The prevalence of depressive symptoms in the postnatal period in Lalitpur district, Nepal

Acta Obstetricia et Gynecologica. 2006; 85: 1186 1192 ORIGINAL ARTICLE The prevalence of depressive symptoms in the postnatal period in Lalitpur district, Nepal SIGNE DØRHEIM HO-YEN 1,2, GUNNAR TSCHUDI BONDEVIK 1, MALIN EBERHARD-GRAN 3 & BJØRN BJORVATN 1 1 Section for General Practice, Department of Public Health and Primary Health Care, University of Bergen, 2 Division of Psychiatry, Stavanger University Hospital, 3 Division of Epidemiology, Norwegian Institute of Public Health, Norway Abstract Background. Mental disorders are highly prevalent across different cultures and are often associated with serious role impairment. In developing countries, more than three-quarters of people with serious mental disease do not receive any treatment. Identifying and treating maternal depression is important also in Nepal, where suicide is the second largest cause of deaths among women of reproductive age. The emotional, cognitive, and physical development of the infant is also negatively influenced by maternal depression. Objectives. The aim of this study was to estimate the prevalence of depressive symptoms among mothers 5 10 weeks after delivery in a clinical, a rural, and an urban population in Lalitpur district, Nepal. Methods. A total of 426 postnatal women were included in a cross-sectional structured interview study of mental health. Depressive symptoms were measured by the Edinburgh Postnatal Depression Scale (EPDS), and mental distress by the Self Report Questionnaire-20 (SRQ-20). Results. The overall prevalence of depressive symptoms in the postnatal period (defined as EPDS/12) was 4.9% (95% CI 2.9 7.0). The prevalence of mental distress (defined as SRQ-20/10) was 3.1% (95% CI 1.44.7). There were no significant differences in prevalences among the three populations studied. Conclusions. The prevalence of depressive symptoms in the postnatal period was lower than previously reported from Nepal. The value of possible protective and precipitating factors needs to be explored. Key words: Postnatal depression, prevalence, Edinburgh Postnatal Depression Scale, Self Report Questionnaire-20, Nepal Abbreviations: CI: confidence interval, DALY: disability adjusted life years, EPDS: Edinburgh Postnatal Depression Scale, SRQ-20: Self Report Questionnaire-20, WHO: World Health Organization Nepal is a small, landlocked country, situated between China in the North and India in the South. It is economically one of the poorest countries in Asia, ranking as number 140 of 177 countries in the UN s Human Development Index in 2004. Much has been invested in development during the last decades, but a population growth of 2.3% per annum conceals much of the gain of development. Access to safe family planning methods has improved, but still Nepali women give birth to on average 4.1 children. Nepal has one of the highest maternal mortality rates in the world; studies estimate 5151,500 maternal deaths/100,000 live births (1). The lack of accessible, affordable, and reliable maternal health care, as well anemia and malnutrition, contributes to this mortality (2). Due to a lack of local employment opportunities in the villages, there is an increasing urbanization with uprooting of traditional family patterns. The ten-year-long ongoing conflict between the Maoists and the security forces also contributes substantially to this internal migration. In 2000, neuropsychiatric disorders accounted for approximately 13% of all disability adjusted life years (DALYs) lost worldwide, and 11% in the South-East Asian region (3). Major depression was ranked fourth among the leading causes of global disease burden, and second among females aged 15 44 Correspondence: Signe Dørheim Ho-Yen, Stavanger University Hospital, Division of Psychiatry, Postbox 1163 Hillevåg, N-4095 Stavanger, Norway. E-mail: sdhy@sir.no (Received 3 May 2005; accepted 28 March 2006) ISSN 0001-6349 print/issn 1600-0412 online # 2006 Taylor & Francis DOI: 10.1080/00016340600753158

Depression in the postnatal period, Nepal 1187 years (10.6% of DALYs lost). A multinational population survey initiated by the World Health Organization (WHO) in 2000 found that mental disorders were highly prevalent, often associated with serious role impairment, and often went untreated. In developing countries, more than threequarters of people with serious mental disease did not receive any treatment (4). Over the last decade, there has been an increasing focus on women s mental health during the puerperium (5). For women of childbearing age, mental disorders may pose serious problems as they affect both the mother and the child. The child s cognitive, emotional, and social development might be impaired by maternal depression (6). Depressed mothers are also less likely to breastfeed (7). Diagnosing depression in postnatal women is difficult because many common symptoms after childbirth may be misconstrued as depressive. Symptoms of depression may also be falsely interpreted as related to the recent delivery. Screening for depression in connection with postnatal visits has proven to identify significantly more women with the disease than routine clinical evaluation (8). Some authors have proposed that depression in the postnatal period is a culturally based syndrome, mainly confined to industrialized societies (9). However, recent research challenges this theory (10). In Nepal, the prevalence of depression among postnatal women in tertiary health care has been estimated to be 12% (11). Suicides have been found to cause 9.5% of deaths among women of reproductive age in Nepal, being second only to mortality related to pregnancy and childbirth (20%) (12). The highest occurrence of suicide was in the age group 1524 years and among women with 2 or 3 children. In South Asia, exposure to maternal mental distress and depression has been found to be associated with poor infant growth (13). Infant mortality is high in Nepal (64/1,000 live births), with malnutrition and infections being among the main causes of death (1). Identifying and treating maternal depression may thus be important in Nepal, not only for the wellbeing of the mother, but also for the physical health and survival of the newborn. Previous studies of depression in the postnatal period in Nepal have been limited to women attending postnatal clinics at hospitals. As 90% of Nepalese mothers deliver at home (1), a study also involving women from communities could give a more representative estimate of the prevalence of depression. The aim of this study was therefore to estimate the prevalence of depressive symptoms among mothers 5 10 weeks after delivery in a clinical, a rural, and an urban population in Lalitpur district, Nepal. Material and methods Design and study population This was a cross-sectional structured interview study. Women who had given birth to a living child 510 weeks earlier were invited to participate. Women whose children had died at birth, or in the period before the interview, were excluded. A consent form was read out to the subjects, asking for a signed informed consent before an interview could be conducted. Illiterate women signed by thumbprint. Three female specially trained Auxiliary Nurse Midwives, not otherwise connected to the health facilities involved, then filled in a questionnaire while interviewing the postnatal women. The interviews were performed in a separate area where the women and the interviewers could speak in privacy, without health workers, patients, or relatives interfering. The study was conducted in a clinical, a rural, and an urban population. The first (clinical) part of the study was performed during two weeks in October 2001 and two weeks in February 2002, interviewing women attending the regular postnatal check-up at Patan Hospital 45 days after delivery. Women from the cities in Kathmandu valley, as well as from the surrounding villages, attend the hospital s Post Natal Clinic on a self-referral basis, following a normal delivery at the hospital. Women with complicated deliveries would be seen at the gynecological outpatient clinic, and were not included in the study. The second (rural) part was conducted from November 2001 to June 2002 among women attending two rural health posts in Lalitpur district. Chapagaun is a village with a population of 12,500, located within the Kathmandu valley 30 min bus drive from Patan Hospital. Battedada is a village with a population of 4,000, located in steep hills four hours bus drive and a further 30 min walk from the hospital. All women who attended the Ante Natal Clinics at the villages local health posts were contacted according to their expected delivery date. As there is no official birth registry in Nepal, the exact number of women who delivered during this time period in Chapagaun is not known. In Battedada, a house-to-house visit two months prior the present study had identified all pregnant women in the village, and women who did not come for a postnatal check up at the health post were contacted at home. In the third (urban) part of the study, we approached women independently of attendance to postnatal check up. Patan City has a population of 160,000. A stratified sampling procedure was done in cooperation with the local authorities, selecting nine out of 22 wards to secure representation from

1188 S.D. Ho-Yen et al. different social, political, and ethnic groups. These wards also had a functioning system of volunteers, which was necessary in order to identify postnatal women in the area. A systematic house-to-house visit by the volunteers was conducted in order to identify women with an expected delivery date within the study period (May 2002 to January 2003). Later, the volunteers, together with the interviewers, revisited the women 6 weeks after the given delivery dates. To assure privacy, the volunteers conversed with other family members while the interviews were conducted. Measures of mental health Two mental health screening questionnaires were used: the Edinburgh Postnatal Depression Scale (EPDS) and the Self Report Questionnaire (SRQ- 20). In addition to these two screening instruments, a general questionnaire with sociodemographical data was completed. The EPDS is a 10-item self-rating questionnaire that was developed in Edinburgh by Cox et al. (14) to screen for depression in the postnatal period. Each question has four alternative answers, scoring 03, giving a maximum total score of 30. The questionnaire has subsequently been validated and used in many cultures and languages (15), including Nepal (11). In the Nepali validation, depression was diagnosed according to the DSM-IV criteria for moderate and major depression. Using a cut-off above 12 at the EPDS, Nepal et al. found a sensitivity of 68.4% and specificity of 93.8%. The SRQ-20 is a 20-item questionnaire designed for use in low-income countries, taking into account that the questionnaire has to be read out to illiterate subjects and that mental distress often is presented through somatic complaints. The answer alternatives are dichotomized (yes/no). It was introduced by Harding et al. for the WHO (16). The SRQ-20 identifies the potential presence of mental distress and psychiatric disturbance. Twelve questions are related to psychiatric complaints, five questions ask about somatic symptoms (headaches, poor appetite, shaking hands, indigestion, and uncomfortable feelings in the stomach), and three questions measure sleep quality (sleeping badly, easily tired, and being tired all the time). In population based studies, the SRQ-20 is a cost-effective instrument with which to measure community mental health (17). In Nepal, Wright et al. (18) determined a SRQ-20 score above 10 as the best cut-off to identify presence of mental distress, and found it to be an understandable and accepted tool among village populations in Nepal. Data analysis Independent samples t-test was used to analyze numerical differences between the study populations. For categorical data, proportions with 95% confidence intervals and x 2 tests were used to study differences between the populations. Cronbach s alpha was calculated as a measure of internal consistency for the EPDS and for the SRQ-20. P-P charts were used to test the normality distribution of EPDS and SRQ-20 scores. Pearson s correlation between the EPDS scores and the SRQ-20 scores were estimated. The level of significance was set at p B/0.05 for all statistical calculations. Ethical considerations The study was approved by the Nepal Health Research Council and the Norwegian National Committee for Ethics in Medical Sciences. All women with an EPDS score above 12 were referred to adequate follow-up at local mental health clinics. Results A total of 426 women were included in the study. From Patan Hospital, 203 women agreed to participate, whereas 12 did not give consent, and one mother s baby had died at birth. From the villages, 102 women were included, whereas eight had temporarily left the area to go to their maternal home, and one woman had a baby older than 10 weeks. All women in the villages gave consent to participate. The house-to-house visit in Patan City identified 268 women with an expected delivery date within the study period. Of these, 58 had later gone to their maternal home, 24 had moved, and 58 women could not be traced due to logistical problems relating to the volunteer system. Of the remaining 128 women, 126 agreed to participate. Five women were later excluded for the following reasons: one had a child who died before the study, two had children who were older than 10 weeks, one had not had the EPDS completed, and one mother had previously worked in the study team. Hence, 121 were included from Patan City. The mean age of the participants was 24.5 years (range 16 40). The distributions of ethnic and religious groups were similar to the general distribution in Nepal (19). All participants were married. The proportion of women living in a polygamous marriage was 7.8% in the villages and 3.4% in both the hospital and the city group. This difference was not statistically significant. Forty-seven percent of the mothers from the villages had delivered at a

Depression in the postnatal period, Nepal 1189 clinical facility, whereas 90% of the women included from Patan City had delivered at a hospital or a birthing center. The mean number of children was 1.7 in the total sample. Women in the villages had significantly more children than women in the hospital group (1.9 versus 1.5; p B/0.001) and women in Patan City (1.7, p B/0.01). The overall illiteracy rate in our study was 28%. A significantly lower proportion of the women in the hospital group were illiterate (17%) compared to the village group (48%). A significantly higher proportion of women had education beyond the 10 years elementary school in the hospital group (33%) as compared to the villages (7%) and the city (12%). The majority of women interviewed described themselves as housewives (83 84% from the hospital and the villages, and 79% from Patan City), whereas the remaining women were office workers, farmers, business workers, or factory workers. The distributions of age, ethnicity, religion, and number of children for the women not giving consent were comparable to the women included in the study. Some demographic characteristics of the respondents are presented in Table I. The internal consistencies of similar questions within the EPDS and within the SRQ-20, estimated by means of Cronbach s alpha, were 0.72 for both scales. Mean EPDS score was 5.0 (range 024); this did not differ between the study areas. The distribution of the EPDS scores was skewed, with more women having lower than higher scores. The overall prevalence of depressive symptoms in the postnatal period, defined as an EPDS score above 12, was 4.9% (Table II). The prevalence was 7.4% in Patan City and 3.9% in the hospital group and in the villages. However, these differences were not statistically significant. The proportions of women scoring above zero on each individual item on the EPDS are displayed in Table III. The questions relating to blaming oneself unnecessarily and to anxiety were most commonly answered affirmatively, 58 and 52% respectively. Only 3.8% reported having had any suicidal thoughts (question 10 in the EPDS). The mean SRQ-20 score was 3.3 (range 015). The prevalence of mental distress, defined as a SRQ- 20 score above 10, was 3.1% (Table II). There were no significant differences between the three study areas. The question regarding suicidal thoughts was answered affirmatively by 3.3%. The EPDS scores correlated moderately high with the SRQ-20 scores. Pearson s correlation was 0.60 (p B/0.01). There were no significant differences in mean EPDS or SRQ-20 scores among the groups of mothers interviewed by each of the three interviewers. Neither were there any significant differences among the interviewers in the proportion of women scoring above the cut-off values. Discussion The prevalence of depressive symptoms in the postnatal period found in this study, 4.9%, was lower than in previous studies from Nepal (12%) and India (2023%) (11,20,21). The present study is so far the largest in Nepal investigating the prevalence of depressive symptoms in the postnatal period. EPDS is a commonly used instrument to screen for depression in the postnatal period. For diagnosis of depression a high score needs to be followed by an interview, but both the EPDS and the SRQ-20 has previously been used alone in assessing maternal mood (i.e. 13,21). When using the EPDS in primary health care as a component of a screening program, a cut-off value above 9 has been recommended (14). If the screening instrument, however, is used for research purposes, a high specificity is important. A higher cut-off value, and therefore higher specificity, will increase the probability that individuals with scores above cut-off value actually do have depression. A sensitivity of 68.4% and a specificity of 93.8% have been presented for a cut-off value /12 on the Nepali version of the EPDS (11). This relatively low sensitivity may have led to an erroneously low prevalence estimate in the present study (15). However, it was essential to use the same cutoff value as in previous Nepali research. The women included from the villages and from Patan City were comparable to the general population of Lalitpur in terms of literacy level (61%), ethnicity, and number of children (19), whereas the women recruited from the hospital had higher proportions of women with education and of primiparas. In Patan Hospital and in Chapagaun Health Post, only women who actively used the Mother and Child Clinics were recruited. According to the Nepal District Health Services, 71% of the women in Chapagaun and 75% of those in Battedada attend the antenatal and postnatal check-ups. This is substantially higher than the 43% average for Nepal (1). Mothers with depression could be less likely to attend the 6-week postnatal check-up. In India, nevertheless, Patel et al. (21) found that mothers with depression were more likely to consult healthcare providers than other mothers. People seeking health care at Patan Hospital and Chapagaun Health Post have previously been found to have a higher prevalence of mental distress than people in the community (18).

1190 S.D. Ho-Yen et al. Table I. Demographic characteristics of the respondents, by study area. Age (years) Number of children Polygamy Illiteracy Education/10 years Mean Range SD Mean Range SD n % 95% CI n % 95% CI n % 95% CI Hospital (n/203) 24.4 1837 3.7 1.5 14 0.7 7 3.4 16 35 17 1222 68 33*** 2740 Villages (n/102) 24.6 1740 5.2 1.9* 16 1.1 8 7.8 313 49 48** 3858 7 7 212 Patan City (n/121) 24.6 1633 4.1 1.7 15 0.8 4 3.4 07 37 31 2239 15 12 618 Total (n/426) 24.5 1640 4.2 1.7 16 0.9 19 4.5 36 121 28 2432 90 21 1725 *Significantly more children compared to Patan Hospital (p B/0.001) and to Patan City (p B/0.01). **Significantly more women who were illiterate compared to Patan Hospital (p B/0.001). ***Significantly more women with education beyond 10 year elementary school compared to the villages and to Patan City (both p B/0.001). Systematic bias could have occurred in the selection of the study population from Patan City, as the selection of the wards was not randomized. On the other hand, this part of the study was the most comprehensive, with women being identified by a systematic house-to-house visit independently of attendance at any postnatal clinic or hospital. Women who had moved out of the area, who had gone to their maternal homes, and who for other reasons were not at home at the time of the interview (i.e. work), were not included in the study. There could be a different prevalence of depressive symptoms among these groups. All the participants were married. Divorce or having children outside marriage is very uncommon in Nepal. On the other hand, polygamy was more commonly reported in our material (4.5%) compared to the proportion reported by the Nepali Census for Lalitpur and Kathmandu (1.5%) (19). The literacy rate in the present study (72%) was substantially higher than the average for the country (43%). Education has been suggested to protect against depression in the postnatal period in India (21). Including more educated women could thus contribute to the relatively low prevalence of depression found. However, in the study by Nepal et al. the proportion of literate women was higher than in our sample (84%) and yet they found a higher prevalence of depressive symptoms among postnatal mothers (11). Our sample showed a higher proportion of women delivering at a hospital than the average for Nepal (10%) (1). This could be due to an increased awareness about obstetric health issues in the selected communities, resulting from more than 30 years history of preventive community health services in the area (22). It could also reflect the selection of the study sample, where women using the antenatal and postnatal services also would be more likely to deliver at a clinical facility. In a district without well functioning maternal and child health preventive services, Osrin et al. (23) found that as few as 6% of women delivered in the care of a skilled attendant in a clinical facility. Our sample might thus not be representative for areas in Nepal with less access to functioning health care. Women with complicated deliveries were not included in the study for logistic reasons. Some studies have shown an association between complicated deliveries and depressive symptoms (7), whereas this has not been established as a risk factor in other studies (5). The EPDS is based on self-rating. This implies that the women should be able to read, understand, and cross off correspondingly. For an illiterate person, this is not possible. In an interview situation

Depression in the postnatal period, Nepal 1191 Table II. The numbers and proportions of women with an EPDS score /12 and of women with a SRQ-20 score /10 in three populations. EPDS score /12 (depressive symptoms) SRQ-20 score /10 (mental distress) n % 95% CI n % 95% CI Hospital (n/203) 8 3.9 1.26.6 5 2.5 0.34.6 Villages (n/102) 4 3.9 0.17.8 4 3.9 0.17.8 Patan City (n/121) 9 7.4 2.712.2 4 3.3 0.17.0 Total (n/426) 21 4.9 2.97.0 13 3.1 1.44.7 EPDS, Edinburgh Postnatal Depression Scale; SRQ-20, Self Report Questionnaire-20. there could also be a risk of under-reporting psychiatric symptoms. This could be aggravated by subjects not being familiar with the use of questionnaires or with language describing emotions. In Nigeria, however, it was shown that reading out psychometric questionnaires to illiterate people did not alter the psychometric properties of the instruments used (24). Somatization has been described as a dominant expression of depressive illness in Nepal (18). Hence, the use of the EPDS might lead to a loss of cases in this culture. Five of the questions in the SRQ-20 ask about somatic complaints, and inclusion of this questionnaire would more likely uncover a somatic presentation of mental distress. A large discrepancy in the proportions classified as cases by the two scales would give an indication of suitability of the EPDS in our population. However, the SRQ- 20 and the EPDS identified comparable proportions of women with mental distress or depressive symptoms, 3.1% and 4.9% respectively. We found a moderately high correlation between the EPDS and the SRQ-20, and we did not classify more women with mental distress when asking about somatic symptoms as compared to asking solely about mental health. Somatic complaints might be a depressed woman s presenting complaint at the health post, but these results could suggest that women are able to talk about their mental state and emotions directly when asked. The responses given to each of the first nine questions on the EPDS show that the women used the scale s potential, with 20 58% of the women having experienced each of the emotional problems mentioned in the scale. This could indicate that these women were able to use emotional language, also in an unfamiliar test situation. The question regarding thoughts of suicide was the only item on which nearly all the women (96.2%) scored zero. Suicidal thoughts would be more frequent with a more severe form of depression. The ability to use emotional language and the markedly lower report of suicidal thoughts could thus support our conclusion that major depression was not common in this population. Nepal is a country with great diversity in terms of economy, geography, culture, and ethnicity. Therefore, the prevalence obtained from our study area might differ from other areas in Nepal. Our study population had a relatively high level of education and access to good health-care facilities. This could explain the low prevalences of depressive symptoms Table III. Depressive symptoms measured. Women scoring /0 EPDS questions, each giving a score 03 n (426) (%) I have been able to laugh and see the funny side of things (nonaffirmative 85 20.0 answers) I have looked forward with enjoyment to things (nonaffirmative answers) 106 24.9 I have blamed myself unnecessarily when things went wrong 247 58.0 I have been anxious and worried for no good reason 220 51.6 I have felt scared and panicky for not very good reason 171 40.1 Things have been getting on top of me 99 23.2 I have been so unhappy that I have had difficulty sleeping 132 31.0 I have felt sad or miserable 177 41.5 I have been so unhappy that I have been crying 116 27.2 The thought of harming myself has occurred to me 16 3.8 EPDS, Edinburgh Postnatal Depression Scale.

1192 S.D. Ho-Yen et al. and mental distress among postnatal mothers. There could also be factors within the Nepali culture and society that are of particular protective value against depression after delivery. Further studies are needed to explore such protective factors, and to evaluate possible risk factors for depression in the postnatal period in Nepal. To get a broader understanding of the high rates of suicides among women of reproductive age, mental morbidity among women in other phases of reproductive life in Nepal should be explored. Acknowledgements We thank the volunteers in Patan City, the health workers at the health posts and Patan Hospital, as well as all staff in the United Mission to Nepal who have helped in the practical conduct of the study. A special thanks goes to Ms Subhasha Shrestha for coordinating the logistics. 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