1

Research Seminar: Presentation

“Post partum anxiety and depression in peri-urban

communities of Karachi, Pakistan: a quasi-experimental study” Niloufer S Ali, Badar S Ali and Iqbal S Azam

BMC Public Health 2009

Presented By

Musarrat Begum

February 9, 2010

2

Rationale To recognized the contributing risk factors

that may lead of anxiety and depression in post partum duration in women. Unwanted pregnancy Excessive burden of family maintenance Gender dominance Effect on Poor marital relationship

To find out the post partum anxiety and depression in public health.

3

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 post partum depression has been widely investigated but as anxiety is a more prominent feature of post partum depression.

4

Definition of the Post Partum Depression and Anxiety

Postpartum depression (PPD), is a form of clinical depression, which can affect women, and after childbirth. Postpartum depression occurs in women after they have carried a child, usually in the first few months .

Postpartum anxiety, As for depression, anxiety occurring around pregnancy or following the birth of a child is clinically no different from anxiety that occurs at any other time.

5

Introduction

Postpartum anxiety and depression is the leading cause of maternal morbidity. It is associated with adverse effects on the cognitive and social development of the infant.

In the postpartum period half to two thirds of women suffer from mood disturbances, for most symptoms are transient and relatively mild, known as postpartum blues and settles spontaneously within four weeks.

6

Introduction (Contd…)

Therefore, postpartum depression (PPD) is typically diagnosed during 4-12 weeks after childbirth.

There is a critical period for the development of affective disorders from birth to the first year postpartum and so depression occurring within a year after childbirth can be labelled as PPD.

7

Introduction (Contd…)

Risk factors for postpartum depression already identified are: personal history of earlier depression particularly antenatal depression, illiteracy and low socio-economic status, anxiety during pregnancy, experiencing stressful life events during

pregnancy/ puerperium female infant gender, low levels of social support and poor marital

relationship

8

Objectives

To assessed the prevalence of anxiety and depression and their associated factors in post partum women.

To identify the impact of postpartum anxiety and depression on child growth and development.

9

Methodology

Design Quasi-experimental study. SettingThe impact of postpartum anxiety and depression on child

growth and development; conducted in two peri-urban, multiethnic, communities of Karachi: Qayoomabad and Manzoor Colony, from February 2004 - December 2006.

ParticipantsTotal pregnant women enrolled in study are 420. Inclusion criteriaAll pregnant women who were living in the defined sites were

identified by house to house survey and obtained consent for participation after giving a live childbirth.

10

Flow Chart Showing the Enrollment and follow up status of Women in the Study

Total women enrolledIn Manzoor colony = 155

Lost of follow upShifted =57Refused = 4

Total women followfor one year or more

=94

Total women enrolledQayoomabad = 265

Lost of follow upShifted =78

Refused = 14

Total women followfor one year or more

=94

Total women enrolledin the study - 420

11

Methodology (Contd…)

Data CollectionInstruments used

Questionnaire

a. Socio-demographic questionnaire

b. Home environment/Family relationship questionnaire

c. Post-natal questionnaire

d. Aga Khan University Anxiety

and Depression Scale

(AKUADS)

12

Methodology (Contd…)

Descriptive SPSS. Chi-square tests Inferential multiple logistic regression were used, odds ratio, 95 percent confidence interval, P-value less than 0.25 at univariate level.

13

Results

420 women were enrolled in two peri-urban settlements of Karachi.

267 women who were followed for one year 64.8% were from Qayoomabad and the rest were from Manzoor colony.

No significant association was observed between lost to follow rates in the two study areas. It was 39.4% in Manzoor Colony and 34.7% in Qayoomabad (P-value =0.341).

14

Results (Contd…)

The overall prevalence of anxiety and depression within one year of childbirth was 28.8%(77 women, 95% C.I.: 23.4 to 34.2).

Women found to be anxious and depressed at least once include 65 women who had reported only once, 11 women twice and 1 woman thrice .

Point prevalence's at 1 month 5.2% (14/267),2 months 5.2% (14/267), 6 months 10.1% (27/267), and 1 year were 13.1% (35/267) respectively.

15

Results (Contd…)

Majority of the study participants were Muslims (88.4%) and no significant difference were observed in anxiety and depression in Muslims and followers of other religions.

Most of the mothers were housewives (92.1%). About one third of the women had a formal education up to schooling of 10 years or more, and a quarter of them had never been to school.

16

Results (Contd…)

Mother tongue was used Sindhi and Balochi are the languages of the original inhabitants of the coastal areas of Karachi and Urdu is spoken by the people who migrated to Karachi.

A higher prevalence of anxiety and depression was observed among immigrants, however it was not statistically significant (P-value = 0.558).

Majority of the women (96.6%) in both areas were satisfied by their current life (P-value =0.765).

17

Results (Contd…)

Similarly a large number of women (81.6%) had unplanned current pregnancy (p-value = 0.017). A small number of women (5.6%) reported verbal or physical abuse by a family member for themselves or their children (p-value = 0.132).

More than two thirds of the childbirths were attended by a trained person such as a doctor (60.3%) or a midwife/Lady Health Visitor (20.2%) and were conducted in either a hospital (58.8%)or a maternity home (18.4%); in spite of this about one third of the mothers reported complications during or after childbirth.

18

Results (Contd…)

In the univariate analysis, unplanned current pregnancy (P-value = 0.017), domestic violence (P-value = 0.012), and child having any difficulty soon after birth (P-value = 0.03) were found to be significantly related to postpartum anxiety and depression.

Other important characteristic was having difficulty in breast feeding the newborn (P-value = 0.125).

Study area (P-value 0.801), which was used as proxyfor immigrant status and mother's age group(P-value = 0.459)was considered biologically important variable for inclusion in multivariable analysis.

19

Discussion

In this study an overall prevalence of postpartum anxiety and depression was found to be 28.8% and point prevalence's at 1 month, 2 months, 6 months and 12 months were 5.2, 5.2, 10.1 and 13.1 percents respectively.

In this study, an association of postpartum anxiety and depression with domestic abuse, resentment about current pregnancy and difficulty in breast feeding was found.

20

Discussion (Contd…)

In this study the factors were not found to be significant in multivariate analysis.

No significant association with employment status of mothers, family structure, and sex of the baby was found in this study.

21

Discussion (Contd…)

The association with difficulties in breast feeding at birth should be further explored by future studies.

The results of this study are similar, as the significant factors that emerged were all stressful life events i.e. domestic abuse, undesired current pregnancy and difficulties in breast feeding.

22

Strengths and Limitation (By Author)

Strengths 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.

Selection of field workers and Training and providing counseling session.

23

Strengths and Limitation (Contd…)

In this study had some limitations Firstly, the unavailability of characteristics

of 231/651 women, who did not consent for participation in the study for comparison.

Secondly ,a large lost to follow rate among consenting women due to frequent change in residence and refusals after providing initial consent because of stigma associated with mental illness.

24

Strengths and Limitation (Contd…)

In this Article study the researcher did not assess the past history of anxiety/ depression particularly during current pregnancy hence are unable to comment that infants of mothers with postpartum anxiety/depression are more vulnerable rather than the conditions themselves existing independently and exerting adverse effects on infants.

25

Strengths and Limitation (Contd…)

The assessment of risk factors for persistent affective disturbance could not be determined.

Another limitation of the study population comprised of only low to lower middle socioeconomic classes.

26

Conclusion

Domestic abuse has to addressed through women's empowerment by a socio cultural change which does not fall directly under the preview of medical practitioners, but unwanted pregnancy is not entirely a result of patriarchy.

several factors directly related to our profession are involved like, lack of knowledge of contraceptive methods, accessibility and cost of contraceptives which can be changed through public health measures.

27

Conclusion (Contd…)

An incidental finding is that more than two third of the deliveries were attended by a trained person such as a Doctor (60.3%) or a Midwife/ Lady Health Visitor (20.2%) and were conducted in either a hospital (58.8%) or a maternity home (18.4%),

Despite this, about one third of the deliveries had complications; and stressful events during puerperium are a risk for PPD and prevention of postpartum complications could contribute to reducing prevalence of PPD.

28

Conclusion (Contd…)

More over clinicians need to be aware of the burden of PPD, and its grave consequences, and would do well to make screening for anxiety and depression a part of routine post partum care.

29

Critique (By Presenter)

Title1. The title of post partum anxiety and depression are

well discussed in this article.

2. The title is self explanatory.

Authors’ Affiliation The authors belong to Department of Family

Medicine and Department of Community Health Science, Aga Khan University, Karachi, Pakistan.

30

Critique (By Presenter)

Abstract1. Well structured

2. Provides comprehensive information about the study.

FundingThe project was funded by the Aga Khan University

Research Council Grant.

31

Critique (By Presenter)

Introduction1. Thoroughly discussed all objectives of the

study.

2. The definition for “post partum anxiety and depression” is not well define.

32

Critique (By Presenter)

MethodologyEthical Consideration1. Ethical approval was obtained from the Ethics

Committee of the Aga Khan University.

2. Informed consent was taken from pregnant women before enrollment.

33

Critique (By Presenter)

Methodology (Contd…) Instruments Used 1. Questionnaire - was well defined and easy to

understand.Questionnaire was mainly focus on:a. Socio-demographic questionnaireb. Home environment/Family relationship questionnairec. Post-natal questionnaire d. Aga Khan University Anxiety and Depression Scale

(AKUADS): was used as a screening instrument for anxiety and depression.

34

Critique (By Presenter)

Methodology (Contd…)

Results are worth to generalize because of:

1. Rigor of research methodology

2. Reducing chance / bias

3. Considerably large sample size.

35

Critique (By Presenter)

Results The results were simple to understand. Data was analyzed using SPSS. Chi-square test,

simple and multiple logistic regression were used to see the association of different factors.

Presents study analysis adjusted for socio-demographic characteristics of women, personal characteristics of women, univariate analysis of mothers and children characteristics.

36

Reference

Ali N S, Ali B S, & Azam I S: Post partum anxiety and depression inperi-urban communities of Karachi, Pakistan: a quasi-experimental study. 12th October 2009, BMC Public Health 2009, 9:384 2-10.