Antenatal depressive symptoms and utilisation of delivery and postnatal care: a prospective study in rural Ethiopia

Depressive disorders constitute a public health challenge that contributes a substantial proportion of years lived with disability, globally [1, 2]. In World Health Organization (WHO) Global health estimates, depressive disorders were single largest contributors to non-fatal health loss with more than 80% of this non-fatal disease burden in Low and Middle Income Countries (LMICs) [3]. In the general population, depression is associated with a number of adverse impacts, including poorer quality of life [4], physical ill-health [2, 4], reduced adherence to medical recommendations [5, 6], increased use of health care services [7] arising because of increased medically unexplained symptoms [5], reduced social support, increased worries [8], co-morbid illness [5], and increased health risk behaviours and reduced self-care [9].

Among perinatal women, depression is additionally associated with particular adverse public health consequences [2, 10‐14] such as adverse effects on perinatal outcomes and the growth, health and development of the child [1, 15, 16], as well as adverse effects on maternal health. During pregnancy, depression has multiple negative effects independent of postnatal depression [1, 15, 16] and is highly prevalent, with estimates ranging from 10 to 20% [17‐22] worldwide, while higher prevalence levels are reported in LMICs (20%–39%) [17, 18, 23‐27]. Most maternal deaths (99% of global maternal deaths) occur in LMICs [28, 29] due to undetected and/or inadequately treated complications such as infection, haemorrhage, unsafe abortion, hypertension and obstructed labour [28, 30‐33]. These complications are mostly preventable by improving the uptake of maternal health care services [34, 35] in general, and through the improvement of skilled delivery in health care facilities, in particular [36‐40]. The WHO has proposed skilled institutional delivery as a key strategy towards reducing maternal deaths across the globe [41].

Established factors associated with institutional delivery in Ethiopia are higher levels of education for the woman [34, 37, 38, 42‐44] or her partner [29, 34], better socioeconomic status [43], urban residence [34, 37, 38, 43, 45, 46], previous experience of attending antenatal care [34, 37, 43, 47], increased women’s autonomy [48, 49], media exposure, and prior experience of obstetric complications [50, 51]. However, the impact of maternal depression on women’s use of maternal health care has received little attention in the literature. The authors were only able to identify one relevant study from Ghana [22] where no association was found between antenatal depression and uptake of institutional delivery, although the analysis did not control for important confounders, such as comorbid medical conditions and obstetric complications.

Investigating the potential impact of antenatal depressive symptoms on uptake of delivery care and postnatal care utilisation is essential to design future intervention strategies in LMIC settings, where perinatal outcomes are poor [52] and prevalence of antenatal depressive symptoms high [19, 21]. We hypothesized that antenatal depressive symptoms would, independent of socio-economic and demographic factors, reduce uptake of institutional delivery and postnatal care due to several behavioural features associated with depression: loss of motivation and interest in common activities including self-care [9]; reduced social support [8], increased cognitive deficit to make decisions and evaluate alternatives [53] and reduced adherence to healthcare practitioner recommendations [5, 6]. Thus, improved detection and treatment of antenatal depressive symptoms, albeit not prioritized [54], is hypothesized to shift these behavioural manifestations and thus increase rates of planned institutional delivery and improve maternal and perinatal outcomes.

Thus, this study aimed to investigate prospectively the association between women’s antenatal depressive symptoms, uptake of institutional delivery (planned and unplanned), and postnatal care utilisation after controlling for socioeconomic, demographic, obstetric and medical factors.

From a baseline of 1311 pregnant participants, a total of 1251 women were prospectively interviewed (n = 1240 face to face and n = 11 by phone) about their delivery setting, method of delivery and postnatal care utilization with a response rate of 95.5% (Fig. 1). Women who were in the baseline sample were not significantly different from women who were in the follow-up sample with respect to selected baseline variables (Table 1).

In this prospective, population-based study from rural Ethiopia, 28.7% of pregnant women were screened to have symptoms of depression. These women had significantly increased odds of unplanned utilisation of institutional delivery care, mostly due to emergency presentations rather than planning to deliver in a healthcare facility. Assisted delivery was also significantly greater in women with antenatal depressive symptoms.

Overall, the prevalence of antenatal depressive symptoms in our study is consistent with studies in Ghana (26.3%) and Cote d’Ivoire (28.3%) which used the same measure [18, 23]. Studies in South Africa [25], Vietnam [17] and Southern Brazil [24] using other screening tools (Self-Reporting Questionnaire and Edinburgh Postnatal Depression Scale) also reported rates of antenatal depressive symptoms of 30–39%.

Prior to the introduction of the health extension programme [71], and until 2011, institutional delivery rates in Ethiopia were very low [52]. Recent trends indicate improving rates, especially in southern Ethiopia, with nearly 50% of women in community-based samples, and nearly three-quarters of women in urbanized areas delivering in health facilities [72‐74]. Our study finding that over 60% of women deliver in an institution is in-line with this positive trend.

We hypothesized that antenatal depressive symptoms are associated with a reduction in women’s uptake of institutional delivery through reduced self-care, social support and reduced women’s adherence to healthcare practitioners’ recommendations. In contradiction with our hypothesis, we found a significantly increase in uptake of institutional delivery among women with antenatal depressive symptoms independent of pregnancy complications and comorbid medical conditions. Increased emergencies related to labour complications might explain this contradiction.

The increased odds of assisted delivery and uptake of unplanned institutional delivery among women with antenatal depressive symptoms supports others’ findings that women with depressive symptoms have an increased risk of labour complications [11, 75‐77]. We found the main reasons for institutional delivery of women with antenatal depressive symptoms to be emergencies related to labour complications endorsed as ‘prolonged labour’ and or ‘referral due to labour complications’. Our findings reflect those of a study in Ghana where antenatal depression was associated with assisted delivery and other perinatal complications, including prolonged labour, vaginal tears, loss of consciousness, heavy vaginal bleeding, surgery to repair or remove the womb and blood transfusion [22]. Similarly, a previous community based cohort study in Ethiopia [14] and studies in China [78] and Ghana [22] demonstrated that antenatal depression was associated with prolonged labour or non-progressive preterm contractions [76]. Studies in Peru [79] and in Finland [80] also demonstrated increased odds of preeclampsia among women with antenatal depression while studies in California [77] and Canada [76] demonstrated increased odds of infection among this group of women. These perinatal complications are thus, more likely to increase unplanned institutional delivery and assisted delivery among women with depressive symptoms. There are also biological explanations for the association of depression with perinatal complications. In these explanations, depression is purported to hyper stimulate Hypothalamus-Pituitary-Adrenal (HPA) axis to produce hormones that have adverse effects on the uterine environment [81‐83].

Furthermore, studies have demonstrated that women with antenatal depressive symptoms are more likely to have somatic complaints, co-morbid medical conditions [6, 84] and other perinatal complications [12, 14, 85, 86] as well as increased fear of childbirth and worries about death and survival during labour [8, 87] which may increase the likelihood of institutional deliveries in this group.

Our study showed that rural residence was associated with reduced odds of institutional delivery and reduced odds of having assisted delivery, while increased access to health care was associated with increased odds of institutional delivery and having an assisted delivery. These results support consistently findings from others’ work [34, 37, 38, 43, 45, 46, 73, 88, 89]. Increased parity was associated with reduced odds of institutional delivery and assisted delivery, which is also consistent with other local studies [45, 46, 88, 89]. This may be due to decreased likelihood of prolonged labour with increase in parity.

The strength of our study is that it was prospective and used a locally validated measure of depressive symptoms. Selection bias was also minimized in this population-based study as a robust method was used to identify all cases during the study period. However, we cannot be entirely certain if all eligible participants in the district were identified during the time period of the study. Respondent recall bias was minimized by measuring outcome variables within 6–11 weeks of birth. Furthermore, a broader range of confounders such as pregnancy complication and comorbid illnesses were controlled in our models.

Our study did not however, consider the cultural beliefs of women regarding seeking postnatal care. This is pertinent in rural Ethiopia where women are not encouraged to leave their homes until 2–3 weeks postpartum. This might explain the non-significant finding in the association between antenatal depressive symptoms and postnatal care utilization. Because of the low predictive value of PHQ-9 [69, 70], as a screening tool, it is likely that a proportion of PHQ-9 positive women do not meet criteria for a diagnosis of depression. Nonetheless, we found an important association of antenatal depressive symptoms with maternal health care utilization.

Among women with antenatal depressive symptoms, there was increased odds of institutional delivery in general, and increased unplanned institutional delivery utilisation mainly due to emergency reasons. Assisted delivery was also increased among this group of women, which might have been due to labour complications. Thus, improved detection and treatment of antenatal depression has the potential to increase planned institutional delivery and reduce perinatal complications, thus contributing to a reduction in maternal morbidity and mortality, as well as improved neonatal health.