|Year : 2018 | Volume
| Issue : 1 | Page : 23-30
Prevalence and sociodemographic correlates of postpartum depression among women attending Postnatal and/or Children's Welfare Clinics in a Tertiary Hospital, Jos, Nigeria
Friday Philip Tungchama1, James Taiwo Obindo1, Aishatu Yusha'u Armiya'u2, Yusufu Taru Maigari1, Francis John Davou1, Suwa Goden Goar1, Christopher Goson Piwuna1, Muas Usman Umar3, Suleiman Abubakar Sadiq4, Michael Terkura Agbir5, Richard Uwakwe6
1 Department of Psychiatry, University of Jos/Jos University Teaching Hospital, Jos, Plateau State, Nigeria
2 Department of Psychiatry, Jos University Teaching Hospital, Jos, Plateau State, Nigeria
3 Department of Psychiatry, Bayero University Kano/Aminu Kano University Teaching Hospital, Kano, Nigeria
4 Department of Psychology, Kaduna State College of Education, Kafanchan, Kaduna State, Nigeria
5 Department of Psychiatry, University of Jos/Jos University Teaching Hospital, Jos, Plateau State; Department of Psychiatry, Benue State University Teaching Hospital, Markudi, Benue State, Nigeria
6 Department of Psychiatry, Nnamdi Azikiwe University/College of Medicine, Nnewi, Anambra, Nigeria
|Date of Web Publication||21-May-2018|
Dr. Friday Philip Tungchama
University of Jos, Jos University Teaching Hospital, Jos, Plateau State
Background: Postpartum depression (PPD) is of public health importance. Estimation of it occurrence in other parts of the developed world showed prevalence rates of approximately 10%–25%. Previous prevalence studies in crisis-ridden areas showed prevalence rates ranging from 28% to 58%. However, since the entrenchment of relative peace in Jos, Nigeria there has not been any other study to the best of the authors' knowledge. Aim: The aim of the present study was to determine the prevalence of PPD in a postethno-religious crisis period among women attending the Postnatal and Children's welfare clinic in a tertiary hospital, Jos, Nigeria. Materials and Methods: In total, 550 women were recruited in a cross-sectional study that involved a two-stage procedure in a Tertiary Hospital in Jos, Nigeria. The Edinburgh Postnatal Depression Scale questionnaire and the Depression Module of the Structured Clinical Interview for DSM-IV axis I Diagnosis were used. Results: A weighted prevalence of 21.8% of PPD was found among the participants. Age (P< 0.001), marital status (P< 0.001), types of marriage (P< 0.001), and educational level (P< 0.001) were significantly associated with PPD. Conclusions: PPD was found in about a quarter of the studied sample in the postcrisis period. Therefore, screening of women in the postpartum period for depression will help in early detection and treatment of women of childbearing age.
Keywords: Jos, Nigeria, postethno-religious crisis, postpartum depression, tertiary hospital, weighted prevalence rate
|How to cite this article:|
Tungchama FP, Obindo JT, Armiya'u AY, Maigari YT, Davou FJ, Goar SG, Piwuna CG, Umar MU, Sadiq SA, Agbir MT, Uwakwe R. Prevalence and sociodemographic correlates of postpartum depression among women attending Postnatal and/or Children's Welfare Clinics in a Tertiary Hospital, Jos, Nigeria. Sahel Med J 2018;21:23-30
|How to cite this URL:|
Tungchama FP, Obindo JT, Armiya'u AY, Maigari YT, Davou FJ, Goar SG, Piwuna CG, Umar MU, Sadiq SA, Agbir MT, Uwakwe R. Prevalence and sociodemographic correlates of postpartum depression among women attending Postnatal and/or Children's Welfare Clinics in a Tertiary Hospital, Jos, Nigeria. Sahel Med J [serial online] 2018 [cited 2018 Sep 24];21:23-30. Available from: http://www.smjonline.org/text.asp?2018/21/1/23/232780
| Introduction|| |
The relationship between childbirth and psychiatric illness has been recognized for 100 of years if not for thousands of years. O'Hara et al. colleagues reported the prevalence rates of postpartum depression (PPD) to be between 10% and 25%. Despite the high prevalence rate, PPD is still not detected early in women and most sufferers do not get the much-needed treatment. This may have profound consequences on the woman, her child, and the entire family. Prevalence rates for PPD reported in the literature vary due to differences in the study locations (both in developed and developing countries)., This range has been attributed to various reasons such as the methodology in terms of instruments used for screening and diagnosis, length of postpartum period under evaluation, multiple criteria, demographic factors, prevalent situation such as crisis, noncrisis, and postcrisis situations under study 
In the United States, PPD prevalence is between 10% and 20%, while in Germany, various prevalence rates of 7%–16% have been reported. The variation in the prevalence rates of PPD in both the United States and Germany was ascribed to under diagnosis and under treatment of the condition in clinical practice., Several studies on PPD in developing countries also showed varying range of prevalence rates. In a meta-analysis conducted by Ramasubramaniam et al. on 17 studies of the prevalence rates of PPD among 9132 Arab women, they found the minimum and maximum prevalence rates of PPD to be 10% and 80%, respectively. Parsons et al. in a meta-analysis found the prevalence of PPD in Asian subcontinent to range from more than a third of the women in a given region (India and Pakistan) to one in 20 women in another region (Nepal). It appears that estimates from the Arab and Asian countries are higher than that of high-income countries of the world. Reports from the South American subcontinent also reported wide estimates within countries and across the continent. Parsons et al. reported the lowest prevalence rate for PPD was in Barbados (16.0%) and the highest in Guyana. In other words, the estimates were higher than the estimates for high-income countries but comparable to estimates from low- or middle-income countries.
In Africa, a wide range of prevalence rates has been reported in studies conducted by researchers. Parsons et al. reported that Uganda had the lowest PPD (7%) and Zimbabwe had the highest (33%). They authors also reported that majority of African countries have estimated prevalence rates higher than those found in high-income countries and that there were no clear differences between prevalence rates of PPD in Northern and/or sub-Saharan African countries.
Various studies reported different prevalence rates of PPD in Nigeria. These rates vary from region to region and also within the same region. Obindo et al. in a cross-sectional study reported a prevalence rate of 44.39% of PPD using the Edinburgh Postnatal Depression Scale (EPDS) among 392 women attending the postnatal clinic and the Children's Welfare clinic in Jos, Nigeria. Owoeye et al. in a prospective cohort study from 5 days postpartum, reported a 23% prevalence rate of PPD in a Maternity Center (a Primary Health Care Centre) in Lagos, South West Nigeria.
Situations or circumstances prevalent at the time of a study may affect the prevalence rates of PPD., Studies from crisis and noncrisis areas have shown variations in prevalence rates with higher prevalence rates in crisis prone areas. The reason for such variation or discrepancy in the prevalence rates may be due to the different ways life events or situations affect the expression of emotions. In crisis-prone areas, it is said that there is increased/or heightened emotional responses in participants than in non-crisis areas. In crisis prone areas such as Jos, in Nigeria (due to ethnoreligious crises) and Pakistan, in Asia (due to sectarian crises) Obindo et al. and Kazi et al. in Nigeria and Pakistan reported high prevalence rates of 44.39% and 28%–57%, respectively., In contrast to these, Abasiubong et al. in Uyo and Uwakwe and Okonkwo in Nnewi, (both in Nigeria) reported lower prevalence rates of 25.7% and 10.7%, respectively , Uyo and Nnewi have experienced little or no crisis, and this might have accounted for the low prevalence rates reported by these authors.
To ascertain the effect of postcrisis period on emotion, authors conducted this research to determine the prevalence of PPD, and associated sociodemographic correlates after a long period of relative peace following ethnoreligious crisis in Jos, Nigeria.
| Materials and Methods|| |
This was a cross-sectional study involving 550 women at 6–8 weeks postpartum attending the postnatal and children's welfare clinic at Jos University Teaching Hospital, Jos, Nigeria.
The study was carried out at the postnatal unit of the Department of Obstetrics and Gynaecology (O and G Department) and the Children's Welfare Clinic of the Department of Community Health, Jos University Teaching Hospital. The women's visit to the postnatal clinic often coincides with their visit to the children's welfare clinic for the second set of immunization (oral polio vaccine, diphtheria, pertussis, and tuberculosis) schedule for their babies.
These include all women who were 6–8 weeks postpartum and attending either the postnatal or children's welfare clinics between September 2012 and January 2013.
Ethical approval was obtained from the joint Ethical Committee of Jos University Teaching Hospital and University of Jos 10th September 2012. Permission was also sought from the various heads of the Departments/clinics. The nature of the study, the confidentiality of the information given, and the right of the women to take part or to opt out at any point without any consequences and the possible outcome of the study were explicitly explained to the women in the languages they understood to obtain their informed consent without coercion.
Instruments used to collect data
This is a semi-structured questionnaire developed to obtain the sociodemographic and clinical characteristics of the women who participated in the study. These characteristics include age, occupational status, marital status, and income. Others were number of children, educational status, ethnicity, religion, etc., clinical parameters such as mode of delivery, gender of the baby were also included in the questionnaire.
The Edinburgh Postnatal Depression Scale
This is a 10-item, self-rating screening questionnaire. When administered 6-week postpartum, it has high specificity and sensitivity in detecting postnatal depression., EPDS has good psychometric properties and was validated in a number of studies in Nigeria. Obindo and Omigbodun validated it in a Sample of 160 women in North-central, Nigeria and found a specificity of 62% and Sensitivity 72% at cutoff of 7. Similarly, Uwakwe and Okonkwo reported a 0.97 specificity and 0.75 sensitivity at a cutoff point of 9 in South-East, Nigeria. The questionnaire rates the intensity of depressive symptoms present within the previous 7 days. This scale takes <5 min to complete. The Hausa version produced through back translation was adopted for this study and was used on women who do not understand English in North-Central, Nigeria. Each item was scored on a 4-point Likert scale, (0–3) the minimum and the maximum total score being zero and 30 respectively.
The EPDS in itself cannot confirm the diagnosis of depression but at a threshold score of 12, it had a specificity of 92.5% and a sensitivity of 88% in a large community study  and this informed the choice of 12 as a cutoff point for this study.
The Structured Clinical Interview for DSM-IV AXIS I disorders
Structured Clinical Interview for Diagnostic and Statistical Manual-IV-AXIS-I disorders (SCID) is a semi-structured instrument that can be used as part of a normal assessment procedure to confirm the diagnosis in research or screening “as a systematic evaluation of a whole range of medical states” and for training of mental health personnels., The Module for Depression on SCID which provides diagnosis according to or as described in the 4th edition of DSM-IV  was used in this study. The SCID has been variously used to diagnose depression in a number of studies, for example, in the third trimester of pregnancy in South-West zone of Nigeria. It was also employed to diagnose comorbid depression in patients with diabetes and epilepsy., A patient having more than 5 or more of the symptoms of depression in the depression module of the SCID is diagnosed as having major depression in the postpartum period. The instrument has been reported to have a good reliability  with respective percentage agreement between raters to be 82% for major depressive disorders and a kappa value of 0.72. These values were reported by Riskind et al.
Method of data collection
Sample size determination
We estimated that at 95% power about 246 participants would be needed or our desired precision of 5%. The sample size was rounded up to 550 to accommodate the possibility of nonresponses and poorly completed questionnaires and also to increase the statistical power of the study.
Sampling method of data collection
The systematic sampling method was used to select participants who were 6–8 weeks postpartum attending the various clinics. All participants who met the inclusion criteria on each clinic day were sampled until the sample size was reached.
Women at 6–8 weeks postpartum who attended either clinics gave consent for the study.
In the first stage of the daily recruitment, participants were approached in the respective clinics, intimidated about the aim and objectives of the study, and informed consent was obtained. Thereafter, the sociodemographic questionnaire and the EPDS questionnaire were administered to the consenting eligible women by the research assistants. Women who scored 12 and above and 20% of respondents, i.e., 1 out of 5 with scores <12 on the EPDS were recruited for the second stage of the interview. Balloting method (“yes” or “no”) of selection was used to select women who scored <12 on EPDS for the second stage of the interview. The second stage interview involved the use of the Depression Module of the SCID by one of the researchers who was not privy to the scoring of the women on EPDS. Each woman was interviewed by the researchers in private.
Data were analyzed using the Statistical Package for Social Sciences version 20.0 (IBM corp, Armonk, New York). A weighted prevalence rate of PPD was calculated. The technique of weighting in a sample has been used by Obindo in the North-Central zone, Nigeria in validating EPDS in women in the postpartum.
| Results|| |
Sociodemographic characteristics and weighted prevalence rate of depression among participants
A total of 550 participants were recruited for the study, out of whom 531 (96.5%) women completed the questionnaires. The sociodemographic details of the participants are shown in [Table 1]. The mean age of respondents was 26.98 ± 5.97 years, with an age range of 18–45 years.
Distribution of the Edinburgh Postnatal Depression Scale among participants
The mean score on the EPDS of all participants was 5.6 ± 5.07 standard deviation with a score range of 0–25 [Table 2].
|Table 2: Distribution of Edinburgh Postnatal Depression Scale of participants in the first (screening) stage (n=531)|
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Weighted frequency distribution of the sample population
[Table 3] shows the frequency distribution of the weighted frequency of the sample population on the EPDS.
|Table 3: Distribution of weighted Edinburgh Postnatal Depression Scores of participants|
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Using the weighting method, to calculate the prevalence rate, 116 (21.8%) of the participants were diagnosed with PPD. The result is shown in [Table 4].
|Table 4: Distribution of weighted prevalence for the study group (n=531)|
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Association between sociodemographic variables and postpartum depression in all participants
[Table 5] shows the relationship between some sociodemographic variables and PPD. There was a significant association between age (χ2 = 32.80, df = 2, P < 0.001), marital status (χ2 = 12.3, df = 1, P < 0.001), educational level (χ2 = 27.19, df = 3, P < 0.001), and occupational status (χ2 = 59.63, df = 4, P < 0.001) and PPD. Participants who were older (age group 36–45 years), single, with no formal education and unemployed were more likely to have depression.
|Table 5: Association between sociodemographic correlates and postpartum depression in all participants|
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| Discussion|| |
A weighted prevalence of 21.8% was found in the study population. This figure is comparable to the findings of 23.5% by Owoeye et al. 25.7% by Abasiubong et al. in Lagos and Uyo, Nigeria, respectively., However, some studies have found relatively lower prevalence rates of PPD such as 10.7% and 14.5% as reported by Uwakwe and Okonkwo and Adewuya et al. in the South-East and South-West, Nigeria, respectively., Other studies found relative large prevalence rates than the present study. These include studies by Obindo et al. who reported a prevalence rate of 44.39% in North-central Nigeria; Kazi et al. reported prevalence range of PPD between 28% and 57% in Pakistan  while Wolf et al. reported prevalence rate of 35%–47% in Latin America. One possible explanation for the discrepancy in the prevalence rates between the current study and that of Obindo et al. may be due to the fact that their study was at a time the ethnoreligious crisis that engulfed the state was at its height  which may explain the heightened emotional responses experienced by their studied sample. On the other hand, in the present study, the state had a much relative peace which may contribute to the relative decrease in distress among participants. Depression, stress and other forms of psychiatric morbidities are known to be rife in an environment where there is crisis or war. Higher prevalence rate of PPD may not be unexpected in Jos during the period Obindo et al. carried out their study. Another plausible reason for the differences between the present study and the study of Obindo et al. may be due to the various cutoff points used in the estimation of or screening for PPD. Obindo et al. used a cutoff point of 7 on EPDS which captures the mildest form of depression as compared to cutoff point of 12 or greater which captured the severest form of depression in postpartum period. The relatively comparable rates of PPD between the present study and those of Owoeye et al. may be due to the high cutoff points used in the respective studies. In the two studies, higher cutoff points of 12 and above on the EPDS were used to screen for PPD. Cutoff point >12 is said to capture the most severe form of depression which may exclude the mild and moderate depression, thereby reducing the prevalence rate of PPD. However, this is not the case when the present study was compared with studies that used lower cutoff points <10 on the EPDS. Lower cutoff points on EPDS (as in other screening instruments) is said to pick more false positives and milder forms of the disorder as shown in the study by Obindo et al. in which a cutoff point of 7 on EPDS was used to determine the prevalence rate of PPD in the North central, Nigeria.
The age range from the studied population was 18–45 years with a mean age of 26.98 ± 5.97 years. Almost all participants were <35 years. This range fell within the reproductive age group of women and is comparable to 17–45 years and mean age of 28 ± 5.8 years obtained by Obindo et al. in their study to determine the prevalence rate of PPD of women in North-central, Nigeria. This relative young age represents the peak age of reproduction in women. Despite finding mothers' young age as an associated factor for PPD in this study, other studies found the contrary., Yet other studies reported that mothers' young age is a significant factor for PPD ,, as reported in this study. The present study revealed that there were more participants within the age range of 18–25 (35.5%) and 26–35 years (59.3%) that were having depression compared to older participants (36–45 years). One possible reason could be that the older participants may have better coping strategies than the younger participants. It is also possible that the experiences of old age in life gave them an edge over their younger counterparts. However, an early study carried out in the same area showed a contrary finding. Finding by Obindo et al. showed no significant association between age and PPD.
This study found that over 60% of the participants to be Muslims which is a contrast to what Obindo et al. reported in their study on women attending postnatal and children's welfare clinics in the same tertiary hospital. They reported that 4 out 10 of their studied participants to be Muslims. The reasons for such a wide difference could be partly associated with the fact that at the time of the present study, the location of one of the arms of children's welfare clinic is at the old site of the tertiary hospital, which is in a Muslim populated area (Gangare Area) and very few of the Christians access health services at the old site of the hospital. The split may have been necessitated by the ethnoreligious crisis that had raptured the various areas within the state (Plateau) along ethnoreligious divide. In a similar vein, 5 in 10 of the participants were Hausas and over half had Islamic marriage.
Religious affiliation has been shown in a study by Obindo et al. with PPD, but our study found the contrary. Not finding such association in our study is not surprising because Obindo et al. reason for their finding was based on an anecdotal evidence suggesting that degree of cohesion and involvement in religious activities determine the stability of an individual and it has a buffering effect to lower the percentage of depression.
Almost all the participants were married and a higher proportion (61.5%) among the single participants had depression compared to the rate of depression (20.8%) among married participants. Marriage is a culturally acceptable norm of raising a family within the study area. Being married in the African context makes a woman more acceptable and respected. Marriage, from the cultural point of view may boost her “self-esteem” which is often lacking in women that are single and pregnant when compared with pregnant women who had delivered babies in the “legitimate way.” Women who may have been stigmatized because of illegitimate deliveries may experience the triad of negative distortion (negative feeling about self, the world, and the future) which is often experienced by patients with depression. The demands of coping with the needs of a new baby may often be stressful and difficult for both young and single mothers. Young mothers may have less coping strategies for the ever demanding needs of the new baby and how to fend for the baby. Single mothers are often not economically and/or educationally advantaged in the society. They are often not given the same economic or educational opportunity given to others to develop their potentials. This may be associated with depression in single mothers. However, this in contrast to what Obindo et al. found in their study in which marital status was not significantly related to depression.
Over 80% of the study population had a minimum of secondary school education with about a third (30.5%) having tertiary education. The studied population were better equipped to be engaged in health-related activities such as reproductive health education and enlightenment. With higher level of education, a woman may easily be informed about choices on things that may improve her health status. She may assimilate faster the principles of health-related quality of life interventions than those that have no formal education or are less educated. Those with no formal education were more likely to be depressed than those with any form of education. This finding is similar to reports from Lebanon and Canada in which studies found a significant relationship between low level of educational and PPD.,, However, there are contrast findings in other studies. For example, Goker et al. found no significant association between low level of education and PPD. Educational level may be directly linked to household income and in turn linked to a woman's ability to take care of her home. The inability of a woman to take care of her home may affect the woman's concern about taking care of her newborn baby and this concern may be a source of distress, which is associated with depression. In the setting of our environment, the spouse is expected to be the breadwinner of the household, and it is his sole responsibility to take care of the household and not the woman. However, times have changed, and we are living in a changing world where some women are beginning to take up the role of a bread winner  and they may feel inadequate with limited resources which may be linked to the level attained in education to execute such responsibilities.
| Conclusions|| |
The study showed that the calculated weighted prevalence of PPD in participants attending either the postnatal or the children's welfare clinic in a tertiary hospital was 21.8% and this is relatively low after a period of relative peace.
Limitation and strength of the study
The cross-sectional design of this study limits the inference to causal direction, but one strength lies in the use of standardized instruments to assess depression status (EPDS and SCID) in participants.
Future research is needed to tease out the prevalence of PPD in other crisis-prone areas with the hope of instituting measures that will curb the incessant ethnoreligious crisis.
We acknowledge the Departmental Heads of Obstetrics and Gyneacology, and Community Medicine of Jos University Teaching Hospital for the permission granted us to carry out the study, the staff of the two departments and the women whose cooperation and understanding made the study possible.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]