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RecommendationTitle and abstractAssessment of antenatal depression and its associated factors among pregnant mothers who attend antenatal care service at jinka public health facilities, jinka town, snnpr, ethiopia, 2018
Antenatal depression is the most common psychiatric disorder during pregnancy and its associated with psychosocial and obstetric factors. Antenatal depression has serious consequences for the mother and fetus, such as recurrent spontaneous abortions, pregnancy induced hypertension, pre-eclampsia, postpartum bleeding, pre-term delivery, postnatal depressive disorders and low birth weight. However it doesnt get appropriate attention.
Institutional based cross-sectional study design was conducted on 446 pregnant women coming for antenatal care service at Jinka public health facilities, from June 01 to June 30, 2018. Data was collected through semi-structured and pretested questionnaire by face to face interview technique and Beck Depression Inventory was used to assess womens depression condition. Collected data was entered in to Epi data version 3.3.1 after checking their completeness and exported to statistical package for social science version 20.0 for analysis. Logistic regression was used to find out association between explanatory and response variables. Explanatory variables which fulfill the assumption of logistic regression and had P-value less than 0.25 from bi-variable logistic regression were considered for the multivariable logistic regression model. Strength of association was evaluated using odds ratio at 95% confidence interval and P-value < 0.05 was considered to declare significant associations.
The magnitude of antenatal depression in this study was 24.4 %( 20.2-28.5 at 95% CI) and it had statistically significant association with unmarried marital status AOR =13.39 [(95%CI); (3.11-57.7)], chronic medical illness AOR=3.97 [(95%CI); (1.07-14.7)], unplanned pregnancy AOR =6.76 [ (95%CI); (2.13-21.4)], history of abortion AOR =2.8 [(95%CI); (1.14-7.02)], history of previous pregnancy complication AOR =4.8 [(95%CI); (2.12-17.35)] and fear of pregnancy related complications AOR=5.4 [(95%CI); (2.32-12.4)].IntroductionBackground/rationaleDepression is a mood disorder that cause persistent feeling of sadness, loss of interest hopelessness, disturbed sleep and disturbed appetite. Its the third leading cause of disease burden worldwide: representing 4.3% of the total disability adjusted life year. In 2020, depression is predicted to become the second leading cause of the global diseases burden ADDIN EN.CITE WHO20122[1]2217WHOdepression as global concernworld health reportworld health report2012[ HYPERLINK \l "_ENREF_1" \o "WHO, 2012 #2" 1] and in 2030, its expected to be the largest contributor for disease burden. Depression is common in both sex, but its burden is higher in females than males ADDIN EN.CITE Shidhaye PR201453[2]535317Shidhaye PR, Giri PA.Maternal depression: A hidden burden in developing countries.Annals of Medical and Health Sciences ResearchAnnals of Medical and Health Sciences Research463-5.4 42014[ HYPERLINK \l "_ENREF_2" \o "Shidhaye PR, 2014 #53" 2]. According to federal ministry of health (FMOH) report in Ethiopia depression contributes about 5% of the disease burden which is the highest share of burden compared to other forms of mental disorders ADDIN EN.CITE FMOH201235[3]353517FMOHNational Mental Health Strategy of Ethiopia,Addis Abeba2012[ HYPERLINK \l "_ENREF_3" \o "FMOH, 2012 #35" 3].
According to world health organization report on mental health aspects of womens reproductive health, depression share the highest magnitude as compare to other psychiatric disorder which occur during pregnancy and at least one in ten women in developed countries and two in five women in developing world develop depression during pregnancy ADDIN EN.CITE who200937[5]373717 World Health Organization/United Nations Population fund whoMental health aspects of womens reproductive health, . Geneva,a global review of literaturea global review of literature2009[ HYPERLINK \l "_ENREF_5" \o "who, 2009 #37" 5]. Antenatal depression can be effectively treated with psychotherapy, cognitive-behavioural therapy, or with medications ADDIN EN.CITE Cunningham201452[4]525213Cunningham, F Gary Williams Obstetrics 24th edition McGraw-Hill Educationpsycatric disorders2014Medical[ HYPERLINK \l "_ENREF_4" \o "Cunningham, 2014 #52" 4]. Despite, large numbers of women do not get treatment ADDIN EN.CITE Bonari200411[7]111117Bonari, LoriPinto, NatashaAhn, EricEinarson, AdrienneSteiner, MeirKoren, GideonPerinatal risks of untreated depression during pregnancyThe Canadian Journal of PsychiatryThe Canadian Journal of Psychiatry726-735491120040706-7437[ HYPERLINK \l "_ENREF_7" \o "Bonari, 2004 #11" 7], due to low help/care seeking in women with antenatal depression, under detection by health care professionals, and low uptake of antidepressant medications in pregnancy period ADDIN EN.CITE Hanlon201432[8]323232Hanlon, CharlotteA Screening for Antenatal depression: a formative study for development of a perinatal mental health liaison service in Zewditu hospital2014Addis Ababa University[ HYPERLINK \l "_ENREF_8" \o "Hanlon, 2014 #32" 8],which increase the impact of untreated depression on the mother, in terms of neglecting her health and increasing the risk of suicide, as well as for the fetus. In addition there is also evidence that untreated antenatal depression is associated with obstetrical complications such as recurrent spontaneous abortion, uterine irritability, pregnancy induced hypertension, preeclampsia, postpartum bleeding, postpartum depression, pre-term delivery and low birth weight ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_7" \o "Bonari, 2004 #11" 7, HYPERLINK \l "_ENREF_9" \o "Rahman, 2007 #13" 9, HYPERLINK \l "_ENREF_10" \o "Marzuk, 1997 #8" 10].
However, antenatal depression is a common problem with multiple symptoms and impacts on both the mother and the fetus, it doesnt get appropriate attention on early detection and treatment in low and middle-income countries (LMICs). Ethiopia is doing a lot to decrease maternal and neonatal morbidity and mortality and to achieve sustainable developmental goals. But a little concern given on the impact of psychological aspects (depression) on obstetrical and neonatal outcome, this may affect the acheivement of sustainable developmental goals.
In different areas of Ethiopia there are different socio demographic and obstetric factors like large family size, low educational status, and low economic status, which contributes for the occurrence of antenatal depression. South omo zone is one of a zone in south nation and nationalities, with the above factors but there is no published information about the problem. For all of the reasons listed above, its better to address the gap in untreated prenatal depression. The first step to address this gap is determining the magnitude of the problem and identify associated factors with it. So this study aimed to assess the magnitude of antenatal depression and associated factors among pregnant women who have ANC follow up in Jinka public health facilities, Jinka town, south omo zone, Ethiopia.
ObjectivesTo determine magnitude of antenatal depression
To identify factors associated to antenatal depression
MethodsStudy designInstitutional based cross-sectional study design was employed.SettingThe study was conducted in Jinka town health facilities, South Omo zone. South Omo is a zone in the Ethiopian Southern nations, nationalities and peoples region, which is bordered on the south by Kenya, on the southwest by the Ilemi Triangle, on the west by Bench Maji, on the northwest by Keffa, on the north by Konta, Gamo Gofa and Basketo, on the northeast by Dirashe and Konso, and on the east by the Oromia Region. The administrative center of south Omo zone is Jinka. As a survey from March to April 2008, there were 25804 (male-13160, female-12644) peoples at the time. It has two public health institutions, one health centers and one general hospital. In the hospital there are two psychiatric nurses who provide psychiatric care in outpatient for those having psychiatric problem. The study was conducted from June 01 to June 30, 2018.
ParticipantsParticipants in this study were pregnant women who receiving antenatal care service in the study period at Jinka public health facilities. Eligible participants who were above age 18, verbal consent was taken and for participants who were under the age of 18 written consent was taken from their parents and pregnant women who were critically ill were excluded in the study. Samples were allocated to each public health institutions based on proportional allocation to sample size. By considering last year June 01 to June 30 report as a sample frame (N) which is 900 pregnant women, Systematic sampling technique was used to identify the study unit to participate in the study. The eligible attending respondents were recruited in order of their coming for antenatal service during each day. The first study participant was selected by lottery method using their card number, then every k value (k=N/n=900/447=2, where N is sample frame, n is sample size for this study and k is regular interval between study participants) were selected based on their order of entry for ANC follow up until reach 447 samples.
VariablesIndependent variables
Socio demographic characteristics; Age, Marital status, Educational status, Residence Occupation, Income, and Family size are socio-demographic characteristics.
Obstetric and other health related variables; Gravida/ Para, trimester of pregnancy, Current pregnancy complications, History of abortion, previous pregnancy related complications, previous labour and delivery complication, and chronic medical illness.
Psychosocial support; oslo social support scale, husband feeling on pregnancy, and fear of pregnancy, labour and delivery related complications.
Substance use; Cigarette smoking, Chat, and Alcohol.
Previous depression history; history of depression and family history of depression.
Dependent variable
Antenatal depression
BiasData collectors didnt work in the ANC clinic were selected for data collection and data was collected after study participants were get ANC serviceStudy sizeTo get the actual sample size, different sample sizes were calculated based on the objectives.
The required sample size for the first objective was determined using a formula for single population proportion by taking p v a l u e s f r o m p r e v i o u s s t u d y ;
n = ( Z / 2 ) 2 p ( 1 - p ) / d 2 . W h e r e ; n = M i n i m u m s a m p l e s i z e f o r a s t a t i s t i c a l l y s i g n i f i c a n t s u r v e y , z = i s t h e s i g n i f i c a n c e l e v e l ( a t 5 % s i g n i f i c a n c e l e v e l i t s v a l u e i s 1 . 9 6 ) , p = i s t h e m a g n i t u d e o f a n t e n a t a l d e pression in Gondar university hospital ADDIN EN.CITE Ayele201625[25]252517Ayele, Tadesse AwokeAzale, TelakeAlemu, KassahunAbdissa, ZewdituMulat, HaregewoinFekadu, AbelPrevalence and Associated Factors of Antenatal Depression among Women Attending Antenatal Care Service at Gondar University Hospital, Northwest EthiopiaPloS onePloS onee015512511520161932-6203[ HYPERLINK \l "_ENREF_25" \o "Ayele, 2016 #25" 25], d= is the margin of error (It has been taken as 4%).
2.Sample Size Determination for the Second Objective
The sample size for some of the factors for antenatal depression obtained from different studies and calculated by Epi Info 7 menu statically, by considering the following assumptions: confidence level 95%, power 80% and exposed to unexposed ratio of 1. Then the largest sample size was used which is 447 pregnant women.
Quantitative variablesDescriptive analysis (frequencies, percentage, means and standard deviations) was done to explore socio-demographic, obstetric and other health related characteristics, depression history, substance use and psychosocial characteristics of study participantsStatistical methodsData was entered in to Epi data version 3.3.1 software after coding and checking their completeness and exported to statistical package for social science SPSS version 21.0 for analysis. Descriptive analysis (frequencies, percentage, means and standard deviations) was done to explore socio-demographic, obstetric and other health related characteristics, depression history, substance use and psychosocial characteristics of study participants. Binary Logistic regression was used to find out association between antenatal depression and explanatory variables and explanatory variables which had P-value less than 0.25 and fulfill the assumption of logistic regression from bi-variable logistic regression were considered for the multi-variable logistic regression model. The model goodness of fit was tested by using Hosmer-Lemeshow and Omnibus test and p-value was 0.532 and 0.000 respectively. Strength of association was evaluated using odds ratio at 95% confidence interval and P-value < 0.05 was considered to declare significant associations.
ResultsDescriptive dataA total of 446 pregnant women were involved in this study with a response rate of 99.7 % and One hundred ninety-one (42.8 %) study participants were in the age group 20-24, followed by age group 25-29 (30%) with minimum age 16 and maximum 40 and mean age 24.22 4.45 years. 422 (94.6%) of pregnant women were married and 348 (78%) mother were live in urban while other 98(22%) were live in rural.
Regarding their religion 210(47.1 %) mothers were protestant religion follower. More than half of (60.1%) of pregnant mothers were house wife. 156(35%) study participants had attended primary school level and more than half (51.3%) had monthly income less than 1000 Ethiopian birr. Regarding family size 310(69.7%) of participants had small family size and 38(8.5%) had large family size while other 97 (21.8%) participant had average family size with minimum 1, maximum 9,mean 3.82 and standard deviation 1.682.
In this study participants had an average of 2.61 pregnancies with minimum 1 and maximum 9. One hundred forty (31.4 %) study participants were primigravida and 410 (91.9%) were planned their current pregnancy. Regarding trimester of pregnancy 211(47.3%) mothers were in third trimester.
From 306 respondents 32 (10.5%) had history of previous pregnancy related complications and 16 (5.2%) had history of labour and delivery complications. On the other 45(15%) of pregnant women had history of abortion and 37(82.25%) were aborted spontaneously. Regarding history of chronic medical illness, twenty two (4.9%) respondents had history of chronic medical illness
Outcome dataThe magnitude of antenatal depression in this study was 24.4 %[( 95% CI); (20.2-285)]Main resultsIn this study pregnant women who were unmarried marital status were 13 times more prone to have antenatal depression than those pregnant women who were married AOR=13.39 [(95%CI); (3.11-57.7)]. Chronic medical illness was another explanatory variable which increase chance of having antenatal depression by four times AOR=3.97 [(95%CI); (1.07-14.7)]. Pregnant women who were not plan their pregnancy were seven times more odds to develop antenatal depression compared to those pregnant women who plan their pregnancy AOR=6.76 [(95%CI); (2.13-21.4)]. On the other pregnant women who had history of abortion were 3 times more likely to develop antenatal depression as compared to those pregnant women who had no history of abortion AOR=2.8 [(95%CI); (1.14-7.02)].
Another explanatory variables which had significant association with antenatal depression in multivariable logistic regression in this study were history of previous pregnancy complication AOR=4.8[(95%CI); (2.12-17.35)] and fear of pregnancy, labour and delivery related complications AOR =5.4 [(95%CI); (2.32-12.4)].
DiscussionKey resultsIn this study the magnitude of antenatal depression was 24.4 %[( 95% CI); (20.2-285)]. Its almost similar with research done in Nigeria 24.5% ADDIN EN.CITE Thompson201622[15]222217Thompson, OkechukwuAjayi, IkeOluwapoPrevalence of antenatal depression and associated risk factors among pregnant women attending antenatal clinics in Abeokuta North Local Government Area, NigeriaDepression research and treatmentDepression research and treatment201620162090-1321[ HYPERLINK \l "_ENREF_15" \o "Thompson, 2016 #22" 15], Addis Ababa 24.9% ADDIN EN.CITE Biratu201523[16]232317Biratu, AberaHaile, DemewozPrevalence of antenatal depression and associated factors among pregnant women in Addis Ababa, Ethiopia: a cross-sectional studyReproductive healthReproductive health9912120151742-4755[ HYPERLINK \l "_ENREF_16" \o "Biratu, 2015 #23" 16] and Gondar University 23% ADDIN EN.CITE Ayele201625[12]252517Ayele, Tadesse AwokeAzale, TelakeAlemu, KassahunAbdissa, ZewdituMulat, HaregewoinFekadu, AbelPrevalence and Associated Factors of Antenatal Depression among Women Attending Antenatal Care Service at Gondar University Hospital, Northwest EthiopiaPloS onePloS onee015512511520161932-6203[ HYPERLINK \l "_ENREF_12" \o "Ayele, 2016 #25" 12]. However, the finding of this study was higher than research done in Brazil 14.2% ADDIN EN.CITE Pereira PK200934[17]343417Pereira PK, Lovisi GM, Pilowsky DL, Lima LA, Legay LF. Depression during pregnancy: prevalence and risk factors among women attending a public health clinic in Rio de Janeiro, Brazil. Cadernos de Sade Pblica2725-2736122009[ HYPERLINK \l "_ENREF_17" \o "Pereira PK, 2009 #34" 17], Mumbai 9.6% ADDIN EN.CITE Ajinkya201315[18]151517Ajinkya, ShaunakJadhav, Pradeep RSrivastava, Nimisha NDepression during pregnancy: Prevalence and obstetric risk factors among pregnant women attending a tertiary care hospital in Navi MumbaiIndustrial psychiatry journalIndustrial psychiatry journal372212013[ HYPERLINK \l "_ENREF_18" \o "Ajinkya, 2013 #15" 18], Hong Kong 18.9% ADDIN EN.CITE Lee200718[19]181817Lee, Antoinette MLam, Siu KeungLau, Stephanie Marie Sze MunChong, Catherine Shiu YinChui, Hang WaiFong, Daniel Yee TakPrevalence, course, and risk factors for antenatal anxiety and depressionObstetrics & GynecologyObstetrics & Gynecology1102-1112110520070029-7844[ HYPERLINK \l "_ENREF_19" \o "Lee, 2007 #18" 19]. This difference might be due to the variation in screening tool used ADDIN EN.CITE Pereira PK200934[17, 19]343417Pereira PK, Lovisi GM, Pilowsky DL, Lima LA, Legay LF. Depression during pregnancy: prevalence and risk factors among women attending a public health clinic in Rio de Janeiro, Brazil. Cadernos de Sade Pblica2725-2736122009Lee200718181817Lee, Antoinette MLam, Siu KeungLau, Stephanie Marie Sze MunChong, Catherine Shiu YinChui, Hang WaiFong, Daniel Yee TakPrevalence, course, and risk factors for antenatal anxiety and depressionObstetrics & GynecologyObstetrics & Gynecology1102-1112110520070029-7844[ HYPERLINK \l "_ENREF_17" \o "Pereira PK, 2009 #34" 17, HYPERLINK \l "_ENREF_19" \o "Lee, 2007 #18" 19], cut off point used for screening ADDIN EN.CITE Ajinkya201315[18]151517Ajinkya, ShaunakJadhav, Pradeep RSrivastava, Nimisha NDepression during pregnancy: Prevalence and obstetric risk factors among pregnant women attending a tertiary care hospital in Navi MumbaiIndustrial psychiatry journalIndustrial psychiatry journal372212013[ HYPERLINK \l "_ENREF_18" \o "Ajinkya, 2013 #15" 18], year of study and sample size used ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_17" \o "Pereira PK, 2009 #34" 17-19].
In the contrary the magnitude of antenatal depression in this study was less than in research done in Greece 28% ADDIN EN.CITE Dagklis201630[20]303017Dagklis, ThemistoklisPapazisis, GeorgiosTsakiridis, IoannisChouliara, FoteiniMamopoulos, ApostolosRousso, DavidPrevalence of antenatal depression and associated factors among pregnant women hospitalized in a high-risk pregnancy unit in GreeceSocial psychiatry and psychiatric epidemiologySocial psychiatry and psychiatric epidemiology1025-103151720160933-7954[ HYPERLINK \l "_ENREF_20" \o "Dagklis, 2016 #30" 20], Tanzania 33.8% ADDIN EN.CITE Rwakarema201529[21]292917Rwakarema, MechtildaPremji, Shahirose SNyanza, Elias CharlesRiziki, PonsianoPalacios-Derflingher, LuzAntenatal depression is associated with pregnancy-related anxiety, partner relations, and wealth in women in Northern Tanzania: a cross-sectional studyBMC women's healthBMC women's health6815120151472-6874[ HYPERLINK \l "_ENREF_21" \o "Rwakarema, 2015 #29" 21] Maichew 31.1% ADDIN EN.CITE Mossie201724[22]242417Mossie, Tilahun BeleteSibhatu, Adam KirosDargie, AbateAyele, Ashenafi DamtePrevalence of antenatal depressive symptoms and associated factors among pregnant women in Maichew, North Ethiopia: an institution based studyEthiopian journal of health sciencesEthiopian journal of health sciences59-6627120171029-1857[ HYPERLINK \l "_ENREF_22" \o "Mossie, 2017 #24" 22] Adama hospital 31.2% ADDIN EN.CITE Sahile201731[23]313117Sahile, Martha AssefaSegni, Mesfin TafaAwoke, TadeseBekele, DessalegnPrevalence and predictors of antenatal depressive symptoms among women attending Adama Hospital Antenatal Clinic, Adama, EthiopiaInternational Journal of Nursing and MidwiferyInternational Journal of Nursing and Midwifery58-649520172141-2456[ HYPERLINK \l "_ENREF_23" \o "Sahile, 2017 #31" 23] wolaita sodo 29.5% ADDIN EN.CITE Bitew201633[24]333317Bitew, TeseraHanlon, CharlotteKebede, EskinderMedhin, GirmayFekadu, AbebawAntenatal depressive symptoms and maternal health care utilisation: a population-based study of pregnant women in EthiopiaBMC pregnancy and childbirthBMC pregnancy and childbirth30116120161471-2393[ HYPERLINK \l "_ENREF_24" \o "Bitew, 2016 #33" 24] and Arba Minch zuria woreda (26.7%) ADDIN EN.CITE Gebremichael201842[25]424217Gebremichael, GebrekirosYihune, ManayeAjema, DessalegnHaftu, DestaGedamu, GenetPerinatal Depression and Associated Factors among Mothers in Southern Ethiopia: Evidence from Arba Minch Zuria Health and Demographic Surveillance SitePsychiatry journalPsychiatry journal201820182314-4327[ HYPERLINK \l "_ENREF_25" \o "Gebremichael, 2018 #42" 25]. This variation might be due to difference in screening tool used ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_20" \o "Dagklis, 2016 #30" 20, HYPERLINK \l "_ENREF_21" \o "Rwakarema, 2015 #29" 21, HYPERLINK \l "_ENREF_24" \o "Bitew, 2016 #33" 24, HYPERLINK \l "_ENREF_25" \o "Gebremichael, 2018 #42" 25], cut off point used for screening antenatal depression ADDIN EN.CITE Mossie201724[22, 23]242417Mossie, Tilahun BeleteSibhatu, Adam KirosDargie, AbateAyele, Ashenafi DamtePrevalence of antenatal depressive symptoms and associated factors among pregnant women in Maichew, North Ethiopia: an institution based studyEthiopian journal of health sciencesEthiopian journal of health sciences59-6627120171029-1857Sahile201731313117Sahile, Martha AssefaSegni, Mesfin TafaAwoke, TadeseBekele, DessalegnPrevalence and predictors of antenatal depressive symptoms among women attending Adama Hospital Antenatal Clinic, Adama, EthiopiaInternational Journal of Nursing and MidwiferyInternational Journal of Nursing and Midwifery58-649520172141-2456[ HYPERLINK \l "_ENREF_22" \o "Mossie, 2017 #24" 22, HYPERLINK \l "_ENREF_23" \o "Sahile, 2017 #31" 23], socio-demographic, year of study, methodological difference used ADDIN EN.CITE Bitew201633[24, 25]333317Bitew, TeseraHanlon, CharlotteKebede, EskinderMedhin, GirmayFekadu, AbebawAntenatal depressive symptoms and maternal health care utilisation: a population-based study of pregnant women in EthiopiaBMC pregnancy and childbirthBMC pregnancy and childbirth30116120161471-2393Gebremichael201842424217Gebremichael, GebrekirosYihune, ManayeAjema, DessalegnHaftu, DestaGedamu, GenetPerinatal Depression and Associated Factors among Mothers in Southern Ethiopia: Evidence from Arba Minch Zuria Health and Demographic Surveillance SitePsychiatry journalPsychiatry journal201820182314-4327[ HYPERLINK \l "_ENREF_24" \o "Bitew, 2016 #33" 24, HYPERLINK \l "_ENREF_25" \o "Gebremichael, 2018 #42" 25] and sample size used ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_20" \o "Dagklis, 2016 #30" 20-25] and unmarried marital status, unplanned pregnancy, history of chronic medical illness, history of abortion, history of previous pregnancy related complications and fear of pregnancy, labour and delivery related complications were factors significantly associated with antenatal depression.
LimitationsEven though Beck's Depression Inventory screening tool has high sensitivity and specificity to screen depression, it is not diagnostic tool. So diagnosing antenatal depression without psychiatric examination may be difficult. On the other since the study conducted in public health institutions it might be not represent pregnant mothers who get ANC care in private clinic and not attending antenatal care.
Other informationFundingThis study was funded by Arba Minch university. In this study the funders did not have any role in the study design, data collection, analysis or interpretation of the data, or in the writing of the manuscript.
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