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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 30  |  Issue : 5  |  Page : 556-560

Antepartum depression among women attending antenatal clinic in a Nigerian teaching hospital


1 Department of Psychiatry, Abubakar Tafawa Balewa University Teaching Hospital, Bauchi, Nigeria
2 Department of Obstetrics and Gynaecology, Abubakar Tafawa Balewa University Teaching Hospital, Bauchi, Nigeria

Date of Submission02-Apr-2021
Date of Decision04-Aug-2021
Date of Acceptance06-Aug-2021
Date of Web Publication11-Oct-2021

Correspondence Address:
Dr. Muhammad Baffah Aminu
Department of Obstetrics and Gynaecology, Abubakar Tafawa Balewa University Teaching Hospital, Bauchi
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/NJM.NJM_56_21

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  Abstract 


Background: Antepartum depression is a clinical depression occurring at any stage of pregnancy. The cause of antepartum depression might be a combination of hormonal changes and psychological factors. Antepartum depression can affect the course and outcome of pregnancy. Objectives: This study aimed to find the prevalence rate of antepartum depression and its determinant among women attending antenatal clinics. Methodology: The study was a cross-sectional questionnaire-based survey conducted among pregnant women at Abubakar Tafawa Balewa University Teaching Hospital, Bauchi, Nigeria. With the use of the Edinburgh Postnatal Depression Scale, depression was screened among the respondents with the cutoff point of 13. Results: The study comprised 320 pregnant women. The majority (64.4%) of the respondents were below the age of 30 years. The predominant religion was Islam (58.7%). Twenty of the respondents were unmarried (6.2%). Only 2.5% had no formal education. Eighty-five of the respondents reported not having adequate support from their partners. Only 30% of the respondents were in their first pregnancy, and more than 66% were in their third trimesters. The prevalence rate of severe depression was 18.4%. Factors associated with antepartum depression were lack of support, first pregnancy, and third trimesters. Conclusion: This study found that a sizeable proportion of pregnant women attending antenatal clinics suffered from depression and highlighted factors associated with this. There is a need for screening for depression among pregnant women.

Keywords: Antepartum, depression, northeastern Nigeria, pregnant women


How to cite this article:
Sulyman D, Aminu MB, Ayanda KA, Dattijo LM. Antepartum depression among women attending antenatal clinic in a Nigerian teaching hospital. Niger J Med 2021;30:556-60

How to cite this URL:
Sulyman D, Aminu MB, Ayanda KA, Dattijo LM. Antepartum depression among women attending antenatal clinic in a Nigerian teaching hospital. Niger J Med [serial online] 2021 [cited 2021 Dec 8];30:556-60. Available from: http://www.njmonline.org/text.asp?2021/30/5/556/327964




  Introduction Top


In a typical African society, pregnancy is considered to be a thing of joy. News of pregnancy is eagerly being awaited few months after the wedding, and some cultures do not consider marriage as being consummated until the woman is pregnant. However, pregnancy is also considered a risky period. Pregnancy can be associated with different symptoms, which may be physical as well as psychological. Symptoms such as morning sickness, sleep problems, change in appetite, fatigue, somatic complaints, and body weakness are common. There are reported increases in cases of psychiatric conditions at all stages of pregnancy. Researchers have documented a rise in cases of psychiatric morbidity during pregnancy.[1] One of the mental illnesses commonly found during this period is depression.[2]

Antepartum depression, also known as prenatal depression, is described as clinical depression occurring at any stage of pregnancy. It is recognized by low mood, loss of interest, reduced energy, and sleep pattern and appetite changes. The expectant mother might also feel unprepared for motherhood and unmotivated to assess antenatal care.[3] Diagnosis of depression in pregnancy is easily missed because of the similarities in symptoms of depression which might also be present during pregnancy.[4],[5] There is a wide variation in the prevalence rates of antepartum depression across the globe.

The estimated prevalence rates of antepartum depression as reported by the American College of Obstetricians and Gynecologists were between 14% and 23% among the American population.[6] Nasreen et al. reported a prevalence of 12.2% among expectant mothers in Malaysia to be having antepartum depression using the Edinburgh Postnatal Depression Scale (EPDS).[7] Using the same instrument and similar methodology, Shittu et al. reported a rate of 27.6% in Ethiopia, while Bindt et al. got a prevalence of 26.6% and 32.9% in Ghana and Cote, d'Ivoire, respectively.[8],[9]

In few studies done in southern Nigeria, Adewuya et al. reported a prevalence rate of 8.3% for pregnant women with antepartum depression, while Esimai reported a rate of 10.8%.[10],[11] However, Thompson and Ajayi showed a rate of 24.5% among their respondents in Abeokuta, a city in southwestern Nigeria.[12] The variation in the prevalence rates may be due to differences in the study settings, studied populations, methodologies, and sociodemographic characteristics of the respondents.[13],[14]

The actual cause of antepartum depression is not known. However, a combination of factors has been postulated as possible causes. These are mainly the combination of hormonal changes and psychological disturbances. Previous history or family history of depression is a significant factor. Lack of social support has also been found in many studies to contribute to the development of antepartum depression. Stress during pregnancy, lack of quality sleep, and domestic violence are other factors that are found among women with antepartum depression. Food lacking the necessary nutrition during pregnancy may also contribute to the development of prenatal depression. Deficiencies of Vitamin D, folate, fat, iron, and zinc have all been implicated.[3]

The presence of antepartum depression can affect the course and outcome of pregnancy. Pregnant women with antepartum depression have more miscarriages, preterm deliveries, and babies with low birth weight than those without.[15],[16] Preeclampsia and emergent operative deliveries are other complications that may result from prenatal depression.[16]

Antepartum depression is said to be most common in the last trimester and least common in the second trimester. Symptoms of depression should be looked out for at these periods and if found, managed appropriately. Studies have revealed that the benefits of treating antepartum depression outweigh the risk of untreated depression during pregnancy.

With the health of women being at the center stage of any society because of their contribution to the socio-economic indices, it is essential to investigate factors that will negatively affect the health of all expectant mothers. Despite the magnitude of this topic, there is a dearth of sufficient studies on antepartum depression in this part of the country, hence the need for this study at this period. The main aim of this study was to find the prevalence rate of antepartum depression among women attending antenatal clinics in a northeastern Nigerian teaching hospital. It also highlighted determinants of antepartum depression.


  Methodology Top


Study design

This is a cross-sectional study of pregnant women that were randomly selected using a simple random technique at the antenatal clinic of the hospital. After informing the pregnant women waiting for antenatal care what the study entails, those who consented to participate and met the study inclusion criteria were recruited into the study. These respondents were administered a pro forma questionnaire as well as an EPDS questionnaire by research assistants. The researchers designed a questionnaire to obtain important sociodemographic as well as clinical characteristics of the respondents such as their age, marital status, their highest level of education, gestational age, and parity. EPDS is used to screen for perinatal depression and it consists of 10 questions. The total scores of the respondents were determined by the addition of scores for each of the 10 items. Higher scores signify more severe depression.[17] The cutoff point of 13 which signifies severe depression was used in this study.

Study population

The study population was all pregnant women aged 18 years and above that came for the antenatal clinic at the Obstetrics and Gynecology Department of the hospital during the study period constituted the study population.

Inclusion criteria are pregnant women that are of the age of 18 years and above that gave informed consent to participate in the study after the nature of the study has been explained to them. Women with a history of depression and those that did not consent were excluded from the study.

Sample size

Sample size was determined by the use of the Fisher's formula.

n = z2pq/d2

n = the estimated sample size

z = the standard normal deviate set at 1.96 (95% confidence level)

p = expected prevalence of the disorder in the population (10.8%)[11]

q = 1− expected prevalence of the disorder in the population (1.0‒0.108 = 0.892)

d = expected level of accuracy, 0.05

n = 1.962 × 0.108 × 0.892/0.052

n = 148.

The calculated sample size was 148. The study lasted 4 months during which 320 respondents were interviewed. Since 320 is larger than the estimated sample size, we believed it will improve the power of the study.

Procedure

Having explained the purpose of the study to the women at the antenatal clinic, those that gave their consent were administered the EPDS questionnaire by the research assistant. They were subsequently seen by professionals caring for antenatal patients at the maternity wing of the hospital. Any respondent who was considered to have high scores on EPDS was referred for detailed psychiatric assessment after counseling.

Data were analyzed using EPI-INFO version 6.04d developed by the Centers for Disease Control and Prevention, Atlanta Georgia, United States of America. A frequency table was generated for sociodemographic and clinical variables such as age, level of education, religion, and gestational age. Chi-square was used to compare statistical significance between those that had severe antepartum depression and those that did not have. The level of significance was a 5% confidence limit for two-tailed tests.

Ethical issue

The ethics and research committee of the hospital (Abubakar Tafawa Balewa University Teaching Hospital, Bauchi) approved the study.


  Results Top


The study comprised 320 gravid women who presented for antenatal care. The least age was 18 years, while the oldest was 44 years with an average age of 26 ± 3.5 years. The majority (64.4%) of the respondents were below the age of 30 years. The predominant religion was Islam (58.7%).

Twenty out of the 320 respondents in this study were unmarried (6.2%). Only 2.5% of the respondents had no formal education, 40% had up to secondary, and an additional 30% had up to postsecondary school education. Eighty-five of the respondents reported not having adequate support from their partners. Only 30% of the respondents were in their first pregnancy and more than 66% were in their third trimesters [Table 1].
Table 1: Sociodemographic variables of antepartum women attending clinics

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Fifty-nine of the 320 pregnant women had scores of 13 and above on the EPDS giving the prevalence of severe depression in pregnancy to be 18.4%. Factors that were significantly associated with presence of depression among our study population were lack of support (χ2 = 5.721, P = 0.017), first pregnancy (χ2 = 6.153, P = 0.013), and third trimesters (χ2 = 9.052, P = 0.011) [Table 2].
Table 2: Comparison of respondents with Edinburgh Postnatal Depression Scale score of <13 and those with ≥13

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  Discussion Top


Antepartum depression is found to be common and has far-reaching effects on the course and outcome of pregnancy. It might, however, be missed because of the similarity in presenting symptoms to symptoms of normal, uncomplicated pregnancy. We found the prevalence rate of severe antepartum depression among our studied respondents to be 18.4%. This is higher than average for the general population, which is usually around 10%. Our finding is similar to the rate of 16% reported by Okagbue et al. in their meta-analysis of 26 studies on antepartum depression.[18] It was also within the range of 14%–23% reported by the American College of Obstetricians and Gynecologists.[6] Findings from many African countries reported prevalence rates >20%. For instance, Bindt et al. found rate of antepartum depression to be 26.6% in Ghana and 32.9% in Cote d'Ivoire. Similarly, a rate of 27.7% was found in Ethiopia in a study conducted by Shittu et al.[8],[9] In addition, Thompson and Ajayi reported a rate of 24.55 in southwestern Nigeria.[12] However, the prevalence rate of antepartum depression we found in our study was higher than the prevalence rate of 9.57% found by Mkpe and Terhenen among pregnant women in southeastern Nigeria.[14] Other studies in southwestern Nigeria also reported lower prevalence rates. Such studies included Esimai et al. who reported a rate of 10.8% and Adewuya et al. who found a prevalence rate of 8.3% among their studied population using EPDS.[10],[11] The difference in prevalence rates might not be unconnected to differences in methodologies and instruments used because the screening instruments are more likely to pick more cases than the diagnostic instruments. Differences in sociocultural practices as it affects pregnancy may also be responsible for the differences observed in prevalence rates in northern and southern Nigeria.

First pregnancy (primigravida) was found to be significantly associated with the presence of depression in this study. The explanation may be that being pregnant for the first time might be linked with fear of uncertainties and worries about the pregnancy outcome and fear of imminent motherhood and its expected responsibilities. Busari et al. also reported that the rate of antepartum depression was more common among primigravida women than multigravida women.[19] Our finding from this survey is different from what Thompson and Ajayi found.[12] They reported that multigravida women were more represented among those with antepartum depression. Increased responsibilities and large family size were cited as possible reasons.

Respondents in our study who were in their last trimesters were more represented among those with antepartum depression. Although most of our respondents were in their third trimesters (63%), a significant proportion of those with prenatal depression was in the third trimesters (83%). Okagbue et al., in their systemic review, reported that cases of antenatal depression are more in the third trimesters than in other stages of pregnancy.[18] As the pregnancy advances, the discomforts and stresses associated with pregnancy are expected to increase. Fear of imminent childbirth, uncertainty about the pregnancy outcome, and societal expectations from new mothers may contribute to psychological stress at this stage of pregnancy. The availability of adequate social support during pregnancy has been reported to significantly reduce the incidence of prenatal depression.[20]

The pregnancy period is associated with additional burdens and responsibilities. It is known to be a period when various physiological and psychological changes are taking place in the body. The lack of support by significant others could be detrimental to the mental health of the woman. This is why it was not a surprise that the lack of social support by the husband was found to be a determinant for antepartum depression. A similar result was found by Stewart et al. and Adewuya et al.[9],[21]

The level of education, the age of the mother, and other factors like the type of marriage were not found to be significant in this present study. Some of these factors were reported to be risk factors for the development of antenatal depression in some studies. For instance, Adewuya et al. found polygamous marriages and not married as some sociodemographic factors associated with antepartum depression. Furthermore, Thompson and Ajayi reported being single, lack of formal education, and unplanned pregnancy as factors.[10],[12]


  Conclusion Top


This study found that a sizeable proportion of pregnant women attending antenatal clinics suffered from antepartum depression, and factors associated with this were first pregnancy, being in third trimesters, and lack of adequate social support by the husband or significant others. There is a need for screening for depression during this vulnerable period because the symptoms might be confusing and could easily be missed. Meanwhile, adequate treatment of depression in pregnancy prevents complications that may result from untreated cases leading to a better outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Nasreen HE, Rahman JA, Rus RM, Kartiwi M, Sutan R, Edhborg M. Prevalence and determinants of antepartum depressive and anxiety symptoms in expectant mothers and fathers: Results from a perinatal psychiatric morbidity cohort study in the east and west coasts of Malaysia. BMC Psychiatry 2018;18:195.  Back to cited text no. 7
    
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Bindt C, Appiah-Poku J, Te Bonle M, Schoppen S, Feldt T, Barkmann C, et al. Antepartum depression and anxiety associated with disability in African women: Cross-sectional results from the CDS study in Ghana and Côte d'Ivoire. PLoS One 2012;7:e48396.  Back to cited text no. 9
    
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Thompson O, Ajayi I. Prevalence of antenatal depression and associated risk factors among pregnant women attending antenatal clinics in Abeokuta North Local Government Area, Nigeria. Depress Res Treat 2016;2016:4518979.  Back to cited text no. 12
    
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