Date Published: May 2, 2019
Publisher: Public Library of Science
Author(s): Rashidul Azad, Rukhshan Fahmi, Sadichhya Shrestha, Hemraj Joshi, Mehedi Hasan, Abdullah Nurus Salam Khan, Mohiuddin Ahsanul Kabir Chowdhury, Shams El Arifeen, Sk Masum Billah, Bishwajit Ghose.
Postpartum depression (PPD) is a serious pubic health concern and known to have the adverse effects on mother’s perinatal wellbeing; and child’s physical and cognitive development. There were limited literatures on PPD in Bangladesh, especially in urban slum context. The aim of this study was to assess the burden and risk factors of PPD among the urban slum women. A cross-sectional study was conducted between November-December 2017 in three urban slums on 376 women within first 12 months of postpartum. A validated Bangla version of Edinburgh Postnatal Depression Scale was used to measure the depression status. Respondent’s socio-economic characteristics and other risk factors were collected with structured validated questionaire by trained interviewers. Unadjusted Prevalence Ratio (PR) and Adjusted Prevalence Ratio (APR) were estimated with Generalized Linear Model (GLM) and Generalized Estimating Equation (GEE) respectively to identify the risk factors of PPD. The prevalence of PPD was 39.4% within first 12 months following the child birth. Job involvement after child delivery (APR = 1.9, 95% CI = 1.1, 3.3), job loss due to pregnancy (APR = 1.5, 95% CI = 1.0, 2.1), history of miscarriage or still birth or child death (APR = 1.4, 95% CI = 1.0, 2.0), unintended pregnancy (APR = 1.8, 95% CI = 1.3, 2.5), management of delivery cost by borrowing, selling or mortgaging assets (APR = 1.3, 95% CI = 0.9, 1.9), depressive symptom during pregnancy (APR = 2.5, 95% CI = 1.7, 3.8) and intimate partner violence (APR = 2.0, 95% CI = 1.2, 3.3), were identified as risk factors. PPD was not associated with poverty, mother in law and any child related factors. The burden of postpartum depression was high in the urban slum of Bangladesh. Maternal mental health services should be integrated with existing maternal health services. Research is required for the innovation of effective, low cost and culturally appropriate PPD case management and preventive intervention in urban slum of Bangladesh.
Postpartum depression (PPD) is a common, non-psychotic mood or mental disorder which typically manifests in mothers within one year of delivery (first year postpartum) [1, 2]. Globally, the prevalence of PPD among mothers ranges from 0.5% to 60.8% . In comparison to women of developed countries, women of developing countries showed higher rates of PPD . A systematic review of 28 developed countries reported that the prevalence PPD symptom (PPDS) was 6–13% among women in high income nations . An independent systematic review on low and middle income countries (LMIC) found the prevalence of postpartum common mental disorder was approximately 20% . Asian countries reported between 3.5–63.3% prevalence rates of depression in postpartum women . In India the prevalence of depression varied from 11% to 16% within fourteen weeks of delivery . Several studies conducted in rural Bangladesh found the prevalence of PPD ranged from 18% to 35% among rural women [8–10].
Among the postpartum mothers 25.2% were adolescents and 31.7% were illiterate or with just enough skills to sign their names. On the other hand, 17.0% of mothers attained a secondary level of education or received a higher education. Approximately half, (48.7%) were first time mothers and 20.0% had three or more children. The mean number of household members was 4.5 and most of the families (83.8%) resided in one room. Only 7.7% of mothers were working after delivering their child, but before their most recent pregnancy around 49.7% of mothers had been engaged in income generating activities. Among the respondents employed before pregnancy, 54.6% were garments or industry workers, 27.3% were part-time house maid; whereas, 10.7% worked in private and other non-government organization and 7.0% involved some sort of home based work (Tailoring, handicraft, etc). Among the respondents we interviewed, 22.6% experienced at least one child death, or miscarriage, or stillbirth during her entire fertility period and 67.6% of respondents planned their most recent pregnancy. About 69.1% of mothers faced intimate partner violence before their last pregnancy, and 47.7% faced it during the pregnancy period as well (Table 1).
This study explored the burden of postpartum depression and the associated factors in slum areas. Our study results show that about 40 women out of 100 women were suffering from PPD and the associated risk factors were current job involvement, job loss due to pregnancy, history of miscarriage, still birth and child death, unintended pregnancy, cost of delivery managed from borrowing/selling asset/mortgage, depressive symptom during pregnancy period, perceived antenatal stress, poor marital relationship with husband, and intimate partner violence.
The main strength of the study was the study focused the rapid increasing segment of urban population of Bangladesh with a large sample size. To our knowledge it was the first study to assess the prevalence and risk factors of postpartum depression in urban slum of Bangladesh. In addition, the study included the wide range of risk factors found in the postpartum literatures of Bangladesh and similar context. We used GLM and GEE model to estimate Prevalence Ratio (PR) and to adjust the clustering effect at slum level. Statistically, estimating PR has some methodological advantages as it is a comparable measure of relative risk (RR) for cross-sectional data, and the estimation models of PR able to control the confounders and interactions more adequately than the Logistic regression models [65, 66]. Most importantly, the study used the repeatedly validated Bangla version of instruments and scale which was nationally and internationally recognized and widely used.
The higher prevalence of PPD suggested the importance of mental health support system for the low income women in slum area. Maternal mental health services should be integrated with existing maternal health services. The primary maternal health care staffs could be provided the basic PPD screening and its primary management training, so that they can refer the PPD cases for appropriate mental health services when needed. They are also needed to educate about the contextually relevant risk factors of PPD as part of the training component. Additionally, the existing maternal health services in slum area should be strengthened and pro-poor friendly.