Prevention of Postnatal Depression in Low and Middle Income Countries

Yeling Zhao, B Pharm, MPH Department of Public Health, University of Sydney yeling.zhao@gmail.com

Prevention of Postnatal Depression in Low and Middle Income Countries

Introduction Postpartum depression (PPD), affects 10% to 15% of mothers, is defined as a condition that affects women who have had a baby recently1,2. For 15% to 85% of mothers, it occurs within the first 10 days after their deliveries, with a peak incidence at the fifth day3. Although studies of perinatal mental health problems have been conducted in more than 90% of high income countries, the statistics is available only 10% in low and middle income countries4. A number of factors have been identified to contribute to the severity of the depression in terms of psychosocial and biological ones. Postpartum blues can have significantly negative impacts on women themselves and their families, as well as the child development. In most low and middle income countries, PPD is still not easily recognized and treated, whereas the obstetrician and pediatrician can serve significant roles in screening and treating it1. Findings from several preventive interventions have shown positive effects. The assignment begins by summarizing our group presentation. It moves on to present prevalence, risks factors and consequences to women with maternal mental health problems and their infants, in low and middle income countries. What follows are the methods of preventive interventions. The assignment ends with conclusions and recommendations for the focus of future research and services. Summary of Group Presentation At the beginning of our group presentation, we introduced the background of postpartum depression briefly, followed by the epidemiology in both high income countries and low and middle income countries. Then, the tools of screening and diagnosis of PPD were presented. After that, we moved to the methods of prevention and treatment, and the effects not only on mothers but also on infants. In order to explain this part clearly, two cases from Fiji and Mexico were used as examples. Finally, we discussed how postnatal depression contributes to Global Burden of Disease (GBD), and how it relates to Millennium Development Goals (MDGs). Epidemiology of Postpartum Depression Methods of epidemiology have been used to investigate the incidence and prevalence of PPD. Studies conducted in 90% high income countries indicate a prevalence of 10% to 15% of perinatal mental problem5,6. However, recent research conducted in low and middle income countries have illustrated that these problems are in range of 10% to 41%; relying upon the place, the perinatal period studied and the instruments applied7. Table 1 presents a summary of these studies conducted with pregnant women in Nigeria with prevalence rates ranging from 14.6% to 32.2% during the period from 2005 to 2006. Table 2 provides the percentage of pregnant women who have anxiety disorders in low and middle income countries. Table 1: Psychiatric and psychological morbidity in the postpartum period in Nigeria Author (s), year Sample Size Results
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Prevention of Postnatal Depression in Low and Middle Income Countries

Adewuya, Afolabi (2005) 8 632 32.2% anxiety and/or depression 9 Adewuya AO, et al (2005) 876 14.6% EPDS* >= 9 10 Abiodun O, et al (2006) 379 18.6% EPDS >= 10 11 Owoeye A, et al (2006) 252 23% EPDS >= 12 * EPDS: Edinburgh Perinatal Depression Scale (see Annex1) Table 2: Psychiatric and psychological morbidity in the low and middle income countries Author (s), year Country Sample Size 12 Patel V, et al 2002 India 270 13 Rahman A, et al 2003 Pakistan 632 14 Limlomwongse N, et al 2006 Thailand 610 15 Rochat TJ, et al 2006 South Africa 242 **GHQ: General Health Questionnaire postpartum period in Results 42% GHQ** > 5 25% depressive episode 41% EPDS >= 13 41.6% EPDS >= 6

These studies illustrate that not all percentages mean the same level of problem, due to different concepts of psychological distress and different screening instruments and standards employed. Moreover, they provide convincing evidence that women across all over the world are more likely to experience postnatal blues symptoms than at other period of their pregnancy. Furthermore, even though the screening is not fully adopted in most low and middle income countries, the prevalence on them is much higher than those in high income countries. Risk Factors of Postpartum Depression A number of risk factors could contribute to the high prevalence of mental health problems during the perinatal period, ranging from biological to psychological and social determinants. Biological Factors In susceptible women, rapidly declining reproductive hormone levels and neurochemical modifications may contribute7. Moreover, family history of mood disorders and past episodes of depression (not necessarily related to pregnancy) also could increase the risks of mental health problems during the delivery period16. Psychological Factors Main factors in this area could be stressful life or life events (pregnancy as a result of rape), domestic violence or abuse, as well as the personality types and ways of thinking7. Social Factors Some of these factors include adolescent pregnancy, unwanted or unintended pregnancy; poverty, socio-economic hardship, lack of support pre/post delivery, marital or love relationship difficulties, and the infant health and temperament2,16.

Prevention of Postnatal Depression in Low and Middle Income Countries

Impact of Postpartum Depression A number of studies have investigated the adverse effects of postnatal depression on both mothers and infants outcomes. Impact on the women Economic losses Only distinguishes 3 classes of mental health disorders: mood disorders (unipolar depressive disorder), schizophrenia, and specific anxiety disorders among women of reproductive ages (15 44 years). The potential economic losses are intangible. This is because the human suffering and the total impact on physical disorder are conceptually and methodologically difficult to estimate. 7 Maternal suicide Research conducted in high income countries has shown that the leading cause of death during the perinatal period was suicide. The rates of these are significantly higher than in non-pregnant, non-puerperal women. Risk factors of this include adolescent pregnancy and self-induced abortion7 17. Unfortunately, the situation in low and middle income countries does not seem to be better. A study, conducted in several provinces in Vietnam in 2000, found that high percentage (8% to 16.5%) of suicide is among women in the perinatal period18. Similar results were found in Harynan of India in 2004, 20% of deaths of mothers after births were attribute to suicide19. Impact on newborns The impact of postnatal depression on infants has been studied in high income countries, mostly in terms of neuropsycho-behavioral variables, the similar patterns are shown in low and middle income countries as well. Numerous studies conducted in India and Vietnam have illustrated that neonates nutritional status can be affected by a mother with high anxiety levels during pregnancy; and the risk of child diarrheal illness can be increased dramatically20,21. In terms of mental development, infants of depressed mothers often have lower regulation of emotional states, poorer motor performance, and lower mental developmental scores at the age of 2 years22,23. Moreover, the electroencephalogram of infants born from depressed mothers demonstrates that they have neurotransmitter imbalances and dysregulations affecting their behavior and physiology 24-27. In sum, depressed mothers can not build a healthy relationship within their infants, incurring in negative impacts on them. Studies have shown that the impacts of PPD on children are wide ranging and affect physical, cognitive, social, behavioral and emotional development. Moreover, the effect is far beyond the time of the depression, it continues to impact children into toddlerhood, the preschool years and beyond.

Prevention of Postnatal Depression in Low and Middle Income Countries

Prevention of Postpartum Depression Due to the multi-aspectual impact of postpartum depression, it has led to increased attention to interventions designed in order to prevent onset of the disorders before it develops. Preventive interventions initiated during pregnancy Family planning Almost half of pregnancies worldwide are unintended or adolescent pregnancies. A number of studies have shown that unwanted pregnancies can increase the risk of postpartum depressive symptoms, as well as major depression in diverse culture context28. Moreover, partners could also serve an important role in secondary prevention of risks to offspring29. However, no studies can ascertain the direct relationship between family planning interventions and reduction in postnatal depression risks. Social support Insufficient social support is highly associated with the postpartum depressive symptoms, especially in low and middle income countries30. Most studies conducted in those areas have found that they can reduce the risk of postpartum depression and the stress on it31. Moreover, the outreach by public health nurses or midwives could be one of the most effective interventions that provide directly support to mothers with postpartum depression32,33, strategies to reduce poverty and domestic violence, and to promote equity of participation in education and income-generating occupations for women. However, some randomized controlled trials of preventive social support interventions have provided ambiguous results. This is because none a sustained, long term preventive effect nor short term preventive effect have been shown directly. Physical activity Some studies among animals have demonstrated that aerobic exercise can protect neurons from toxic effect of stress, leading to less depression-like behavior of them34. What is not clear is whether a similar preventive effect could occur in humans; however, studies still suggest that more physical activities during pregnancy period could contribute to reducing the risk of postpartum depression symptoms28. Researchers from American proposed that 30 minutes moderate exercise every day could benefit pregnant women for postnatal depression35. Preventive interventions initiated postpartum Nutrition support Certain nutrients serve an essential role in biosynthesis and normal functioning of monoamine neurotransmitters. For example, Omega-3 essential fatty acids (n-3 EFA) are particularly important in reducing perinatal depression symptoms. This results from their ability to promote- amino butyric acid receptor binding36 and reduce inflammation37. In addition, it has been shown that iron deficiency anemia can
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Prevention of Postnatal Depression in Low and Middle Income Countries

increase the risk of postpartum depression; whereas taking prenatal vitamins with folate has not been demonstrated that it results in reducing postnatal depression risks38,39. Risk assessment and screening28 Clinical assessment could be the best primary intervention for early identification of women with risk of postpartum depression symptoms, due to the absence of widely validated screening tools. Essential elements of a clinical assessment could be: history of depressive episodes, family history, current and past stressors etc. Moreover, early and effective detection and treatment of postnatal depressive symptoms could be a key to secondary and tertiary intervention. There are two screening tools, which have been validated extensively and used frequently: Edinburgh Perinatal Depression Scale and Patient Health Questionnaire-9. Other preventive interventions Anti-depression medication Preventive medication for anti-depression is likely to be indicated for women who have a family history of medication-responsive major depressive episodes28. Clinical trials, in terms of randomized double-blind ones and placebo-controlled ones, have demonstrated that a dramatic decline in postpartum recurrence of major depression40. However, two important questions are requiring more clinical trails to be conducted: time to begin the medication and duration of the preventive treatment. Conclusions and recommendations Postpartum depression, a condition that affects women who have had a baby recently, has become a global public health problem. Although the screening has not been fully adopted in most low and middle income countries, the prevalence on them is much higher than those in high income countries. The risk factors for this could range from biological to psychological and social determinants. The adversely effects not only on women themselves, but also on their children; which can be lifelong with delay in growth and development in both physical and mental. Researchers should conduct more epidemiological studies of PPD, as they provide important information to identify more risk factors, which could be helpful in informing decisions about health care services. In most low and middle income countries, there is a lack of awareness about womens mental health in the perinatal period and its impact on child health and development. Thus, community-based intervention should be widely encouraged, in terms of family planning, social support. Moreover, to be able to develop low-cost non-stigmatizing and accessible interventions, is essential to have local evidence concerning the nature and prevalence of the problem. Furthermore, need integration between mental health care and primary perinatal health care, as well as strategies to reduce poverty and domestic
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Prevention of Postnatal Depression in Low and Middle Income Countries

violence, and to promote equity of participation in education and income-generating occupations for women. In addition, further studies - in terms of pharmacotherapy, neuro-protection, neuro-modulation, and neuro-feedback should be recommended. Finally, approaches must include research, education, community-based interventions, health service development, health system strengthening and social policy formation. The acceptability of interventions should be considered, as many women would have concerns about using medication or other agents if pregnant or breastfeeding.

Prevention of Postnatal Depression in Low and Middle Income Countries

Annex 1

Prevention of Postnatal Depression in Low and Middle Income Countries

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34. Marais L, Stein DJ, Daniels WMU. Exercise increases BDNF levels in the striatum and decreases depressive-like behavior in chronically stressed rats. Metabolic brain disease 2009;24:587-97. 35. Heh SS, Huang LH, Ho SM, Fu YY, Wang LL. Effectiveness of an exercise support program in reducing the severity of postnatal depression in Taiwanese women. Birth 2008;35:60-5. 36. S gaard R, Werge TM, Bertelsen C, et al. GABAA receptor function is regulated by lipid bilayer elasticity. Biochemistry 2006;45:13118-29. 37. Kendall-Tackett K. A new paradigm for depression in new mothers: the central role of inflammation and how breastfeeding and anti-inflammatory treatments protect maternal mental health. International Breastfeeding Journal 2007;2:1746-4358. 38. Corwin EJ, Murray-Kolb LE, Beard JL. Low hemoglobin level is a risk factor for postpartum depression. The Journal of nutrition 2003;133:4139. 39. Cho Y, Han J, Choi J, et al. Prenatal multivitamins containing folic acid do not decrease prevalence of depression among pregnant women. Journal of Obstetrics & Gynecology 2008;28:482-4. 40. Wisner KL, Perel JM, Peindl KS, Hanusa BH, Piontek CM, Findling RL. Prevention of postpartum depression: a pilot randomized clinical trial. American Journal of Psychiatry 2004;161:1290.

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