Assessing prevalence and determinants of PPD Pakistani population

30/9/2007WHO study on PPD for urban and rural

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Assessing prevalence and determinants of PPD Pakistani population

Presenter: Dr. Rozina Farhad MistryAga Khan Health Service Pakistan


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PAKISTAN-SHARE OF THE WORLD 2005

POPULATION: 153 MILLION ( 2.37%)

WOMEN IN RH GROUP: >33 million

CHILDREN IN <5: >22 million


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Countries HDI Countries HDI

Canada 4 China 94

United States 8 Kyrgystan 110

Cyprus 30 Sao Tome 123

Poland 37 India 127

Mexico 53 Ghana 131

Brazil 72 Cameroon 141

Georgia 97 Pakistan 142

Peru 85 Bangladesh 138

Turkey 88 Sierra Leon 177

Ecuador 100

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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University ofCentral As ia

The Aga KhanUniversity

IMAMAT

THE AGA KHAN DEVELOPMENT NETWORK

Economic Deve lopment CultureSocial Development

Age Khan Fund forEconomic Development

Aga KhanFoundation

The Aga Khan Trustfor Culture

Tour ism PromotionServices

IndustrialPromotion Services

Aga KhanEducation Services

Aga Khan Awardfor Architecture

Historic CitiesSupport Programme

Fi nancialInstitutions

Aga KhanHealth Services

Education andCulture Programme

Aga Khan Building andPlanning Services

Aga Khan Program for Is lamic Architectureat Harvard University and Massachuset ts

Institute of Technology


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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.

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.

Research Questions


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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

WHY?WHY?????

WHY?WHY?????

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 .

In the absence of Rx, PPD can get worse and last for as long as a year.

PPD is a serious condition, it can be effectively treated with antidepressant medications and counseling

PPD has consequences for the physical and psycho-social development of children.

Infants show growth retardation at several time points in the first year of life


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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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Biological factors

Socio environmental

factors

Obstetric related factors

Post Partum Depression

Impact On maternal

Health

Impact onGrowth outcome

of Children

CONCEPTUAL FRAMEWORK

Child related factors


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• 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).

STUDY DETAILS


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Actual sample surveyed Total: 1256Urban: 720Rural : 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

RESULTS


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General Socio-demographic charecteristics of the population

26.51

2.23

1.98

1.95

8.07

21.94

26.8

3.07

2.87

2.77

11.13

18.84

0 5 10 15 20 25 30

Age in years

Number of Pregnancies

Number of Live Births

Number of alive children

Persons in the house

Age at marriage

Rural

Urban


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61

191 195197

166

83

221

57

5 8

72

00

50

100

150

200

250

Ultra Low Low Middle High Don’tKnow

Noresponse

Comparative analysis of socio-economic status

KarachiNorth


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Method of assessing nutritional status

% Malnourished

Urban Area

n=720*

Rural Area

n=536*

Overalln=125

6*

Weight for Age Z-scores % < -2

o 95% CI

3.3%(2.2, 5.0)

1.3%(0.6, 2.8)

2.5%(1.7, 3.5)

Weight for Length (height) Z-scores

% < -2o 95% CI

4.5%(3.1, 6.3)

2.2%(1.1, 4.3)

3.7%(2.7, 5.0)


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31%

40%

19%

9%

1%

0% 5% 10% 15% 20% 25% 30% 35% 40%

Immediately afterdelivery

Within first 2 hoursof delivery

Within first 24hours of delivery

After 24 hours ofdelivery

Never breast fed

Breast feeding practice in the combined sample


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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 <0.05 was considered significant


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Prevalence of depressive symptoms

650

70

475

61

0

100

200

300

400

500

600

700

800

Urban Rural

Developed PPD

Not developed PPD

(11.4%)

(9.7%)


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21.8

19.5

20.6

18

18.5

19

19.5

20

20.5

21

21.5

22

Urban Rural Combined

Family history of depression

Percentages

OR=2.66P<0.001


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Variables Total Positive (%) OR P-value

Any health problem during ANC

YesNo

157 (12.5)1099 (87.5)

15.39.7

1.67 0.033*

Delivery assisted byUnskilled Skilled

128 (10.2)1128 (89.8)

16.49.8

1.82 0.029

Place of deliveryHomeHospital/ Clinic

141 (11.2)1115 (88.8)

15.69.8

1.71 0.033*

Complications during deliveryYesNo

237 (18.9)1019 (81.1)

19.48.3

2.64 < 0.001*

Type of deliveryCaesarean section Vaginal delivery

216 (17.2)1040 (82.8)

14.49.6

1.58 0.038*

OBSTETRIC RELATED CONTRIBUTORY FACTORS OF PPD


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SOCIO-ENVIRONMENTAL CONTRIBUTORY FACTORS OF PPD

Variables Total Positive (%) OR P-value

Husband/ family feelings about pregnancy

Upset Happy

14 (1.1)1242 (98.9)

28.610.2

3.51 0.049

Personal feeling after deliveryStressful Relaxed

28 (2.2)1228 (97.8)

08 28.610.0

3.59 0.006*

Performing daily workingStressfully Calmly

619 (49.3)637 (50.7)

24.36.1

1.33 < 0.001*

Support from Husband /Others in daily work

HusbandOthers

466 (37.1)790 (62.9)

38 (8.2)93 (11.8)

1.50 0.042

Breast feedAfter 24 hours Within 24 hours

119 (9.5)1137 (90.5)

16.89.8

1.87 0.017*

Gender of babyGirl Boy

615 (49.0)641 (51.0)

12.28.7

1.45 0.045*


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Child related contributory factors of PPD

Variable

Mother with PPD

Mothers without PPD

p-value(n=131) (n=1124 )

Mean Birth Weight of babies (kg.) 2.91 3.02 0.01*

Mean Current Weight (kg.) 4.22 4.37 0.03*

% of mothers reported illness of their baby during preceding 2

weeks

47 % 26 % <0.001


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Comparison Of Significant Contributory Factors Of PPD Between Rural And Urban Cohorts

9

21.8

15.6

12.5

14.6

24

14.1

18

13.9

19.5

13.8

24.8

12.5

25.4

25.9

16.4

0 10 20 30

Low S.E. structure

F.H. of depression

Any health problems duringANC

Complication during delivery

Operative delivery

Stressful routine w orking

Breast feeding >24 hours

Baby suffering from illness

PercentageRural

Urban

0.126

0.746

0.891

0.560


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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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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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• 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 baby’s age.

CONCLUSION


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RECOMMENDATIONRECOMMENDATION


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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 >12 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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• 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

Acknowledgment


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Assessing prevalence and determinants of PPD Pakistani population

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