Depression in antenatal period among women attending a Rural maternity hospital in South India

Introduction

Depression is a mood disorder that affects one in four women at some point during their lifetime. Reproductive events have been suggested to be involved in the onset and course of depression¹ . The prevalence of major depressive disorder diagnosis in pregnancy ranges from 3 - 5%, and up to 14% of pregnant women are estimated to have probable major depressive disorder² . These rates are comparable to those seen among similarly aged non pregnant women3 and among women during the postpartum period^4,5,6.

It is important to identify antenatal depression early because, without treatment, it can lead to postnatal and ongoing depression. It can adversely affect the pregnancy outcome; can also have an impact on maternal competence in childcare and has lasting and serious consequences upon the physical and psychological development of the child⁷ . The first and most important step to manage antenatal depression is the accurate assessment of the symptoms and early diagnosis. Screening during the antenatal period is the best because the women are in regular contact with the health services during this period⁸ . Identifying factors responsible for depression in the antenatal period will enable the development of effective interventions directed at preventing antenatal depression. However research on depression in the antenatal period in the Indian context is limited. Hence the present study was done to determine the prevalence of probable depression among antenatal women attending a maternity hospital in Bangalore rural district and identify the risk factors that affect antenatal depression.

Materials and methods

This was a descriptive cross sectional study, based in a rural maternity hospital located in Solur in Ramanagara district in Bangalore. The study was conducted from September to November 2011. Of the women who attended the rural antenatal clinic during the study period 300 participated. All antenatal women attending outpatient department of the rural maternity hospital, irrespective of their age, gestational age, parity and socioeconomic statuswere included in the study while those previously diagnosed to have depression or those who were on treatment for any Psychiatric disorder including depression were excluded from the study.

The participants were administered the Edinburgh Postnatal Depression Scale (EDPS) in the local language by trained research assistants. EDPS is a validated tool for screening for antenatal depression. The 10 item scale gauges depression based on a 7-day recall of mood and feelings, each item scored on a severity scale of 0 to 3, giving a total score ranging from 0 to 30. At cut – off score of 9, it has 100% specificity and sensitivity of 76%⁹ .

Statistical Analysis

Data was entered in Microsoft Excel and analyzed using SPSS version 16. Data was described using, mean, median, mode and standard deviations. Bivariate analysis was done using Chi square tests following which variables with a significance level of < 0.25 were included in a logistic regression model to assess the factors associated with antenatal depression. All statistical tests were twotailed and significance level set at 0.05.

Ethics statement

Ethical approval for the study was obtained from the Institutional Ethics Committee, St. John’s Medical College, Bangalore, Karnataka, India. Written informed consent was obtained from all participants prior to participation in the study.

Results

The demographic details of the participants are described in table 1.

Obstetric details

Of the participants 156 (52%) were in their third trimester, 112 (37.3%) in their second trimester and the remaining 32(10.7%) were in their first trimester and 159(53%) were primigravida and 149(47%) were multigravida. 258 (86%) of them were registered during the 1st trimester of pregnancy, 38 (12.7%) during the 2nd trimester and the remaining 4 (1.3%) during the third trimester. 10.3% of the 300 pregnant women interviewed were belonging to the category of high risk pregnancy. Risk factors included women suffering from the following- pregnancy induced hypertension, gestational diabetes, bad obstetric history, rheumatic heart disease, previous caesarean section, Rh incompatibility and twin gestation. The girl’s age at marriage was considered and it was seen majority of the girls (51.2%) were married by the age of 20, 48% were married between the age of 20-25 and only 0.8% of the girls were married beyond 25 years. Family planning details showed that majority (87%) did not practice any family planning measures.13% reported to have used temporary family planning measures, most common being Copper-T(52%) followed by condoms (43.4%) and others (4.6%).

Only 48 % reported that they had a planned pregnancy. Most (98.7%) did not have a family history of depression. Most (96.3%) women reported that they had a happy married life.16% of the women were unhappy with their in laws. 20% of the women had desire for a male child. An overwhelming majority 90.3% of women reported that their husbands did not consume alcohol. On asked whether there had been a death or any other major illness in the family in recent past, majority of women (94.3%) replied negative.

Prevalence of probable depression and associated factors

The prevalence of probable depression in our study was found to be 12% with mean score being 2.94±5.32 and ranging from 0-28 and median score being zero (Inter quartile range: 0 – 4). Women with a high risk pregnancy {Adjusted OR= 5.6; 95% CI (1.49 – 21.62)}, those who were unhappy with their in-laws {Adjusted OR= 3.4; 95% CI (1.12 – 10.57)} and those with allow family income (<5000 per month) {Adjusted OR=2.7; 95% CI (1.009 – 7.62)} had a higher risk of probable antenatal depression.

Other risk factors

There was no significant association between presence of probable antenatal depression and age of the women, educational status, occupation, and desire for a male child, death in the family in the recent past, unplanned pregnancy, or marital disharmony.

Discussion

The present study provides information on prevalence and risk factors associated with antenatal depression. The prevalence of probable depression among antenatal women in the present study was found to be 12%.Studies from high income settings have shown antenatal depression ranging from 10-20%¹⁰. A longitudinal cohort study done in Bristol, UK using EPDS showed prevalence of antenatal depression 13.5%¹ . A prospective study at a district hospital West Midlands UK showed that 9.8% of the women suffered from depression during pregnancy and 7.4% suffered from depression 8 weeks postpartum¹¹. Our study findings are consistent with these studies. In a cross-sectional study carried out in obstetric outpatient department of tertiary care hospital in Mangalore, the prevalence of antenatal depression assessed using EDPS was found to be 36.7% which is much higher than reported in the present study¹². These differences in reported prevalence might be due to differences in the cutoff score used for EDPS, reporting style, differences in perception of mental health, differences in educational status, levels of social support or its perception, as well as biological vulnerability factors.

Factors studied to see whether they played a role in antenatal depression were individual characteristics like age, education and occupation of the women, family income, pregnancy related factors like high risk pregnancy, unplanned pregnancy, desire for male child, husband/marital relationship factors like relationship with inlaws, happy marriage and significant life events like death in recent past. The factors which were significantly associated with probable antenatal depression were unhappy relationship with inlaws, high risk pregnancy, and low family income. Similar findings have been reported in other studies in Western countries^13,14, however conflicts with inlaws, and is a unique Asian cultural related factor determining depression. Studies in Hong Kong, India, Japan, Korea, and Turkey also demonstrated mother-in-law conflicts as a significant problem among married women^15,16. Although pregnancy and child births generally viewed as a joyful time in most families, they also put an economic burden on the family, especially in low income families, probably leading to anxiety and depression seen in antenatal women.

Marital disharmony¹⁷, male gender preference, and previous history of depression are factors known to cause antenatal depression¹⁸. In the present study women with previous history of depression were excluded. In India, the influence of boy preference has a major effect on mothers. The baby girl is viewed as a heavy economic drain on the family. This is partly due to the perception that most girls marry and thus contribute little economically to the family. Thus, dowry payments made at the time of marriage are crucial. The baby boy, on the other hand will one day be an earning member of the family. If women give birth to a baby girl, they are faced with a lack of support and hostility from their husband and mother-inlaw¹⁹. These expectations may play a role in male gender preference, but it was noteworthy that in the present study, the desire to have a male child was not found to be a significant risk factor for probable antenatal depression.

Certain limitations should be kept in mind while interpreting results of the present study. The study was conducted among antenatal clinic attendees only, limiting generalisability to all pregnant women in the Indian context. The prevalence of probable antenatal depression in the present study could be an underestimate considering the fact that depression itself may inhibit a women's engagement with health services during pregnancy. The use of a single scale to measure probable ante-natal depression, i.e. the EPDS was another limitation of our study. The inherent limitations of the EPDS, especially when it is investigator administered, include, it being a questionnaire based on recall and depending greatly on the woman’s comprehension of the questions and rapport with the investigator.

Conclusion

The prevalence of probable depression among pregnant women in this study was 12%.The factors in the present study which were significantly associated with probable antenatal depression were relationship with in-laws, high risk pregnancy and low family income. These findings highlight the importance of routine antenatal screening for depression in primary health care given that antenatal depression is already known to negatively impact the uptake of antenatal care as well as fetal and obstetric outcomes and is a strong predictor of postnatal depression. Understanding the culture-related issues that contribute to antenatal depression in women may help health care professionals more readily detect depression in these women and provide appropriate support and treatment.