A controlled study of postpartum depression among Nepalese women: validation of the Edinburgh Postpartum Depression Scale in Kathmandu

Does mistreatment during institutional childbirth increase the likelihood of experiencing postpartum depressive symptoms? A prospective cohort study in Nepal

BACKGROUND

Postpartum depression is associated with low socioeconomic status, adverse birthing processes, and life stress. Increasing evidence of mistreatment during childbirth, negative birth experiences, and poor quality of maternal care is of global concern.

OBJECTIVE

To assess the risk of experiencing depressive symptoms among postpartum women exposed to mistreatment during institutional birthing in Nepal.

METHOD

We conducted a prospective cohort study from 29 March to 19 August 2022. Of 1629 women who gave birth in a hospital in Nepal, 1222 were assessed for mistreatment during childbirth and depressive symptoms using the Edinburgh Postnatal Depression Scale. We used binomial generalized linear mixed model to examine the risk ratio of postpartum depressive symptoms in women exposed to mistreatment during childbirth.

RESULTS

The prevalence of postpartum depressive symptoms was 4.4%. Women exposed to mistreatment during childbirth were almost fifty percent more likely to have postpartum depressive symptoms (cRR 1.47; 95% CI 1.14, 1.89; p = 0.003) compared with the unexposed group. Furthermore, adolescent mothers exposed to mistreatment during childbirth had a seventy percent increased risk of depressive symptoms (aRR 1.72; 95% CI 1.23, 2.41; p = 0.002). Similarly, women who gave birth to female infants were thirty percent more likely to experience postpartum depressive symptoms (aRR 1.32; 95% CI 1.01-1.74; p = 0.039).

CONCLUSION

We observed an association between postpartum depressive symptoms and mistreatment during institutional births in Nepal. The implementation of appropriate respectful maternity care during childbirth and also routine screening for depressive symptoms is critical to improving perinatal mental health and well-being.

Prevalence of maternal depression and anxiety symptoms and associations with child mental health outcomes in rural Nepal

OBJECTIVES

This study describes the prevalence, associated factors and child mental health outcomes related to symptoms of maternal depression and anxiety within 5 years after childbirth in a rural district in Nepal. This association is not well-understood in rural, community-based settings in low- and middle-income countries (LMIC).

METHODS

A sample of 347 women with children under 5 years was recruited in September 2019 for a cross-sectional study in the rural Saptari district in Nepal. Multivariable logistic regression was used to investigate the association between maternal depressive or anxiety symptoms and children's experience and impact of emotional and behavioural difficulties.

RESULTS

In total, 144 women (41.5%) had moderate or severe depression symptoms and 118 (34%) had anxiety symptoms. Mothers with a lower income were more likely to have anxiety symptoms than the highest income group (OR: 1.8, 95% CI: 1.1-3.0). An association existed between maternal depressive symptoms and the impact of emotional or behavioural difficulties in children (OR: 2.44, 95% CI: 1.02-5.84). In contrast, there was no association between maternal anxiety and child outcomes.

CONCLUSIONS

Our findings suggest that the prevalence of probable maternal anxiety and depression symptoms was relatively high in this rural, low-resourced and community-based setting in Nepal. Maternal depressive symptoms were associated with the degree of impact on children's mental health post-infancy, emphasising the importance of improving maternal mental health in the early years of a child's life.

Antenatal depression and its associated factors among women of Godawari Municipality, Lalitpur, Nepal: a cross-sectional study

OBJECTIVES

To estimate the prevalence of antenatal depression and identify its associated factors among pregnant women of Godawari Municipality, Lalitpur, Nepal.

DESIGN

Community-based cross-sectional study.

SETTING

Godawari Municipality, Lalitpur, Nepal, between September and November 2021.

PARTICIPANTS

250 randomly selected pregnant women of Godawari Municipality, Lalitpur, Nepal.

MAIN OUTCOME MEASURES

The level of antenatal depression was assessed using Edinburgh Postnatal Depression Scale. χ² test and multivariate logistic regression analysis were applied to determine the association between antenatal depression and related variables at 95% level of confidence.

RESULTS

The prevalence of antenatal depression was found to be 24.8% (95% CI: 19.2 to 30.7). Multigravida (AOR: 2.219, 95% CI: 1.113 to 4.423), unintended pregnancy (AOR: 2.547, 95% CI: 1.204 to 5.388), male sex preference of child by family (AOR: 2.531, 95% CI: 1.204 to 5.321) and intimate partner violence (AOR: 2.276, 95% CI: 1.116 to 4.640) were found to be the positive predictors of antenatal depression.

CONCLUSION

This study showed a high prevalence of depression among pregnant women. The results suggest a need for mental health assessment during pregnancy. Screening for depression should be part of routine antenatal checkups for early detection and management of mental health concerns during this vulnerable period.

Resilience and prenatal mental health in Pakistan: a qualitative inquiry

Background

Women in Pakistan suffer from a high rate of depression. The stress of low-income, illiteracy, exposure to violence and living in a patriarchal society are predisposing vulnerabilities for depression, particularly during and following pregnancy. The resilience of an individual plays a significant role in promoting prenatal mental health, but this has yet to be thoroughly researched. In this article, our objective is to identify the core characteristics of resilience among pregnant women, which will then help us in developing an intervention.

Methods

The exploratory-descriptive study was conducted over 6 months in five different antenatal hospitals in Sindh, Pakistan. A total of 17 semi-structured interviews were conducted with pregnant women, purposefully selected with heterogeneous characteristics to explore diverse perspectives, while symptoms of depression were quantified by the Edinburgh Postnatal Depression Scale before the interview. Verbatim transcriptions were coded openly and merged into categories and themes.

Result

A total of six themes emerged from in-depth thematic analysis: 1) purpose of life, 2) dealing with emotions, 3) believing in yourself, 4) optimistic approach, 5) strengthening support and relationship and 6) spirituality and humanity. Women agreed that these characteristics could help them improve their mental health.

Conclusion

In conclusion, these themes were the core components of pregnant women’s resilience which ultimately could help to promote prenatal mental health. These pave a pathway towards developing culturally and contextually resilience interventions aimed at enhancing mental health of pregnant women which then may improve neonatal and family mental wellbeing.

Prevalence and Risk Factors Associated With Postpartum Depressive Symptoms Among Women in Vientiane Capital, Lao PDR

Postpartum depression (PPD), the onset of depressive episodes after childbirth, is the most common psychological condition following childbirth, and a global public health concern. If undiagnosed and/or untreated, postpartum depression can have negative effects on maternal and child health, however, there are few studies on the prevalence of postpartum depression in low- and middle-income countries. To contribute to filling this gap, this study examined the prevalence and risk factors associated with postpartum depressive symptoms among women after delivery in Vientiane Capital, Lao PDR. The study was a cross-sectional design, with multistage sampling used to identify women between 4 and 24 weeks after giving birth (N = 521). The Edinburgh Postnatal Depression Scale was used to identify women with postpartum depressive symptoms. Univariate and multivariate logistic regressions identified risk factors associated with postpartum depressive symptoms. The prevalence of postpartum depressive symptoms among participants was 21.3%. Associated factors were having at least 2-3 living children (AOR: 1.9, 95% CI: 1.1-3.0), experiencing mental health problems during pregnancy (AOR: 3.3, 95% CI: 1.4-7.6), experiencing conflicts with family members (AOR: 2.5, 95% CI: 1.5-4.0), the experience of intimate partner violence (AOR: 2.6, 95% CI: 1.3-5.5), and receiving moderate social support (AOR: 5.6, 95% CI: 3.2-10.0). In contexts where access to mental health specialists has severely constrained maternal and child healthcare providers at primary health care must be supported to develop the necessary skills to identify risk factors and symptoms and offer basic essential services for postpartum depressive symptom (PDS). The study identified a high proportion of mothers with postnatal depressive symptoms, highlighting the need to screen and treat mothers who present with PDS, as not doing so exposes mother and their children to a range of negative health and social outcomes. Addressing the stigma associated with mental health illness and mental health illness and domestic violence that prevents women from seeking healthcare, must also be developed, implemented, and evaluated.

Assessment of difference in postpartum depression among caesarean and vaginally delivered women at 6-week follow-up in hospitals in Pune District, India: an observational cohort study

OBJECTIVES

To compare the proportion of postpartum depression at 6 weeks among women who had caesarean delivery and women who had vaginal delivery and to assess its association with some sociodemographic factors.

DESIGN

This is a descriptive comparative study with prospective enrolment. We followed the enrolled women and assessed them for postpartum depression 6 weeks after delivery.

SETTING

We conducted the study in Pune District, India from July 2017 to December 2018. The study sites were all non-teaching government hospitals performing five or more caesarean sections per month and two teaching hospitals: one government and one private.

PARTICIPANTS

We included in the study group women who have undergone caesarean section in the participating hospitals and were residents of Pune District. Women who delivered vaginally and matched in age and parity were included in the comparison group. We followed 1556 women in each group.

MAIN OUTCOME MEASURES

An Edinburgh Postnatal Depression Scale score of 10 or more for each woman was the primary outcome. χ2 test and multivariable binary logistic regression were performed to assess the effect of mode of delivery on postpartum depression.

RESULTS

The proportion of postpartum depression at 6 weeks was 3.79% among women who had caesarean delivery and 2.35% among those who had vaginal delivery (χ2=4.50, p=0.03). The adjusted OR was 1.86 (95% CI 1.14 to 3.03). Women of age less than 25 years had higher risk of postpartum depression. The adjusted OR was 2.10 (95% CI 1.21 to 3.65). The study did not observe any association between postpartum depression and income, education, occupation or sex of the newborn child.

CONCLUSIONS

We conclude that young women particularly those who had caesarean delivery should be screened 6 weeks after delivery.

Maternal depression is associated with less dietary diversity among rural Nepali children

Maternal depression has been associated with adverse child growth and development; less is known about its relation to children's diet. In a cross-sectional study embedded at endline of a longitudinal community development intervention, mothers of 629 children (age 23-66 months) in rural Nepal responded to household and children's diet questionnaires and were screened for depression. Child anthropometry and development (Ages and Stages Questionnaire) were assessed. Regression models examined children's diet, growth and development, adjusting for household, child and maternal characteristics. The prevalence of maternal depression was 21%. Maternal depression was associated with 11% lower likelihood that the child consumed one additional food group [Poisson regression, adjusted relative risk (aRR) 0.89, 95% confidence intervals (95% CI 0.81, 0.99), p = 0.024] and 13% lower likelihood that the child consumed one additional animal source food (ASF) [aRR 0.87, (95% CI 0.76, 1.01), p = 0.061] compared with children of nondepressed mothers. However, maternal depression was not associated with either child anthropometry or development: these outcomes were strongly associated with better home child-rearing quality. Stunting also related to child age and intervention group; child development related to mother's education and household wealth. This study suggests a correlation between maternal depression and child dietary diversity. This association could be due to unmeasured confounders, and therefore, further research is warranted. Understanding the relationship of depression to child outcomes-and the role of other potentially compensatory household factors-could help address some of the earliest, modifiable influences in a child's life and contribute to innovative approaches to improve child well-being.

Adverse Childhood Experiences and Changing Levels of Psychosocial Distress Scores Across Pregnancy in Kenyan Women

Background: Adverse childhood experiences (ACEs) have been associated with deleterious effects on mental health in pregnancy. Methods: The ACE International Questionnaire (ACE-IQ) was used to measure neglect, abuse, and household dysfunction. Longitudinal mixed effect modelling was used to test the effect of ACEs on pregnancy-related anxiety, depressive symptoms, and perceived stress at two time points (12–19 and 22–29 weeks) during pregnancy. Results: A total of 215 women who were predominantly married (81%) and had attained tertiary education (96%) were enrolled. Total ACEs were significantly associated with depressive symptoms (r = 0.23, p < 0.05) and perceived stress (r = 0.18, p < 0.05). As depressive symptoms decreased, t (167) = −8.44, p < 0.001, perceived stress increased, t (167) = 4.60, p < 0.001, and pregnancy-related anxiety remained unchanged as pregnancy progressed. Contact sexual abuse (p < 0.01) and parental death or divorce (p = 0.01) were significantly associated with depression over time (p < 0.01). Total ACEs in this study were associated with depressive symptoms early but not late in pregnancy. Conclusions: Higher total ACEs were positively associated with depressive symptoms and perceived stress during pregnancy, suggesting that mental disorders may have an impact on pregnancy outcomes and ought to be addressed. Further validation of the Edinburgh Postnatal Depression Scale (EPDS) tool in local settings is required.

Factors Associated with Postpartum Depressive Symptoms in Community of Central Nepal

Background

Pregnancy and postpartum are considered as high risk periods for the emergence of psychiatric disorder. Although postpartum depressive symptoms have been associated with tragic outcome, such as maternal suicide and infanticide, it is a neglected area of mental health care in developing countries. This study was conducted to find the prevalence and factors associated with postpartum depressive symptoms.

Method

A community-based cross-sectional research design was carried out after selecting the three wards of Bharatpur submetropolitan by nonprobability purposive sampling method. A total of 160 mothers in their 1 month to 12 months of postpartum period were interviewed through semistructured interview schedule and Edinburgh Postnatal Depression Scale (EPDS). Collected data were entered in Epi, data 3.1, and was exported into IBM SPSS 20 version.

Results

The prevalence of depressive symptoms among postpartum mothers was 27.5%. The multivariate analysis identified two factors significantly associated with postpartum depression including respondents who had education level of ≤10 class (odds ratio [AOR] = 3.25, P = 0.03, confidence interval [CI] = 1.10 − 9.58), chronic disease in their family (odds ratio [AOR] = 3.25, P = 0.01, confidence interval [CI] = 1.19 − 8.16).

Conclusion

More than one out of four mothers is suffering from depressive symptoms. The major factors associated with postpartum depressive symptoms are education of respondents and chronic disease in the family. Screening and timely management of depressive symptoms should be incorporated in routine maternal care so as to enhance maternal and child health. Likewise, concerned authority should plan and organize awareness-raising programs and provide attractive package to attract the female population for higher education.

Understanding the antepartum depressive symptoms and its risk factors among the pregnant women visiting public health facilities of Nepal

INTRODUCTION

Antepartum depression is a contributing factor for adverse maternal and perinatal outcome. The study aimed to assess the antepartum depressive symptoms in selected public health facilities of Nepal.

METHODOLOGY

This is a mixed-method cross-sectional study that included 143 pregnant women attending the antenatal checkup in four public health facilities of Kathmandu. Edinburgh Postnatal Depression Scale (EPDS) tool with cut-off score > = 10 was used to assess the antepartum depressive symptoms. Bivariate and multivariable analysis was carried out to identify factors associated with the depressive symptoms. Further semi-structured interviews were conducted with 12 pregnant women identified with the depressive symptoms.

RESULT

Of the total 143 pregnant women, 26 (18%, CI at 95% 12.6-25.5) reported depressive symptoms. Multivariable analysis reported higher odds of antepartum depressive-symptoms with health problem, early gestational age, sex preference, and spousal alcohol intake. Thematic analysis of qualitative data further revealed participants' apprehension on; birth outcome, a family expectation of male child, inadequate support from the family/husband and disturbed family environment.

CONCLUSION

Notable proportion of pregnant women were reported with antepartum depressive symptoms. Women's perception on patriarchal values for childbirth was revealed to be important factor for the depressive symptoms. The study draws an attention to a need for screening for antepartum depression into primary health care system. Strengthening ongoing efforts on gender equity could contribute the psychological well-being of pregnant women.

Identifying the factors associated with depressive symptoms among postpartum mothers in Kathmandu, Nepal

Purpose

This study aimed to identify the factors associated with depressive symptoms among postpartum mothers in Kathmandu, Nepal.

Method

A hospital-based cross-sectional study that included 346 postpartum mothers at 4-14 weeks after delivery was carried out. Validated Nepalese version of Edinburgh Postnatal Depression Scale with cut-off value of ≥12 was used to screen depressive symptoms and structured questionnaires were used to identify the associated factors. Possible factors associated with depressive symptoms were identified by logistic regression analysis.

Result

The mean age of the mothers was 22.75 (SD = 4.51). The prevalence of depressive symptoms among postpartum mothers was 17.1% (95% CI = 15.07-19.12). No significant association existed between postpartum depressive symptoms and socio demographic and economic characteristics. In multivariate analysis, risk factors for postpartum depressive symptoms were identified as follows: women without adequate rest during pregnancy (aOR = 4.023, 95% CI = 1.294-12.501), abortion history (aOR = 3.25, 95% CI = 1.208-9.065), poor relationship with husband (aOR = 1.67, 95% CI = 1.073-8.384), marital dissatisfaction (aOR = 4.053, 95% CI = 2.281-12.819) and stressful life events (aOR = 3.89, 95% CI = 1.504-9.810).

Conclusions

This study aids to draw attention on the incorporation of routine screening for basic support and intervention for identified risk factors in postpartum period. Policies can be formulated to encourage postpartum women to obtain adequate rest during pregnancy, support women with poor partner relationship, reduce marital dissatisfaction, help women adjust with stressful life events, and prevent and manage abortion appropriately. These policies may reduce harmful consequences of postpartum depressive symptoms for women, newborn and their family.

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.

Validating the Edinburgh Postnatal Depression Scale as a screening tool for postpartum depression in Kathmandu, Nepal

BACKGROUND

Edinburgh Postnatal Depression Scale (EPDS) is considered well accepted screening tool for postpartum depression (PPD). The objective of the study was to validate the EPDS as a screening tool for postpartum depression in Kathmandu, Nepal.

METHODS

A hospital based cross sectional study using EPDS was conducted among 346 mothers between 4 and 14 weeks of postpartum period. All the participants were examined by psychiatrist for possible clinical PPD diagnosis using International Classification of Disease tenth revision (ICD-10). Sensitivity, specificity, positive predictive value and negative predictive value were calculated for validation of EPDS. The best cut off point for Nepalese version of EPDS was identified and area of the receiver operating characteristics curve was calculated.

RESULTS

The overall prevalence of PPD was 17.1 %.The sensitivity, specificity, positive predictive value and negative predictive value of the Nepalese version EPDS was found to be 92, 95.6, 77 and 99.3 % respectively. The best cut-off point of EPDS for screening of PPD was found to be 12/13 and the area of the curve was 0.98 (95 % CI 0.970-0.994, p = 0.001).

CONCLUSIONS

The prevalence of PPD is not that far from the previous studies of Nepal. Nepali version of EPDS was acceptable and the study demonstrates good validity, thus EPDS can be used as valid screening tool for PPD for early detection, prompt treatment and to prevent possible consequences.

Dirty and 40 days in the wilderness: Eliciting childbirth and postnatal cultural practices and beliefs in Nepal

Background

Pregnancy and childbirth are socio-cultural events that carry varying meanings across different societies and cultures. These are often translated into social expectations of what a particular society expects women to do (or not to do) during pregnancy, birth and/or the postnatal period. This paper reports a study exploring beliefs around childbirth in Nepal, a low-income country with a largely Hindu population. The paper then sets these findings in the context of the wider global literature around issues such as periods where women are viewed as polluted (or dirty even) after childbirth.

Methods

A qualitative study comprising five in-depth face-to-face interviews and 14 focus group discussions with mainly women, but also men and health service providers. The qualitative findings in Nepal were compared and contrasted with the literature on practices and cultural beliefs related to the pregnancy and childbirth period across the globe and at different times in history.

Results

The themes that emerged from the analysis included: (a) cord cutting & placenta rituals; (b) rest & seclusion; (c) purification, naming & weaning ceremonies and (d) nutrition and breastfeeding. Physiological changes in mother and baby may underpin the various beliefs, ritual and practices in the postnatal period. These practices often mean women do not access postnatal health services.

Conclusions

The cultural practices, taboos and beliefs during pregnancy and around childbirth found in Nepal largely resonate with those reported across the globe. This paper stresses that local people’s beliefs and practices offer both opportunities and barriers to health service providers.

Maternity care providers need to be aware of local values, beliefs and traditions to anticipate and meet the needs of women, gain their trust and work with them.

Psychiatric Morbidity and Correlates in Postpartum Women in a Tertiary Care Hospital

BACKGROUND

A range of psychological disorders occur in women in the postpartum period apart from the traditional blues, postpartum depression and psychosis. These include obsession of infanticide, PTSD, morbid preoccupations regarding child birth and disorders of mother-infant relationships, though they are under emphasized.

METHODS

it is a cross-sectional study conducted in the tertiary maternity care hospital. A total of 152 study subjects were interviewed on MINI (Mini International Neuropsychiatric Inventory) and GAF (Global Assessment of Functioning) within 2 weeks after delivery.

RESULTS

The psychiatric morbidity was seen in 67 (44%) of the study subjects. About 26% of subjects had Depressive disorder NOS. Obsessive harm to the child, Panic disorder, Social phobia were the other disorders identified. There were no cases of Mania, Bipolar disorder, psychosis, post traumatic stress disorder or substance use disorder diagnosed across the sample. The Global Assessment of Functioning (GAF) score averaged 87.8. Statistically significant association was seen to be present between psychiatric illness and number of previous still births and dead children before this delivery (P = 0.045).

CONCLUSIONS

The study reveals that psychiatric co-morbidity is very common in the postpartum period and can be detected as early as first week after delivery. Social phobia identified as a common association is a new finding and needs further replication. It needs a larger sample with a prospective assessment to generalize the findings of our study.

Reliability and validity of the Edinburgh Postnatal Depression Scale (EPDS) for detecting perinatal common mental disorders (PCMDs) among women in low-and lower-middle-income countries: a systematic review

BACKGROUND

The Edinburgh Postnatal Depression Scale (EPDS), originally developed in Britain, is one of the most widely used screening instruments for assessing symptoms of the Perinatal Common Mental Disorders (PCMDs) of depression and anxiety. However, its potential to detect PCMDs in culturally diverse low- and lower-middle income countries (LALMICs) is unclear. This systematic review aimed to appraise formally validated local language versions of the EPDS from these resource-constrained settings.

METHODS

Following the PRISMA protocol, we searched MEDLINE-OVID, CINAHL-Plus and PUBMED to identify studies reporting translation, cultural adaptation and formal validation of the EPDS to detect PCMDs among women in LALMICs. The quality of the studies meeting inclusion criteria was assessed using standard criteria and a new process-based criteria; which was developed specifically for this study.

RESULTS

We identified 1281 records among which 16 met inclusion criteria; three further papers were identified by hand-searching reference lists. The publications reported findings from 12 LALMICs in 14 native languages. Most of these local language versions of the EPDS (LLV-EPDS) had lower precision for identifying true cases of PCMDs among women in the general perinatal population compared to the original English version. Only one study met all criteria for culturally sensitive translation, the others had not established the comprehensibility of the local version amongst representative groups of women in pre-testing. Many studies tested the LLV-EPDS only amongst convenience samples recruited at single health facilities. Diagnostic interviews for confirmation of mental disorders could have been influenced by the mental health professionals' lack of blinding to the initial screening results. Additionally, even when diagnostic-interviews were carried out in the local language, questions might not have been understood as most studies followed standard diagnostic protocol which had not been culturally adapted.

CONCLUSIONS

Most of the LLV-EPDS from non-English speaking low- and middle-income-countries did not meet all criteria for formal validation of a screening instrument. Psychometric properties of LLV-EPDS could be enhanced by adopting the new process-based criteria for translation, adaptation and validation.

Household water insecurity, depression and quality of life among postnatal women living in urban Nepal

OBJECTIVES

This observational study aimed to assess distress related to the household water supply and to examine the relationship between household water insecurity and psychological health among Nepali postnatal women.

METHODS

In total, 300 women consented to participate in the study, of which 267 women were able to participate in a follow-up 1 month after discharge. We developed a household water insecurity scale (HWIS; total score range 0-24 points) by adapting the household food insecurity access scale.

RESULTS

The Cronbach's coefficient alpha for the HWIS was moderately acceptable. Psychological health was assessed in terms of postnatal depression and physical health-related quality of life (HRQOL). The median score of the HWIS was 8, and more than 60% of the participants answered that they sometimes or often worried about not having enough water, used only small amounts of water, had a lack of hygiene, and had insufficient time for childrearing. Multiple regression models showed that women with high levels of stress derived from household water insecurity had greater odds of probable depression and lower physical HRQOL scores than did women with low HWIS scores.

CONCLUSION

The results suggest that improving water security is necessary to foster maternal psychological health in developing countries.

Maternal mental health in primary care in five low- and middle-income countries: a situational analysis

BACKGROUND

The integration of maternal mental health into primary health care has been advocated to reduce the mental health treatment gap in low- and middle-income countries (LMICs). This study reports findings of a cross-country situation analysis on maternal mental health and services available in five LMICs, to inform the development of integrated maternal mental health services integrated into primary health care.

METHODS

The situation analysis was conducted in five districts in Ethiopia, India, Nepal, South Africa and Uganda, as part of the Programme for Improving Mental Health Care (PRIME). The analysis reports secondary data on the prevalence and impact of priority maternal mental disorders (perinatal depression, alcohol use disorders during pregnancy and puerperal psychosis), existing policies, plans and services for maternal mental health, and other relevant contextual factors, such as explanatory models for mental illness.

RESULTS

Limited data were available at the district level, although generalizable data from other sites was identified in most cases. Community and facility-based prevalences ranged widely across PRIME countries for perinatal depression (3-50 %) and alcohol consumption during pregnancy (5-51 %). Maternal mental health was included in mental health policies in South Africa, India and Ethiopia, and a mental health care plan was in the process of being implemented in South Africa. No district reported dedicated maternal mental health services, but referrals to specialised care in psychiatric units or general hospitals were possible. No information was available on coverage for maternal mental health care. Challenges to the provision of maternal mental health care included; limited evidence on feasible detection and treatment strategies for maternal mental disorders, lack of mental health specialists in the public health sector, lack of prescribing guidelines for pregnant and breastfeeding women, and stigmatising attitudes among primary health care staff and the community.

CONCLUSIONS

It is difficult to anticipate demand for mental health care at district level in the five countries, given the lack of evidence on the prevalence and treatment coverage of women with maternal mental disorders. Limited evidence on effective psychosocial interventions was also noted, and must be addressed for mental health programmes, such as PRIME, to implement feasible and effective services.

Postnatal depression among Sudanese women: prevalence and validation of the Edinburgh Postnatal Depression Scale at 3 months postpartum

Purpose

Postnatal depression (PND) rates in low-resource countries have reached levels between 4.9% and 59%. Maternal mental health has not been researched in Sudan, and there are no existing statistics on prevalence or significant risk factors for PND. Consequently, no screening test has been validated to screen for PND at the primary health care level. This study investigates the 3 months prevalence of PND and validates the Edinburgh Postnatal Depression Scale (EPDS) against the Mini-International Neuropsychiatric Interview (MINI).

Methodology

Pregnant Sudanese women in the second and third trimesters were recruited to the study during routine antenatal care visits in two major maternity hospitals in Khartoum state. They were screened for PND at 3 months postpartum using the EPDS. Test positive women were matched with test negative women according to nearest date of birth. A clinical psychologist verified their depression status using the MINI.

Results

The follow-up rate was 79%. At a cutoff point of ≥12, the 3 months prevalence of PND was 9.2%. The sensitivity and specificity of the EPDS were 89% and 82%, respectively. The EPDS and MINI showed a strong positive relationship (odds ratio =36). The positive predictive value and negative predictive value, using this study’s prevalence, were 33% and 98.7%, respectively. The receiver operator characteristic analysis showed an area under the curve of 0.89. The cut-off point ≥12 was the most acceptable point as it had the lowest number needed to diagnose (1.4) and a false-positive rate of 18%.

Conclusion

The EPDS is a valid tool for screening for PND on a Sudanese population. It was accepted, easily administered, and understood by postnatal women. Health care personnel, especially village midwives, should be trained on screening and referral of depressed women for clinical evaluation and management. Due to limited resources available in Sudan, shorter screening tests need to be validated in the future.

Postnatal depression among rural women in South India: do socio-demographic, obstetric and pregnancy outcome have a role to play?

INTRODUCTION

Postnatal depression (PND) is one of the most common psychopathology and is considered as a serious public health issue because of its devastating effects on mother, family, and infant or the child.

OBJECTIVE

To elicit socio-demographic, obstetric and pregnancy outcome predictors of Postnatal Depression (PND) among rural postnatal women in Karnataka state, India.

DESIGN

Hospital based analytical cross sectional study.

SETTING

A rural tertiary care hospital of Mandya District, Karnataka state, India.

SAMPLE

PND prevalence based estimated sample of 102 women who came for postnatal follow up from 4th to 10th week of lactation.

METHOD

Study participants were interviewed using validated kannada version of Edinburgh Postnatal Depression Scale (EPDS). Cut-off score of ≥ 13 was used as high risk of PND. The percentage of women at risk of PND was estimated, and differences according to socio-demographic, obstetric and pregnancy outcome were described. Logistic regression was applied to identify the independent predictors of PND risk.

MAIN OUTCOME MEASURES

Prevalence, Odds ratio (OR) and adjusted (adj) OR of PND.

RESULTS

Prevalence of PND was 31.4% (95% CI 22.7-41.4%). PND showed significant (P < 0.05) association with joint family, working women, non-farmer husbands, poverty, female baby and pregnancy complications or known medical illness. In binomial logistic regression poverty (adjOR: 11.95, 95% CI:1.36-105), birth of female baby (adjOR: 3.6, 95% CI:1.26-10.23) and pregnancy complications or known medical illness (adjOR: 17.4, 95% CI:2.5-121.2) remained as independent predictors of PND.

CONCLUSION

Risk of PND among rural postnatal women was high (31.4%). Birth of female baby, poverty and complications in pregnancy or known medical illness could predict the high risk of PND. PND screening should be an integral part of postnatal care. Capacity building of grass root level workers and feasibility trials for screening PND by them are needed.

Prevalence and factors associated with depressive symptoms among post-partum mothers in Nepal

Background

Post-partum depression is a common complication of women after childbirth. The objective of this study was to determine the prevalence of and factors associated with depressive symptoms among post-partum mothers attending a child immunization clinic at a maternity hospital in Kathmandu, Nepal.

Methods

This cross-sectional study was conducted among 346 post-partum mothers at six to ten weeks after delivery using systematic random sampling. Mothers were interviewed using a semi-structured questionnaire. The Edinburgh Postnatal Depression Scale (EPDS) was used to screen for depressive symptoms. Logistic regression analysis was used to calculate the association of post-partum depressive symptoms with socio-demographic and maternal factors.

Results

The prevalence of post-partum depressive symptoms among mothers was 30%. Mothers aged 20 to 29 years were less likely to have depressive symptoms (adjusted odds ratio (aOR) = 0.40; 95% CI: 0.21-0.76) compared to older mothers. Similarly, mothers with a history of pregnancy-induced health problems were more likely to have depressive symptoms (aOR = 2.16; CI: 1.00-4.66) and subjective feelings of stress (aOR = 3.86; CI: 1.84-4.66) than mothers who did not.

Conclusions

The number of post-partum mothers experiencing depressive symptoms was high; almost one-third of the participants reported having them. Pregnancy-induced health problems and subjective feelings of stress during pregnancy in the post-partum period were found to be associated with depressive symptoms among these women. Screening of depressive symptoms should be included in routine antenatal and postnatal care services for early identification and prevention.

Are symptom features of depression during pregnancy, the postpartum period and outside the peripartum period distinct? Results from a nationally representative sample using item response theory (IRT)

BACKGROUND

Whether there are systematic differences in depression symptom expression during pregnancy, the postpartum period and outside these periods (i.e., outside the peripartum period) remains debated. The aim of this study was to use methods based on item response theory (IRT) to examine, after equating for depression severity, differences in the likelihood of reporting DSM-IV symptoms of major depressive episode (MDE) in women of childbearing age (i.e., aged 18-50) during pregnancy, the postpartum period and outside the peripartum period.

METHODS

We conducted these analyses using a large, nationally representative sample of women of childbearing age from the United States (n = 11,256) who participated in the second wave of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC).

RESULTS

The overall 12-month prevalence of all depressive criteria (except for worthlessness/guilt) was significantly lower in pregnant women than in women of childbearing age outside the peripartum period, whereas the prevalence of all symptoms (except for "psychomotor symptoms") was not significantly different between the postpartum and the nonperipartum group. There were no clinically significant differences in the endorsement rates of symptoms of MDE by pregnancy status when equating for levels of depression severity.

CONCLUSIONS

This study suggests that the clinical presentation of depressive symptoms in women of childbearing age does not differ during pregnancy, the postpartum period and outside the peripartum period. These findings do not provide psychometric support for the inclusion of the peripartum onset specifier for major depressive disorder in the DSM-5.

Mental health problems and influencing factors in Japanese women 4 months after delivery

BACKGROUND

Postpartum mental health problems are a major public health issue; however, studies on the mental health status of mothers and its influencing factors between 8 weeks and 1 year postpartum are scarce. Furthermore, it would be necessary to examine the factors influencing mothers' mental health in order to evaluate their physiological adaptations to the nursing environment.

METHODS

We examined the mental health status of postpartum women and the factors influencing poor mental health at 4 months after delivery. A cross-sectional study of 584 postpartum women was conducted. Information on mental health status, delivery, and other factors was collected using a self-administered questionnaire. Women were asked about their age, height, weight, gestational or marital status, whether they were eating regular meals, appetite, frequency of going out, financial difficulty, stressful life events, and history of depression. The Japanese version of the 12-item General Health Questionnaire (GHQ-12) was used to identify potential poor mental health status. Participants with GHQ-12 scores of ≥4 were classified as the high GHQ-12 score group (poor mental health status) and participants with GHQ-12 scores of ≤3 were classified as the low GHQ-12 score group (good mental health status).

RESULTS

Forty-five women (7.7%) were classified as having high GHQ-12 scores. Multiple logistic regression analysis revealed that older age, not eating meals regularly, and history of depression were significantly associated with poor mental health. Financial difficulty had a borderline association with poor mental health in this model.

CONCLUSIONS

These risk factors might help practitioners identify women at high risk of poor mental health after delivery.

Factors associated with post-natal anxiety among primiparous mothers in Nepal

BACKGROUND

In Nepal, new mothers are fatigued by childcare responsibilities because of lack of knowledge and preparation for their new role. Knowledge deficit and adherence to traditional health practices place infants at risk. Some cultural practices for the care of newborns may cause tetanus, hypothermia or other life-threatening illnesses. Maternal education, previous experience of newborn care, economic status, relationship problems with husband or mothers-in-law and dissatisfaction with social relations are the variables of interest for this study.

AIMS

To examine the association between socio-demographic variables and post-natal anxiety among primiparous mothers in Nepal.

DESIGN

The study was designed as a correlational study.

SETTING

A major maternity hospital in Kathmandu, Nepal.

PARTICIPANTS

The sample were 216 primiparous mothers who were followed at 5-6 weeks after delivery.

METHODS

Three instruments were used for data collection: a demographics questionnaire, the Newborn Care Knowledge Questionnaire and the State-Trait Anxiety Inventory for Adults.

RESULTS

The mothers' knowledge of newborn care, general educational level and income were inversely related to maternal anxiety, that is, mothers with a lower educational level and socio-economic status demonstrated a higher level of post-natal anxiety. Poor relationships with husbands or mothers-in-law and low social support presented potential for the development of anxiety and depression during post-partum period.

CONCLUSION

Maternal education, socio-economic status and knowledge of newborn care were major factors of post-natal anxiety. On the other hand, women with low income and education, poor relationships with their husbands or mothers-in-law, and insufficient social support are vulnerable to the development of moderate to severe anxiety.

HEALTH POLICY

Policy implications from these results indicate the need for support and funding from the Ministry of Health for education for women at hospitals, which must work together to offer newborn care education during the ante-natal and post-natal periods.

Detecting maternal depression in a low-income country: comparison of the self-reporting questionnaire and the edinburgh postnatal depression scale

OBJECTIVE

To validate the Self-Reporting Questionnaire (SRQ-20) and the Edinburgh Postnatal Depression Scale (EPDS) against the Clinical Interview Schedule-Revised (CIS-R).

DESIGN

Two-phase design.

SUBJECTS AND METHODS

664 mothers were approached, 601 of them completed the EPDS and SRQ questionnaires. The CIS-R was administered to confirm the diagnosis for depression. The diagnostic accuracy was compared using the receiver operating characteristic analysis.

RESULTS

At the threshold of 11, the SRQ had better sensitivity, negative predictive values and positive predictive values compared with the EPDS optimal threshold of 14.

CONCLUSION

Both measures (EPDS and SRQ) have adequate validity to screen for depression in mothers in Pakistan. However, the SRQ performed better, with participants finding it easy to understand. The scales can be of great value to detect maternal depression in primary care and pediatric settings in low-income countries.

Predictors of psychological distress among postnatal mothers in rural Nepal: a cross-sectional community-based study

BACKGROUND

Perinatal common mental disorders are a major cause of disability among women and have consequences for children's growth and development. We aimed to identify factors associated with psychological distress, a proxy for common mental disorders, among mothers in rural Dhanusha, Nepal.

METHODS

We used data from 9078 mothers who were screened for distress using the 12-item General Health Questionnaire (GHQ-12) around six weeks after delivery. We assessed the association between GHQ-12 score and socioeconomic, gender-based, cultural and reproductive health factors using a hierarchical analytical framework and multilevel linear regression models.

RESULTS

Using a threshold GHQ-12 score of ≥6 to indicate caseness, the prevalence of distress was 9.8% (886/9078). Factors that predicted distress were severe food insecurity (β 2.21 (95% confidence interval 1.43, 3.40)), having a multiple birth (2.28 (1.27, 4.10)), caesarean section (1.70 (0.29, 2.24)), perinatal health problems (1.58 (1.23, 2.02)), no schooling (1.37 (1.08, 1.73)), fewer assets (1.33 (1.10, 1.60)), five or more children (1.33 (1.09, 1.61)), poor or no antenatal care (1.31 (1.15, 1.48) p<0.001), having never had a son (1.31 (1.14, 1.49)), not staying in the parental home in the postnatal period (1.15 (1.02, 1.30)), having a husband with no schooling (1.17 (0.96, 1.43)) and lower maternal age (0.99 (0.97, 1.00)).

LIMITATIONS

The study was cross-sectional and we were therefore unable to infer causality. Because data were not collected for some established predictors, including infant death, domestic violence and history of mental illness, we could not assess their associations with distress.

CONCLUSIONS

Socioeconomic disadvantage, gender inequality and poor reproductive health predict distress among mothers in Dhanusha. Maternal and child health programmes, as well as poverty-alleviation and educational interventions, may be beneficial for maternal mental health.

Understanding psychological distress among mothers in rural Nepal: a qualitative grounded theory exploration

BACKGROUND

There is a large burden of psychological distress in low and middle-income countries, and culturally relevant interventions must be developed to address it. This requires an understanding of how distress is experienced. We conducted a qualitative grounded theory study to understand how mothers experience and manage distress in Dhanusha, a low-resource setting in rural Nepal. We also explored how distressed mothers interact with their families and the wider community.

METHODS

Participants were identified during a cluster-randomised controlled trial in which mothers were screened for psychological distress using the 12-item General Health Questionnaire (GHQ-12). We conducted 22 semi-structured interviews with distressed mothers (GHQ-12 score ≥ 5) and one with a traditional healer (dhami), as well as 12 focus group discussions with community members. Data were analysed using grounded theory methods and a model was developed to explain psychological distress in this setting.

RESULTS

We found that distress was termed tension by participants and mainly described in terms of physical symptoms. Key perceived causes of distress were poor health, lack of sons, and fertility problems. Tension developed in a context of limited autonomy for women and perceived duty towards the family. Distressed mothers discussed several strategies to alleviate tension, including seeking treatment for perceived physical health problems and tension from doctors or dhamis, having repeated pregnancies until a son was delivered, manipulating social circumstances in the household, and deciding to accept their fate. Their ability to implement these strategies depended on whether they were able to negotiate with their in-laws or husbands for resources.

CONCLUSIONS

Vulnerability, as a consequence of gender and social disadvantage, manifests as psychological distress among mothers in Dhanusha. Screening tools incorporating physical symptoms of tension should be envisaged, along with interventions to address gender inequity, support marital relationships, and improve access to perinatal healthcare.

Social relationships and postpartum depression in South Asia: a systematic review

BACKGROUND

Evidence suggests a much higher prevalence of postpartum depression in South Asia than in 'western' contexts.

AIM

To conduct a rapid systematic review of evidence on the association between social relationships and postpartum depression in South Asia.

METHODS

Five databases were searched to identify relevant studies. Studies meeting the selection and quality criteria were analysed and integrated in a narrative review.

RESULTS

Nine mostly quantitative studies were included in the review. Low support and poor relationships with the husband and parents-in-law were associated with postpartum depression, although associations were weakened in multivariate analyses. The different dimensions of support have not yet been systematically investigated and the likely complex interrelationships between social relationship risk factors are not yet well understood.

CONCLUSIONS

Findings mirror those from 'western' contexts, showing the key role of social relationships in the aetiology of postpartum depression. Yet, they also reinforce the hypothesis that the social and cultural context influences the association. The importance of relationships with the extended family, as well as the husband, in South Asia is highlighted. Further research is recommended to develop an understanding of these relationships to better inform interventions.

Prevalence of postpartum depression in a hospital setting among Malaysian mothers

INTRODUCTION

Postpartum depression (PPD) is a disorder that affects not only mothers, but also can lead to family, social, economic and vocational breakdown. The objective of this study was to determine the prevalence and factors associated with postpartum depression among mothers in an urban hospital setting in Malaysia.

METHODS

In this cross-sectional study, mothers attending routine visits at six to eight weeks postpartum at a postnatal clinic were assessed on socio-demographic data, obstetric history, social support, breastfeeding status and psychiatric history. Mini International Neuropsychiatric Interview (M.I.N.I.) was administered to establish a diagnosis of postpartum depression.

RESULTS

A total of 411 subjects participated in the study. The prevalence rate of postpartum depression was 6.8%. Univariate analysis found that being a housewife, having a cesarian section, low social support, family history of depression, previous history of depression and non-exclusive breastfeeding were significantly associated with postpartum depression. Predictors for postpartum depression were non-exclusive breastfeeding (P < 0.01, OR = 23.7, 95% CI 3.1-179.7) and previous history of depression (P < 0.05, OR = 82.3, 95% CI 1.2-5897.6).

DISCUSSION

The prevalence rate of postpartum depression in urban Malaysian mothers was comparable to the rates in other countries. Mothers who did no exclusively breast feeding their babies appeared to have more risk for postpartum depression. Therefore, screening for depression should become a routine during postpartum period and mothers must be encouraged to exclusively breastfeed their babies.

Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review

OBJECTIVE

To review the evidence about the prevalence and determinants of non-psychotic common perinatal mental disorders (CPMDs) in World Bank categorized low- and lower-middle-income countries.

METHODS

Major databases were searched systematically for English-language publications on the prevalence of non-psychotic CPMDs and on their risk factors and determinants. All study designs were included.

FINDINGS

Thirteen papers covering 17 low- and lower-middle-income countries provided findings for pregnant women, and 34, for women who had just given birth. Data on disorders in the antenatal period were available for 9 (8%) countries, and on disorders in the postnatal period, for 17 (15%). Weighted mean prevalence was 15.6% (95% confidence interval, CI: 15.4-15.9) antenatally and 19.8% (19.5-20.0) postnatally. Risk factors were: socioeconomic disadvantage (odds ratio [OR] range: 2.1-13.2); unintended pregnancy (1.6-8.8); being younger (2.1-5.4); being unmarried (3.4-5.8); lacking intimate partner empathy and support (2.0-9.4); having hostile in-laws (2.1-4.4); experiencing intimate partner violence (2.11-6.75); having insufficient emotional and practical support (2.8-6.1); in some settings, giving birth to a female (1.8-2.6), and having a history of mental health problems (5.1-5.6). Protective factors were: having more education (relative risk: 0.5; P = 0.03); having a permanent job (OR: 0.64; 95% CI: 0.4-1.0); being of the ethnic majority (OR: 0.2; 95% CI: 0.1-0.8) and having a kind, trustworthy intimate partner (OR: 0.52; 95% CI: 0.3-0.9).

CONCLUSION

CPMDs are more prevalent in low- and lower-middle-income countries, particularly among poorer women with gender-based risks or a psychiatric history.

Postnatal depression and its effects on child development: a review of evidence from low- and middle-income countries

INTRODUCTION OR BACKGROUND

It is well established that postnatal depression (PND) is prevalent in high-income countries and is associated with negative personal, family and child developmental outcomes.

SOURCES OF DATA

Here, studies on the prevalence of maternal PND in low- and middle-income countries are reviewed and a geographical prevalence map is presented. The impact of PND upon child outcomes is also reviewed.

AREAS OF AGREEMENT

The available evidence suggests that rates of PND are substantial, and in many regions, are higher than those reported for high-income countries. An association between PND and adverse child developmental outcomes was identified in many of the countries examined.

AREAS OF CONTROVERSY

Significant heterogeneity in prevalence rates and impact on child outcomes across studies means that the true extent of the disease burden is still unclear.

AREAS TIMELY FOR DEVELOPING RESEARCH

Nonetheless, there is a compelling case for the implementation of interventions to reduce the impact of PND on the quality of the mother-infant relationship and improve child outcomes.

Screening for perinatal common mental disorders in women in the north of Vietnam: a comparison of three psychometric instruments

BACKGROUND

There is increasing recognition that Perinatal Common Mental Disorders (CMDs) are a major public health problem for women in resource-constrained countries. There is an urgent need for screening tools suitable for use by community based health workers to assist in the identification of people with compromised mental health. The aim of this study was to establish the validity of three widely used psychometric screening instruments in detecting CMDs in women in northern Viet Nam.

METHODS

Translated and culturally verified versions of the Edinburgh Postnatal Depression Scale (EPDS), General Health Questionnaire 12 items (GHQ-12), Zung's Self-rated Anxiety Scale (Zung SAS) and a gold-standard diagnostic tool, the Structured Clinical Interview for DSM IV, were administered to a community-based representative cohort of 364 Vietnamese women in the perinatal period. Post-hoc analyses, Cronbach's alpha, and Receiver Operating Characteristic (ROC) analyses were performed to identify the optimal cut-off points and to compare the validity of three scales.

RESULTS

The Areas under the ROC Curve were: EPDS 0.77 (95%CI 0.72-0.82); Zung SAS 0.79 (95%CI 0.74-0.84) and GHQ-12 0.72 (95%CI 0.67-0.78). The optimal cut-off point for the EPDS was 3/4 (Se 69.7%; Sp 72.9%). The corresponding value for Zung SAS was 37/38 (Se 67.9%; Sp 75.3%) and for GHQ-12 was 0/1 (Se 77.1%; Sp 56.6%). The internal reliability Cronbach's alpha for EPDS was 0.75, for Zung SAS was 0.76, and for GHQ-12 was 0.64.

CONCLUSIONS

These instruments are suitable for use as screening tools for CMDs in women in northern Viet Nam, but probably because of differences in emotional literacy, familiarity with test-taking and the effects of chronic social adversity require much lower cut off scores to detect clinically significant symptoms than in other settings.

Validation of the Edinburgh Postnatal Depression Scale among women in a high HIV prevalence area in urban Zimbabwe

Despite the significant burden of common mental disorders (CMD) among women in sub Saharan Africa, data on postnatal depression (PND) is very limited, especially in settings with a high HIV prevalence. The Edinburgh Postnatal Depression Scale (EPDS), a widely used screening test for PND has been validated in many countries, but not in Zimbabwe. We assessed the validity of the EPDS scale among postpartum women compared with Diagnostic Manual of Mental Disorders (DSM-IV) criteria for major depression. Six trained community counselors administered the Shona version of the EPDS to a random sample of 210 postpartum HIV-infected and uninfected women attending two primary care clinics in Chitungwiza. All women were subsequently subjected to mental status examination using DSM IV criteria for major depression by 2 psychiatrists, who were blinded to the subject's EPDS scores. Data were analyzed using receiver operating characteristic (ROC) curve analysis. Of the 210 postpartum mothers enrolled, 64 (33%) met DSM IV criteria for depression. Using a cut-off score of 11/12 on the Shona version of the EPDS for depression, the sensitivity was 88%, and specificity was 87%, with a positive predictive value of 74%, a negative predictive value of 94%, and an area under the curve of 0.82. Cronbach's alpha coefficient for the whole scale was 0.87.

CONCLUSION

The Shona version of the EPDS is a reliable and valid tool to screen for PND among HIV-infected and un-infected women in Zimbabwe. Screening for PND should be integrated into routine antenatal and postnatal care in areas with high HIV prevalence.

Detecting postnatal common mental disorders in Addis Ababa, Ethiopia: validation of the Edinburgh Postnatal Depression Scale and Kessler Scales

BACKGROUND

The Edinburgh Postnatal Depression Scale (EPDS) has been used successfully across diverse cultural settings. However, a recent study found poor validity in detecting postnatal common mental disorders (CMD) in rural Ethiopia. Using similar methodology, the study was replicated in the capital, Addis Ababa.

METHODS

Semantic, content and criterion validity of EPDS, Kessler Scale-6 (K6) and Kessler Scale-10 (K10) were assessed in postnatal women attending vaccination clinics. Criterion validation was undertaken on 100 postnatal women, with local psychiatrist diagnosis of CMD using the Comprehensive Psychopathological Rating Scale (CPRS) as the criterion measure.

RESULTS

The areas under the Receiver Operating Characteristic (AUROC) curve for the EPDS, K6 and K10 were 0.85 (95%CI 0.77-0.92), 0.86 (95%CI 0.76-0.97) and 0.87 (95%CI 0.78-0.97), respectively. The EPDS generated sensitivity, specificity and misclassification rates of 78.9%, 75.3% and 24.0%, respectively at an optimal cut-off point of 6/7. The corresponding values for the K6 were 84.2%, 82.7% and 17.0% at a cut-off point of 4/5, and for K10 were 84.2%, 77.8% and 21.0% at a cut-off point of 6/7, respectively. The internal reliability Cronbach's alpha for the EPDS, K6 and K10 were 0.71, 0.86 and 0.90, respectively.

LIMITATIONS

Not all postnatal women bring their infants to vaccination clinics which may limit generalisability.

CONCLUSION

The EPDS, K6 and K10 all demonstrated acceptable clinical utility as screening scales for postnatal CMD in an urban setting in Ethiopia. The marked urban-rural difference in EPDS performance within Ethiopia highlights the difficulty of applying urban-validated instruments to rural settings in LAMIC.

Postpartum depression in Recife - Brazil: prevalence and association with bio-socio-demographic factors

OBJECTIVE:To use a semi-structured interview to detect depression in postpartum women according to the criteria proposed by the DSM in child health care clinics in the city of Recife, together with the proper association of this disorder to bio-socio-demographic data. METHODS: The study used a cross-section method and contained a convenience sample of 400 women that were between 2 and 26 weeks of postpartum in child health care clinics. A bio-socio-demographic questionnaire and the Portuguese version of the Structured Clinical Interview for DSM-IV Axis I Disorders were used. RESULTS: Twenty nine of the mothers (7.2%) were diagnosed as suffering from postpartum depression. Women with a past history of psychiatric disorders, a family history of psychiatric disorder and some sort of clinical complication presented a higher prevalence of depression. The same happened to those with a past history of spontaneous abortion, those who had a transpelvic birth and those over 8 weeks of puerperium. CONCLUSION: The rate of postpartum depression in this sample, 7.2%, was lower than that reported by other Brazilian studies. It probably occurred because the other researchers used screening scales to assess this estimate instead of a clinical interview.

Post partum anxiety and depression in peri-urban communities of Karachi, Pakistan: a quasi-experimental study

Background

Postpartum anxiety and depression is a major public health concern because of its adverse effects on the cognitive and social development of the infant. Globally postpartum depression has been widely investigated but as anxiety is a more prominent feature of postpartum depression we assessed the prevalence of anxiety and depression and their associated factors in post partum women.

Methods

A quasi-experimental study investigating the impact of postpartum anxiety and depression on child growth and development was conducted in two peri-urban, multiethnic, communities of Karachi, a mega city of Pakistan. A house to house questionnaire based survey was done by trained field workers; 420 consenting pregnant women were identified and data for socio-demographic, home environment and family relationship variables was collected between 36 weeks of pregnancy and within 10 days of childbirth. Mother's levels of anxiety and depression were assessed after one month, two months, six months and twelve months of childbirth; this was two step process: initially an indigenous, validated screening instrument Aga Khan University Anxiety and Depression Scale was used and diagnostic confirmation was done through a psychologist's interview based on DSM IV criteria. Women found to be anxious and depressed at least once out of four assessments were considered for the computation of overall prevalence of postpartum anxiety and depression as well as its risk factors. However, point prevalence's of postpartum anxiety and depression were also reported at each assessment time. Two sixty seven women could be followed for one year. Data was analyzed using SPSS. Chi-square test, simple and multiple logistic regression were used to see the association of different factors.

Results

The overall prevalence of postpartum anxiety and depression was found to be 28.8 percent. Domestic violence, difficulty in breast feeding at birth and unplanned current pregnancy were found to be significantly associated with postpartum anxiety and depression.

Conclusion

Domestic violence and not having the right to plan pregnancy are related to the patriarchal culture and lack of empowerment of women. The association with difficulties in breast feeding needs to be further explored in future studies

A systematic review of studies validating the Edinburgh Postnatal Depression Scale in antepartum and postpartum women

OBJECTIVE

The Edinburgh Postnatal Depression Scale (EPDS) is the most widely used screening tool for postpartum depression (PPD). We systematically reviewed the published evidence on its validity in detecting PPD and antepartum depression (APD) up to July 2008.

METHOD

Systematic review of validation studies of the EPDS included 1987-2008. Cut-off points of 9/10 for possible PPD, 12/13 for probable PPD and 14/15 for APD were used.

RESULTS

Thirty-seven studies met the inclusion criteria. Sensitivity and specificity of cut-off points showed marked heterogeneity between different studies. Sensitivity results ranged from 34 to 100% and specificity from 44 to 100%. Positive likelihood ratios ranged from 1.61 to 78.

CONCLUSION

Heterogeneity among study findings may be due to differences in study methodology, language and diagnostic interview/criteria used. Therefore, the results of different studies may not be directly comparable and the EPDS may not be an equally valid screening tool across all settings and contexts.

Assessing the quality of diagnostic studies using psychometric instruments: applying QUADAS

BACKGROUND

There has been an increase in the number of systematic reviews of diagnostic tests, which has resulted in the introduction of two checklists: statement for reporting of diagnostic accuracy (STARD) and quality assessment of diagnostic accuracy studies (QUADAS).

OBJECTIVE

To examine the validity and usefulness of QUADAS when applied to diagnostic accuracy studies using psychometric instruments and to examine the quality in reporting of these studies during practical application of the checklist.

METHOD

Two reviewers independently rated the quality of 54 studies using QUADAS. The proportion of agreement was used to assess overall agreement and individual agreement of QUADAS items between reviewers.

RESULTS

The overall agreement between the two reviewers for all QUADAS items combined was 85.7%. The proportion of agreement between reviewers for each item ranged from just over 57-100% and was over 80% for 8 of the items. The poorest agreement was associated with the items for selection criteria, indeterminate results and withdrawals. None of the studies adequately reported all relevant information to enable all QUADAS item to be scored as 'yes'.

CONCLUSION

Overall QUADAS was relatively easy to use and appears to be an acceptable tool for appraising the quality of diagnostic accuracy studies using psychometric instruments. The application of QUADAS was hampered by the poor quality of reporting encountered.

Psychiatric disorders in pregnant and postpartum women in the United States

CONTEXT

Psychiatric disorders and substance use during pregnancy are associated with adverse outcomes for mothers and their offspring. Information about the epidemiology of these conditions in this population is lacking.

OBJECTIVE

To examine sociodemographic correlates, rates of DSM-IV Axis I psychiatric disorders, substance use, and treatment seeking among past-year pregnant and postpartum women in the United States.

DESIGN

National survey.

SETTING

Face-to-face interviews conducted in the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions.

PARTICIPANTS

A total of 43 093 respondents were interviewed, of whom 14 549 were women 18 to 50 years old with known past-year pregnancy status.

MAIN OUTCOME MEASURES

Prevalence of 12-month DSM-IV Axis I psychiatric disorders, substance use, and treatment seeking.

RESULTS

Past-year pregnant and postpartum women had significantly lower rates of alcohol use disorders and any substance use, except illicit drug use, than nonpregnant women. In addition, currently pregnant women had a lower risk of having any mood disorder than nonpregnant women. The only exception was the significantly higher prevalence of major depressive disorder in postpartum than in nonpregnant women. Age, marital status, health status, stressful life events, and history of traumatic experiences were all significantly associated with higher risk of psychiatric disorders in pregnant and postpartum women. Lifetime and past-year treatment-seeking rates for any psychiatric disorder were significantly lower among past-year pregnant than nonpregnant women with psychiatric disorders. Most women with a current psychiatric disorder did not receive any mental health care in the 12 months prior to the survey regardless of pregnancy status.

CONCLUSIONS

Pregnancy per se is not associated with increased risk of the most prevalent mental disorders, although the risk of major depressive disorder may be increased during the postpartum period. Groups of pregnant women with particularly high prevalence of psychiatric disorders were identified. Low rates of maternal mental health care underscore the need to improve recognition and delivery of treatment for mental disorders occurring during pregnancy and the postpartum period.

Detecting perinatal common mental disorders in Ethiopia: validation of the self-reporting questionnaire and Edinburgh Postnatal Depression Scale

BACKGROUND

The cultural validity of instruments to detect perinatal common mental disorders (CMD) in rural, community settings has been little-investigated in developing countries.

METHODS

Semantic, content, technical, criterion and construct validity of the Edinburgh Postnatal Depression Scale (EPDS) and Self-Reporting Questionnaire (SRQ) were evaluated in perinatal women in rural Ethiopia. Gold-standard measure of CMD was psychiatric assessment using the Comprehensive Psychopathological Rating Scale (CPRS). Community-based, convenience sampling was used. An initial validation study (n=101) evaluated both EPDS and SRQ. Subsequent validation was of SRQ alone (n=119).

RESULTS

EPDS exhibited poor validity; area under the receiver operating characteristic (AUROC) curve of 0.62 (95%CI 0.49 to 0.76). SRQ-20 showed better validity as a dimensional scale, with AUROC of 0.82 (95%CI 0.68 to 0.96) and 0.70 (95%CI 0.57 to 0.83) in the two studies. The utility of SRQ in detecting 'cases' of CMD was not established, with differing estimates of optimal cut-off score: three and above in Study 1 (sensitivity 85.7%, specificity 75.6%); seven and above in Study 2 (sensitivity 68.4%, specificity 62%). High convergent validity of SRQ as a dimensional measure was demonstrated in a community survey of 1065 pregnant women.

LIMITATIONS

Estimation of optimal cut-off scores and validity coefficients for detecting CMD was limited by sample size.

CONCLUSIONS

EPDS demonstrated limited clinical utility as a screen for perinatal CMD in this rural, low-income setting. The SRQ-20 was superior to EPDS across all domains for evaluating cultural equivalence and showed validity as a dimensional measure of perinatal CMD.

Aspectos epidemiológicos da depressão pós-parto em amostra brasileira

INTRODUÇÃO: Sintomas psiquiátricos são freqüentes após o parto, momento marcado por alterações hormonais e mudanças no caráter social, na organização familiar e na identidade feminina. A Escala de Depressão Pós-Parto de Edimburgo (EPDS) é instrumento de auto-avaliação para rastrear depressão após a gestação, nem sempre adequadamente reconhecida pelos profissionais de saúde. O objetivo deste estudo foi avaliar prevalência de depressão pós-parto em mulheres atendidas em unidades básicas de saúde. MÉTODOS: Estudo transversal com aplicação da EPDS em 292 mulheres que se encontravam entre 31 e 180 dias após o parto. Adotamos o ponto de corte < 12 na EPDS como depressão. RESULTADOS: Do total, 115 (39,4%) apresentaram escores < 12, na EPDS, foram consideradas deprimidas; 177 (60,6%), com escores < 12, foram consideradas não-deprimidas. Mulheres com menor escolaridade, maior número de gestações, maior paridade, maior número de filhos vivos e menor tempo de relacionamento apresentaram mais depressão. CONCLUSÃO: A elevada freqüência de depressão pós-parto está relacionada com fatores sociais, demonstrando a importância dos profissionais de atenção básica na detecção precoce da depressão, tendo como auxílio instrumentos como a EPDS, pela sua eficácia e praticidade.

Complex emotions, complex problems: understanding the experiences of perinatal depression among new mothers in urban Indonesia

In this article, we explore how Javanese women identify and speak of symptoms of depression in late pregnancy and early postpartum and describe their subjective accounts of mood disorders. The study, conducted in the East Java region of Indonesia in 2000, involved in-depth interviews with a subgroup of women (N = 41) who scored above the cutoff score of 12/13 on the Edinburgh Postnatal Depression Scale (EPDS) during pregnancy, at six weeks postpartum, or on both occasions. This sample was taken from a larger cohort study (N cohort = 488) researching the sociocultural factors that contribute to women's emotional well-being in early motherhood. The women used a variety of Indonesian and Javanese terms to explain their emotional states during pregnancy and in early postpartum, some of which coincided with the feelings described on the EPDS and others of which did not. Women attributed their mood variations to multiple causes including: premarital pregnancy, chronic illness in the family, marital problems, lack of support from partners or family networks, their husband's unemployment, and insufficient family income due to giving up their own paid work. We argue for the importance of understanding the context of childbearing in order to interpret the meaning of depression within complex social, cultural, and economic contexts.

Validation of the Thai Edinburgh Postnatal Depression Scale for screening postpartum depression

This study aimed to validate and determine an appropriate cut-off score on the Thai Edinburgh Postnatal Depression Scale (EPDS) as a screen for postpartum depression. A prospective cohort of postpartum women at 6-8 weeks were tested using the EPDS and clinically interviewed by psychiatrists to establish a DSM-IV diagnosis of major or minor depressions in a university hospital in Southern Thailand. Of 351 postpartum women interviewed, 38 postpartum women met the criteria for depressive disorders, major depression in four women (1%) and minor depressive disorder in 34 women (10%). The area under the curve was 0.84 (95% confidence interval 0.76-0.91). Using an EPDS cut-off sum score of 6/7, major and/or minor depression was detected with a sensitivity of 74%, specificity of 74%, positive predictive value of 26% and negative predictive value of 95%. When the cut-off score was higher, the sensitivity was lower but the specificity was higher. The Thai version of the EPDS is a valid self-report instrument and is useful in Thailand where no other screening instrument for postpartum depression is available.