Background
Historically, pregnancy is a time of enjoyment and fulfillment for women. However, evidence indicates that there is an increase in psychiatric morbidity, particularly depression and anxiety, during this period [
1]. Depressive symptoms during pregnancy may have devastating consequences, not only for the women, but also for the child and family [
2]. Antepartum depressive and anxiety symptoms (ADS and AAS, respectively) can lead to postpartum depression [
3,
4], lower birth weight, and premature delivery [
5], and have a negative impact on child development [
6,
7].
A meta-analysis of 21 studies reported the mean prevalence of ADS to be 12% in high-income countries [
8]. Yonkers et al. reported the prevalence of AAS to be 24% [
9]. Studies in high-income countries suggest a link between disadvantaged socioeconomic background, domestic violence, and ADS and AAS [
5,
8].
Despite World Health Organization (WHO) estimates that depressive disorders will be the second leading cause of global disease burden by 2020 [
10], only a few studies on ADS and even less on AAS have been conducted in low-income countries. Two community-based studies of pregnant women in Pakistan found that 18% were anxious and depressed [
11] and 25% were depressed [
12]. The prevalence of depression during the third trimester was about 16% among South Indian women [
13]. The predictors of antepartum depression and anxiety in Pakistan were husband's unemployment, low household wealth, 10 or more years of formal education, unwanted pregnancy, and partner violence [
11]. In a study in Nigeria, socioeconomic and obstetric factors were not found to be associated with ADS and AAS [
14]. Age at current pregnancy and at first delivery, obstetric complications, having no friends in the community, living in a crowded household, lower occupational status, and history of previous psychiatric disorder were found to be associated with common mental disorders in Brazil [
15]. Depression and anxiety during pregnancy are rarely reported in Bangladesh. One study involving 316 pregnant women in a rural subdistrict in the southwest part of Bangladesh found a 33% prevalence of ADS [
16]. The study reported that partner violence, unsupportive husband and/or mother-in-law, and family preference for son were predictors of antepartum depression. The few studies and partly inconsistent results emphasize the need for further research on antepartum depression, particularly antepartum anxiety among women in low-income countries. This study aims to examine and identify the prevalence of potential contributors to antepartum anxiety and depressive symptoms among women in a rural area of Bangladesh.
Discussion
The main finding of this study suggests that ADS is prevalent in almost one in five women, and AAS in one third of the women, in the last trimester of pregnancy in a rural area of Bangladesh. The women's literacy, their poor household economy (anxiety only), poor relationships with husbands, and partner violence showed strong associations with ADS and AAS. A previous history of depressive symptoms was found to have the strongest association with ADS.
The prevalence of ADS (18%) and AAS (29%) are in agreement with previous reports from both high-income countries (ADS 12% [
8], AAS 24% [
9]) and low-income countries, with 20% in Pakistan (both ADS and AAS) [
11], and 10%-20% in Brazil [
25,
26]. A previous study in Bangladesh had reported a higher prevalence of ADS, 33%, which may be due to a recruitment of women at a later stage of pregnancy, in this case 34-35 weeks, compared to the current study [
16]. The prevalence of depression may be affected by the time point in pregnancy at which symptoms are assessed [
8], types of instrument used i.e. use of standard clinical interviews or screening tools [
27], and different cut-off points on screening tools [
28]. For instance, the higher prevalence of antepartum anxiety (54%) and depressive (37%) symptoms reported in Hong Kong compared to our study may be due to that the sample was selected from an antenatal clinic who went through screening interviews using the Hospital Anxiety and Depression Scale which was developed especially for medical patients [
29].
The direct association between poverty and depression is well documented in high-income countries [
30,
31], and the evidence based on this association from low-income countries is growing [
32]. A recent study in Pakistan found a positive association between lower household wealth and antepartum depression/anxiety [
11]. The relationship between poverty (indicated by low level of education, minimum wage, low household income, and husband's unemployment) and mental disorder have been elucidated in a recent review of studies from six low- and middle-income countries [
33]. This association was also observed in our data in cases of AAS, but not for ADS. Bangladesh is a socially disadvantaged country where 40% of the population lives below poverty line [
34]. Poverty may be a general source of anxiety for pregnant women in terms of the family's growing financial needs with the increased number of children and the need to ensure food and education for the children. However, because of the homogeneity of poverty, this does not necessarily lead to depressive symptoms among women expecting a new member of the family.
The positive effect of literacy was pronounced in our study on the outcomes of both ADS and AAS and is consistent with the findings from Brazil, Chile, Indonesia, and Pakistan [
33]. Literate women may have good social networks and social support, which has been identified as a protective factor in previous research [
35]. Francis et al [
36] and Weiss et al [
37] explain that literacy gives individuals a sense of improved self-esteem or self-efficacy, enhances their feelings of self-worth, diminishes feelings of shame, and in turn, reduces depressive and anxiety symptoms. In contrast, a U.S.-based study highlighted education as a risk factor, explaining that highly educated individuals are more sensitive to and/or are not embarrassed about admitting depressive symptoms [
38]. Consistently with previous research, a history of previous depression was a significant contributory factor for the development of perinatal depression [
35,
39].
Bangladesh has one of the highest rates of violence in the world [
40]. Of the women in the current study, 34% reported being abused physically by multiple (three or four) acts and 80% sexually (forced into having sex) by their husbands, results that compare well with the level of violence (two fifths) among rural women found in another study in Bangladesh [
41]. Yet only about a quarter of the women reported poor relationships with their husband in general. It is reported in previous research that rural women in Bangladesh do not necessarily recognize certain acts (such as a slap or shove) as violence and that such violent behavior is considered to be the husband's prerogative [
42]. Hence, the single acts of violence reported by 70% of the women in this study may be viewed by them as corrective punishment by their husband [
43]. A WHO multicountry study indicated that 50%-90% of the women accepted violence by their husbands under certain circumstances as normal, such circumstances being if a woman goes out without informing her husband, neglects their children, argues with him, refuses to have sex with him, or burns the food [
19]. Gender-based violence has been described as the single most important predictor of depression [
44] and anxiety [
11] in women. This evidence is well documented in high-income countries [
31] and is growing in low-income countries [
11,
16,
25]. Violence during pregnancy results in adverse consequences for fetal and maternal survival [
25]. The current study identifies intimate partner violence, particularly physical violence, as contributing to ADS and AAS, and violence during pregnancy as contributing to AAS. Our findings also strengthen the results of the only study in Bangladesh identifying partner violence and partner relationship as predictors of ADS [
16]. Despite the relatively low percentage of women reporting poor relationships with their husbands particularly in terms of the prevalence of intimate partner violence, this study shows that poor marital relationship does have a significant impact on reporting both ADS and AAS. An even more pronounced effect was observed in the case of AAS, when poor partner relationship interacted with poor household economy.
This study identified practical support from the mother-in-law and husband as protective against anxiety and depressive symptoms among pregnant women. These findings reflect the observations of other researchers that family/social support during pregnancy plays a significant role in predicting women's emotional status in the antepartum period [
45]. Support from family members may be of special significance in the context of traditional South Asian societies. In these societies, the newlywed couple usually becomes part of the husband's extended family, including his parents and siblings. Rarely do couples set up homes of their own. In such cases, the newlywed woman's mother-in-law is the matriarch who holds effective power and control over household matters. Under her guidance and supervision, the daughter-in-law is expected to carry out all instructions and household chores [
46]. In this context, receiving support from the mother-in-law is a sign of approval and a source of confidence and, hence, protective against antenatal depressive and anxiety symptoms.
The current study has utilized a widely used and locally validated scale to measure postpartum depressive symptoms [
22] that is also routinely used in the antepartum period and in clinical and community settings [
21]. However, the anxiety scale used in the study is not validated for low-income countries such as Bangladesh; thus, the STAI was used as a continuous scale in a linear regression. The cutoff at a ≥45 percentile in the study to report prevalence is similar to that used in high-income countries [
24]. A further limitation of the study is that it was conducted in two subdistricts of rural Bangladesh and does not represent the urban scenario. Although the findings cannot be generalized even for other rural areas of the country, the community-based sample is likely to be indicative of the situation among rural women. As the study was cross-sectional in nature, issues related to causality cannot be addressed. Additionally several important variables were not controlled for, such as physical illness, gynecological morbidities, previous infertility, complications during pregnancy (hypertension, preeclampsia, bleeding), and smoking. It is very difficult to set a cutoff for any psychological state because of its subjective nature which may over- or under-report the prevalence of ADS and AAS. In the case of reporting physical violence, women may not have reported the actual scenario due to its sensitive nature.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
All authors (HEN, ZNK, YF, ME) participated in the planning and conception of the research questions and the study design. ME was the principal investigator of the study and primarily conceptualized the research. HEN was responsible for data collection, and HEN and ME were responsible for analyzing the data. HEN drafted the article, and all authors participated in interpreting the data and revising the manuscript. All authors read and approved the final manuscript.