To assess prevalence of postpartum depression (PPD) amon

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Assessing prevalence and determinants of PPD
Pakistani population
Presenter Dr. Rozina Farhad Mistry Aga Khan
Health Service Pakistan
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PAKISTAN-SHARE OF THE WORLD 2005
POPULATION 153 MILLION ( 2.37) WOMEN IN RH
GROUP gt33 million CHILDREN IN lt5 gt22 million
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COUNTRIES ACCORDING TO THE HUMAN DEVELOPMENT
INDEX 2004
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2005 - OTHER HARD FACTS - MILLIONS

• POPULATION LIVING BELOW POVERTY LINE 35.5
• POPULATION WITH NO ACCESS TO SAFE
• WATER FOR DRINKING 56.9
• POPULATION WITH ONE ROOM HOUSE 57.9
• POPULATION WITH NO SANITATION 78.2
• ADULT LITERATCY RATE 57.4.

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Research Questions

• Primary
• To assess prevalence of postpartum depression
  (PPD) among postpartum mothers in urban area
  (Karachi) and in the rural (Northern Areas) of
  Pakistan using the screening tool of Edinburgh
  Postpartum Depression Scale (EPDS).
• Secondary
• To assess any differences in health and growth
  outcomes of children of the mothers diagnosed as
  having PPD versus the mothers without it.

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Definition of Post Partum Depression

• DSM IV defines Postpartum depression as a form of
  severe depression after delivery that requires
  treatment.
• Studies state that postnatal depression is a
  psychological disorder which occurs within six
  weeks after childbirth

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• After delivery
• 50-75 of the new mothers experience "baby
  blues"
• 10 of these women develop a longer-lasting
  depression
• one in 1,000 women develop the more serious
  condition called postpartum psychosis

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ICD 10 diagnostic criteria for PPD

• i) At least two of the following features must be
  present for at least two weeks
• A depressed mood for most of the day
• Loss of interest or pleasure in activities that
  are normally pleasurable, such as playing with
  the baby
• Tiredness, decreased energy, and fatigue

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• ii) Any four of the following should be present
• Loss of confidence and self esteem
• Feelings of guilt and blaming oneself
• Recurrent thoughts of suicide or death, including
  that of the child
• Difficulty in concentration
• Agitation or lethargy
• Sleep disturbance
• Appetite disturbance

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PPD-WHY SHOULD WE BE CONCERNED
PPD is a serious condition, it can be effectively
treated with antidepressant medications and
counseling
Mother suffering from PPD is unable to do things
she needs to do every day
Only 20 seek Rx. The remaining individuals
remain either undiagnosed, misdiagnosed, or seek
no medical assistance .
PPD has consequences for the physical and
psycho-social development of children.
WHY???
Infants show growth retardation at several time
points in the first year of life
In the absence of Rx, PPD can get worse and last
for as long as a year.
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Rationale for the study

• Widely different PPD rates have been documented
  for developing countries
• Scarce country specific data
• Advocacy for incorporating early diagnosis and
  management of PPD mother and her baby
• To develop culturally appropriate interventions
  to create awareness about impact of PPD on
  mothers and children

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CONCEPTUAL FRAMEWORK
Socio environmental factors
Obstetric related factors
Biological factors
Post Partum Depression
Child related factors
Impact On maternal Health
Impact on Growth outcome of Children
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STUDY DETAILS

• Cross sectional study with simple random sampling
• Study Sites
• a) Karachi (urban setting)
• Three women and children hospital of Aga
  
  Khan Health Service, Pakistan
• b) Gilgit and Ghizer district in the
  Northern Areas (rural setting).

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• Actual sample surveyed Total 1256
• Urban 720
• Rural 536
• Response rate Urban 97.5
• Rural 95.7

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Data collection instrument

• The instrument used in the study had two
  sections
• General information section
• Developed on the basis of log of factors
  identified from various studies
• Edinburgh post partum depression scale

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RESULTS
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ANALYTICAL FINDINGS
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Statistical analysis

• SA was done using SPSS-10.0
• Frequencies and percentages of the variables was
  calculated
• Logistic regression analysis was performed to
  assess the significance of the variables by
  taking PPD either present or absent as a binary
  variable
• P value of lt0.05 was considered significant

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Prevalence of depressive symptoms
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OR2.66 Plt0.001
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OBSTETRIC RELATED CONTRIBUTORY FACTORS OF PPD
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SOCIO-ENVIRONMENTAL CONTRIBUTORY FACTORS OF PPD
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lt0.001
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0.746
0.560
0.891
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Factors that were not found to be contributory in
the urban and the rural population

• Age of the mother (less than 20 years)
• Parity
• History of child death
• Family structure nuclear/extended
• Education of parents
• Planned or unplanned delivery
• Married more than once

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0.891
0.50
0.33
0.32
0.39
0.74
0.326
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lt0.301
lt0.195
lt0.281
lt0.757
lt0.621
of PPD
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CONCLUSION

• Our study has highlighted that the prevalence of
  PPD is
• almost similar (10.4) to that found in the
  developed and many developing country setting
• PPD is more prevalent in rural then in urban
  population
• While there are many common determinants of PPD,
  there are also determinants which vary in urban
  and rural setting of Pakistan

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CONCLUSION

• A very strong association of PPD exists with the
  biological factor (family history of mental
  illness), obstetric and child growth related
  parameters
• Our study confirms that babies born to mothers
  vulnerable to PPD exhibit signs of lagging on the
  growth parameters as early as in 4-6 weeks of
  babys age.

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RECOMMENDATION
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CREATE SUPPORTIVE ENVIRONMENT

• More awareness programs are needed to reduce
  stigma attached to diagnosis of mental illness
• The roles of father and mother need to be
  redefined from their traditional boundaries into
  creating a more supportive environment.
• More awareness need to be created amongst the
  family member for extending additional social
  support to the new mothers.

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DEVELOP PERSONAL SKILLS

• Women and young girls need to learn to prepare
  themselves for different stages of life, to
  diagnose the condition and seek help at the right
  time.
• Birth preparedness should be an integral
  component of the reproductive health strategy

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REORIENT HEALTH SERVICES

• Midwifery, Nursing, and medical education should
  develop capacity in skilled birth providers about
  diagnoses, management and counseling skills on
  PPD
• Health care providers need to be trained to act
  as an enabler, mediator and advocate for
  implementation of policies and strategies that
  will support a mother suffering from PPD

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REORIENT HEALTH SERVICES

• Screening of mother for PPD should be instituted
  at 4-6 weeks of post natal period
• Unskilled birth attendants (TBAs) should be
  trained in early diagnosis and referral at the
  right time for PPD.

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STRENGTHEN COMMUNITY ACTION

• Support groups and networks need to be
  established for PPD mothers from where she and
  her husband should be able to get the support
  required to deal with this condition.

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HEALTH PUBLIC POLICY

• Promote Multisectoral interventions for
  destigmatizing mental illness in Pakistani
  society
• Media should be encouraged to bring about social
  change through challenging the traditional role
  of husbands in child rearing

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FUTURE STUDIES

• Assessment of prevalence of Ante-natal depression
• Prospective study of babies born to PPD mother
  upto two years of age
• Qualitative studies to understand the underlying
  norms of the societies related to gender
  preferences
• Further analysis of differential impact of
  socio-economic status on the occurrence of PPD

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STRENGTHS OF THE STUDY

• Estimated PPD prevalence both in rural and urban
  areas.
• Also assessed the impact of PPD on child growth
  parameters as early as 4 -6 weeks of age
• Wide representation of the population from
  various socio-economic class

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Limitation of our study

• The cases identified at risk of PPD with gt12
  score or equal to 12 score were not clinically
  evaluated to confirm the diagnosis.
• It was not possible to undertake advanced
  statistical analysis such as multivariate
  analysis
• Findings cannot be generalized to the entire
  rural population of Pakistan because of the
  ethnically different population living in
  different rural areas of Pakistan.

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Acknowledgment

• Ms. Laila Khalfan
• Dr. Abid Hoosein
• Mr. Rasool Bux
• Mr. Intisar Siddiqui
• Mr. Shamsu Rehman
• Field teams and staff of AKHS, P
• Board of AKHS, P

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Thanks and Questions Please !