Bitew, Tesera (2017) Effect of Antenatal Depressive Symptoms on Women’s Access to Healthcare and Perinatal Complications: A Population-Based Study in Rural Ethiopia. PhD thesis, Addis Ababa University.
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Abstract
Background Maternal Mortality in Low and Middle Income Countries (LMICs) remains a major public health challenge despite the encouraging achievement of the fifth Millennium Development Goal (MDG-5). Almost all (99.0%) of the global maternal deaths occur in LMICs where there are high resource constraints and low access to health care services. In Sub-Saharan Africa, more than half of perinatal women have no access to maternal healthcare services. The situation is reflected in Ethiopia where only 34% of women attended for antenatal care (ANC) and skilled practitioners attended only 26% of deliveries in 2015. Mental disorders, especially depressive disorders, are also common affecting about one in seven perinatal women. Perinatal depression has been shown to be an independent risk factor for maternal healthcare service utilisation on behalf of the child but there has been little exploration of its potential impact on utilisation of maternal healthcare services. Objective The main objective of this study was to investigate the impact of antenatal depressive symptoms on utilisation of maternal healthcare services (antenatal care, uptake of institutional delivery and postnatal care use) and its effect on perinatal complications. Methods Study Design: The study that formed the basis of this thesis was a population-based study that comprises three sub-studies linked to three main outcomes. Sub-study-I was a crosssectional study carried out at the initiation of the prospective study. Sub-study-II and III were prospective follow-ups of participants identified with probable depression in sub-study-I to assess impact of depressive symptoms on (a) institutional delivery and postnatal care use; b) perinatal complications respectively. Participants: The participants were pregnant women in their second and third trimester residing in Sodo District, Gurage Zone, Southern Nations, Nationalities and Peoples Region of Ethiopia. Eligibility Criteria included: (1) Age 15 years and above; (2) permanent residence as defined by continuous residence in the area for at least the preceding six months;(3) Able to provide informed consent; (4) Not having hearing or cognitive impairment to the extent of impairing capacity to give informed consent or to communicate adequately. Assessments: During baseline assessment, at the second and third trimesters of pregnancy, participants were screened for antenatal depressive symptoms and background demographic and socio-economic information along with other potential confounders such as intimate partner violence, social support, history of chronic medical conditions and adverse perinatal outcomes. Antenatal depressive symptoms were assessed using a locally validated version of the Patient Health Questionnaire-9 (PHQ-9). Participants scoring five or more on the PHQ-9 were considered to have probable antenatal depression. ANC attendance and pregnancy related emergency healthcare visits were cross-sectional outcomes that were assessed as part of the initial baseline assessment. At a median of eight weeks after childbirth, the participants were re-interviewed about their place of delivery, attendance of postnatal care services and whether they had experienced an of perinatal and postpartum complications. Statistical Analysis: Poisson and Negative binomial regression models were used for crosssectional evaluation of the association of antenatal depressive symptoms with antenatal service use and pregnancy related emergency healthcare provider visits. Binary logistic regression was used to examine the association of antenatal depressive symptoms with early initiation and adequacy of ANC services. Binary logistic regression was also used to examine association of antenatal depressive symptoms with uptake of institutional delivery, having assisted delivery and women’s experience of perinatal complications. Results Participant Characteristics: Among study participants, 98.7% were married, 67.5% were non-literate, 92.2% were rural residents and the mean age of the participants was 26.8 years. The majority (64.8%) of women initiated ANC visits (37.0% by 16 weeks gestation) and nearly two-thirds (62.3%) delivered in healthcare institutions. Baseline (Cross-sectional) Study: At PHQ-9 cut-off of five or more, 29.5% of baseline participants and 28.7% of followed up participants had probable antenatal depression. Women with depressive symptoms had an increased risk of having greater number of unscheduled ANC visits (adjusted Risk Ratio (aRR)=1.41, 95% CI: 1.20, 1.65). These group of women also had an increased number of emergency healthcare provider visits to bothtraditional healthcare providers (aRR=1.64, 95% CI: 1.17, 2.31) and biomedical healthcare providers (aRR=1.31, 95% CI: 1.04, 1.69) for pregnancy-related emergencies. Prospective Studies: Women with probable antenatal depression also had increased odds of reporting institutional birth [adjusted Odds Ratio (aOR) =1.42, 95% Confidence Interval (CI): 1.06, 1.92] and increased odds of reporting having had an assisted delivery (aOR=1.72, 95% CI: 1.10, 2.69) than women without these symptoms. In sub-group analysis of women with institutional deliveries, the increased odds of institutional delivery was associated with emergency reasons during labour (aOR = 1.62, 95% CI: 1.09, 2.42) rather than pre-planning to deliver in healthcare institutions. Furthermore, there was increased odds of pregnancy (OR=2.44, 95% CI: 1.84, 3.23), labour (OR= 1.84 95% CI: 1.34, 2.53) and postpartum (OR=1.70, 95% CI: 1.23, 2.35) complications among these group of women compared to women without antenatal depressive symptoms. However, antenatal depressive symptoms were not significantly associated with early initiation of ANC or postnatal care visits, pregnancy loss or neonatal mortality. Conclusion Establishment of a system for detection, referral and treatment of antenatal depression, integrated within existing antenatal care, has the potential to reduce treatment costs and promote efficiency of the health care system through increased use of scheduled ANC and planned uptake of institutional delivery. It also has potential to reduce perinatal complications, thus contributing to a reduction in maternal morbidity and mortality, as well as improved neonatal health. But, further studies should ensure whether early detection and treatment of depressive symptoms may reduce the risk of perinatal complications.
| Item Type: | Thesis (PhD) |
|---|---|
| Subjects: | R Medicine > RA Public aspects of medicine > RA0421 Public health. Hygiene. Preventive Medicine R Medicine > RC Internal medicine > RC0321 Neuroscience. Biological psychiatry. Neuropsychiatry |
| Divisions: | Africana |
| Depositing User: | Emmanuel Ndorimana |
| Date Deposited: | 06 Aug 2018 13:40 |
| Last Modified: | 06 Aug 2018 13:40 |
| URI: | http://thesisbank.jhia.ac.ke/id/eprint/8184 |
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