximum liklhood estimation

Subject: Public Health thesis

Thesis type: Doctor of Philosophy
Completed: 2020
School: College of Medicine and Public Health
Supervisor: Associate Professor Lillian Mwanri