Introduction
Depression is one of the most frequent psychiatric conditions among reproductive-age women [
1]. It is the leading contributor to disease burden among childbearing women with depressive episode within 4 weeks following childbirth [
2]. The World Health Organization stated that 20–40% of women in developing countries experienced depressive symptoms during pregnancy or after childbirth [
3]. Globally, 10%–20% of mothers suffer from depressive symptoms during their postpartum period [
4]. Half of the depressed women were expected to have an episode of depression following pregnancy [
5]. In Ethiopia, depressive symptoms affect at least 1 in 20 following delivery [
6]. Even though every woman is potentially at risk of developing postpartum depressive symptoms, an early age of childbearing is more vulnerable to develop postpartum depression [
7]; low education level, poverty [
8], poor social support [
9], and childbirth without the presence of relatives [
10] were factors that increased the risks of depressive symptoms after delivery. Besides the above factors, previous history of depression [
11], obstetric complication, miscarriage [
12], parous women, an unplanned pregnancy [
13], intimate partner violence [
14], stressful life events [
15], and poor woman autonomy [
16] were factors of postpartum depressive symptoms. Postpartum depressive symptoms have physical and mental health consequences for mothers and their families. Postpartum depression is an extreme feeling of sadness, hopelessness, the recurrent thought of death, and risk of the mother harming herself [
14,
17]. Depressed mothers provide inadequate care to their children, show negative parenting behavior, and present poor mother–infant bonding [
18]. Children of depressed mothers had impaired emotional, social, and cognitive development [
19‐
21].
Women’s health is a public concern, but the diagnosis of postpartum depressive symptoms has received little attention. Although nearly 90% of the world’s children live in low- and middle-income countries, we know little about the prevalence of maternal depressive symptoms in Ethiopia. Therefore, the finding of this study will fill the gap in making a necessary solution by assessing the prevalence and associated factors of postpartum depression among mothers attending maternal and child health clinics in the study area.
Discussion
This study revealed that the prevalence of postpartum depressive symptoms was found to be 22.1% (95%, CI 18.6%, 25.8%). Regarding prevalence, the current study result is in line those of others studies carried out in Ethiopia, Kenya, Nigeria, and Pakistan, with the prevalence estimated at 19%, 20%, 22.9%, and 22.3%, respectively [
5,
15,
32,
33].
On the other hand, our findings are higher than those of other studies done in three areas of Ethiopia, Sudan, Kenya, Egypt, Ghana, and the USA, where the prevalence was estimated at 12.2%, 13.11%, 16.3%, 9.2%, 13%, 7.14%, 7%, and 14.8%, respectively [
4,
8,
34‐
39]. The variation may be due to distinctions in sample sizes, measurement tools, rating scales, timing of postpartum period, study designs, and socio-cultural differences between Ethiopia and the other countries. In South Ethiopia, 3147 participants were included between 1 and 12 months of the postpartum period by using Patient Health Questionnaire nine [
34]. Only 196 participants were included in the northern part of Ethiopia by assessing Beck Depression Inventory Scale (BDIS) with the cutoff points greater than 14 [
36] and in East Ethiopia, 122 postnatal mothers had participated by using the non-probability convenience sampling technique [
35]. In Sudan, 238 pregnant women took 3 months with PPD, but in this study included from 2 to 6 weeks of postpartum period by using EPDS at the cutoff greater or equal to 12 [
8]. In Kenya, 200 participants from 6 to 14 weeks duration were included [
37]. In Egypt, 658 women took part within 6 weeks after birth [
4], and in Ghana, only 212 mothers selected by using convince sampling methods used to assess by Patient Health Questionnaire (PHQ-9) [
38]. Finally, in the USA, 325 mothers from community health centers using the Pregnancy Risk Assessment Monitoring System (PRAMS) and stratified sampling techniques were included [
39].
The result of the study was lower than those of other studies conducted in South Africa, China, Turkey, and Bangladesh, with the prevalence estimated at 50.3%, 30%, 35.2%, respectively [
40‐
42]. This might be due to measurement tools, sample sizes, and duration. For instance, in South Africa, 159 participants were included from the rural community within 4–14 weeks of the postpartum period using a cohort study design [
40]. In Bangladesh, EPDS was used with the cutoff point 10 or more to define clinically significant symptoms of postpartum depressive symptoms [
42]. In China, 506 participants were assessed using the Center for Epidemiologic Studies Depression Scale (CES-D) to measure participants’ depression symptoms with the cutoff point greater than or equal to 16 and to detect people at risk of experiencing depressive disorder on mothers 1–3 years of the postpartum period [
41].
Intimate partner violence was three times higher compared to mothers who did not expose to intimate partner violence. Partner violence during pregnancy was significantly associated with depressive symptoms in the rural area of Ethiopia [
43]. A study was done in Sudan, in which the history of domestic violence increased seven times the postnatal depression [
8]. In a cross-sectional study in four sub-Saharan African countries, intimate partner violence was the risk factor for developing depressive symptoms [
44]. In South Africa, intimate partner violence during pregnancy and postpartum period had a risk of depressive symptom severity [
45]. In China, violence was one of the factors responsible for postpartum depressive symptoms [
46]. A study was done in the UK on domestic violence among women with a high level of depressive symptoms in the antenatal and postnatal periods [
47]. In the USA, the rates of mental health problems were at least three to five times higher in women exposed to intimate partner violence [
48]. In another meta-analysis study done in India, the presence of domestic violence increased postnatal depressive symptoms [
49]. The explanations for the association may be that violence could lead to psychological trauma; especially if the action was in front of other people, neighbors, friends, and relatives, psychological trauma leads to a negative belief about self and others.
The odds of postpartum depression were increased by two times among mothers who had no autonomy in domestic decision making than those who had autonomy. Despite the variability and broadness of the concept of autonomy in this study, women empowerment typically refers to freedom of movement, decision making regarding children, and decision making in household tasks. This finding is supported by those of other studies in Nepal and Bangladesh [
12,
42]. A study in China showed that low autonomy to decide indicated a high chance to develop mental health problem [
50]. The explanation for this could be that if women had limited right and control over resources, restriction in their mobility, lack of personal power in intra-household ability to make and execute independent decisions based on her own concern or about children, this inequality could result in some psychological traits that negatively affect her cognition.
This study found that postpartum depressive symptoms were 2.8 times higher among respondents who experienced stressful life events compared to mothers who did not experience these. The finding in Egypt supported this result, and a history of different psychosocial stressors was a predictor of postpartum depressive symptoms [
7]. In the UK, events related to the partner relationship during pregnancy and postpartum were risk for depression onset, especially the occurrence of related events in the preceding months [
11]. A study was done in the USA, which showed that different life stressors were a factor to develop postpartum depressive symptoms [
51].
In contrast, in a study on psychosocial risk and protective factors for postpartum depressive symptoms in the United Arab Emirates, neither anxiety nor depression and a number of stressful life events were found to be risk factors [
9]. The explanation for the association could be stressful life events acting as the onset persistence of depression. Mothers who had hospitalized their babies were found to be 2.7 times more likely to become depressed than their counterparts. This finding is consistent with those of other studies carried out in Egypt [
7], and India [
52] in that puerperal woman had the ill baby become more stressed about the health outcome of their infant.
Unplanned pregnancy was about two times risky for PPD compared to planned pregnancy. This finding is in line with those of other studies carried out in Southern Ethiopia. Unwanted pregnancy was the risk factor for depressive symptoms among pregnant women living in rural area [
43]. In Egypt, unwanted pregnancy was the predictor of postpartum depressive symptoms [
7]. In India, those who had mood swings during pregnancy and those who had low mood during pregnancy [
53] and in China women with cesarean delivery and unplanned pregnancy had risk factor for postpartum depressive symptoms. In the USA, unplanned pregnancy was a predictor of postpartum depressive symptoms [
50,
51].
The explanation for the association might that unwanted pregnancy causes psychological distress in women. Unplanned pregnancy could lead to negative emotional reaction and increase psychosocial stress, decrease support provided to her by the partner, and risk of having depression. This study was a cross-sectional design cannot permit conclusions for some variables, for example, to decide whether PPD are risks for or consequence. The finding is likely only to hint at the complex interactions between PDD and explanatory variables. Another limitation was that we did not use a standardized screening tool to assess women’s autonomy. Therefore, the interpretation and usage of the study must be considered a limitation.
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