The association of unwanted pregnancy and social support with depressive symptoms in pregnancy: evidence from rural Southwestern Ethiopia

Mental health problems, such as depression, rank among the top causes of disability among women worldwide; however, they still remain inconspicuous as a component of reproductive health care [1]. Several studies have shown that depression, anxiety, and stress in pregnancy are risk factors for adverse outcomes for women and children. Depression places pregnant women at greater risk for inadequate prenatal care, increased alcohol use and poorer weight gain in pregnancy [1‐3]. The adverse intergenerational effects of maternal depression on children’s health, development, and behavior are also well documented [3‐5]. For instance, a meta-analysis involving studies from both developed and developing countries showed that antenatal depression is associated with preterm birth, intrauterine growth restriction, and low birth weight [6]. A study from Ethiopia found that antenatal common mental disorders such as depression, anxiety and somatic symptoms are associated with prolonged labor, delayed initiation of breast feeding and more diarrheal episodes for infants [7]. Moreover, antenatal depression is a predictor of postnatal depression--women who are depressed during pregnancy have a higher risk of developing depression during the postpartum period [8, 9].

We focus on depressive symptomatology in pregnancy due to its adverse consequences for mothers and children. Unlike postnatal depression, which is increasingly recognized as an important public health issue in low-income countries, antenatal depression and its effects on maternal and child health is relatively less studied. Estimates of the prevalence of antenatal depression vary substantially. A recent systematic review of studies from developed countries found that antenatal depression affects 13% of pregnant women in the second and 12% of women in third trimester [10]. Studies from South Asia and Latin America have reported rates of 20% and higher [11‐14]. Evidence from developing countries suggests that depression during pregnancy is common-- in Sub-Saharan Africa prevalence ranged from 8.3% to 39% [15‐18]. In Ethiopia, its magnitude and risk factors are not well known.

For most women, pregnancy is a time of positive expectation, but may also be a time for psychological and physiological challenges. It is accompanied by hormonal changes and can represent a time of increased vulnerability for the onset or return of depression [19]. However, the high prevalence of maternal depression in poor countries may be related to women’s exposure to several depression-related risk factors, including poverty [12, 17, 20], low social support [21‐24], domestic violence [25‐27], HIV/AIDS [28, 29] and reproductive health outcomes and behaviors such as high parity, unwanted pregnancy, unsafe abortion, infertility, and pregnancy complications [30‐33].

The intersection of unintended pregnancy and maternal mental health is not well studied in developing countries. The few studies that considered the influences of unintended pregnancy have shown that women with an unintended pregnancy are at an increased risk of depression during pregnancy than women with intended pregnancies [32‐37]. Unintended pregnancy may increase a woman’s exposure to psychosocial stressors, decrease social support provided to her by the partner, increase her level of depressive symptoms, and decrease her overall life satisfaction [34‐36]. Some studies show no association between unintended pregnancy and depressive symptoms during pregnancy [11, 38].

Social support has the potential to play a protective role by buffering the impacts of life stress on emotional wellbeing of the woman during pregnancy [24, 39, 40]. Studies have shown that social support plays a buffering role from stressful life events by providing resources, support and strength during pregnancy. Understanding women’s pregnancy intention and the extent of social support they receive may help to improve healthy behaviors during pregnancy and consequently better maternal and neonatal health outcomes. This study attempts to examine the associations between pregnancy intention, social support and depressive symptoms among pregnant women in Ethiopia, where there are high levels of unintended pregnancy (estimated at 32% in 2011^a) and women have low partner support during pregnancy [41].

Of the 627 women targeted for inclusion in the study, 622 were successfully interviewed (99% response rate). The mean age of study participants was 26 years, and ranged from 14 to 40 years (SD ±5.02). Nearly all (99%) of the respondents were married, 72% had no formal education, 77% were housewives, and 76% lived in rural areas. The median gestational age of the participants was 7 months. The average number of children ever born was 3.9, and nearly one-third (32.6%) had given birth to 5 or more children. With regards to pregnancy intention, 59% of women reported that their current pregnancy was wanted, while 28% and 13% of women their current pregnancy was mistimed and unwanted respectively. Forty-one percent of women reported food insecurity during pregnancy (Table 1).

The overall prevalence of depressive symptoms among the pregnant women was 19.9% (95% CI, 16.8-23.1). The mean score on the EPDS was 8, and ranged from 0 to 25 (SD ±5.4). Bivariate analysis showed that the prevalence of depression during pregnancy did not vary by age, wealth index, parity and trimester of pregnancy. However, the prevalence of prenatal depression varied by education, occupation, pregnancy intention, social support, perceived work burden, intimate partner physical violence, food security status and previous experience of miscarriage or stillbirth. Considering educational status, a relatively higher proportion of women with secondary and above level of education (24%) reported depression than women with no education (22%) or with primary education (11.6%). The prevalence of depressed mood in pregnancy also varied by pregnancy intention--35% of women with an unwanted pregnancy reported depressive symptoms as compared to 16% of women with wanted pregnancy. Moreover, women who scored 13 and above on the EPDS scale were more likely to have low social support, high work burden, and be farmers by occupation. Women with a high score on the EDPS were also more likely to have experienced intimate partner violence, food insecurity, and have previous history of miscarriage or stillbirth. Social support was inversely related to depressive symptoms with women reporting high social support being less likely to have depressive symptoms (Table 2).

Women who did not want the current pregnancy were nearly twice as likely as women who wanted the pregnancy to experience depression during pregnancy (Odds Ratio (OR) = 1.96, 95% CI: 1.04-3.69). Women who reported a mistimed pregnancy did not differ significantly from those who wanted the pregnancy in prenatal depression. The level of social support was strongly associated with depression during pregnancy. Women with high social support were significantly less likely to experience depression during pregnancy compared with women who had high levels of social support (OR: 0.23, 95% CI 0.11-0.47). Those with moderate score on the social support scale were also less likely (OR: 0.27, 95% CI 0.14-0.53) to experience depression during pregnancy. With regards to occupation, women engaged in farming (OR: 3.43, 95% CI 1.95-6.05), and those engaged in the service sector such as family business or government employee (OR: 2.50, 95% CI 1.13-5.56) were more likely to report depressive symptoms in pregnancy than house wives. Moreover, women with household food insecurity are nearly five times as likely to be depressed during pregnancy as compared to women from food secure households (OR: 4.60, 95% CI 2.75-7.70). Presence of intimate partner violence during pregnancy was also associated with an increased likelihood that a woman was depressed during pregnancy, although the association was marginally significant (Table 3).

The magnitude of antenatal depression in the current study population, 19.9% (95% CI, 16.8-23.1), though within the range of findings reported from Sub-Saharan Africa and other developing countries [11‐17], is high when compared to findings from a systematic review that showed prevalence of prenatal depression of 12.0% in developed countries [10]. In Sub-Saharan Africa, the prevalence of antenatal depression ranged from 8.3% to 39% [16‐18]. A very high level of depression was reported in a recent study in Cape Town, South Africa, where depressed mood in pregnancy was 39%. There has been no study of antenatal depression in Ethiopia, but in one study that used the Hopkins symptoms checklist (HSCL) to measure the prevalence of postnatal maternal and paternal symptoms of anxiety and depression, the prevalence of depression (defined as mean score for each HSCL item of ≥1.75) among adult women was 37% [20].

In this study, factors that were significantly associated with depressed mood in pregnancy include pregnancy intention, social support, occupation, food security status and partner violence during pregnancy. With regards to pregnancy intention, having unwanted pregnancy, not mistimed pregnancy, is associated with antenatal depression. Women reporting unwanted pregnancy are nearly 2 times more likely to be depressed as compared to women with planned pregnancies. Several previous studies have shown such an association between unwanted pregnancy and depression during pregnancy [32, 34, 35]. However, women reporting mistimed pregnancies did not differ significantly from women with wanted pregnancy in terms of depressive symptoms during pregnancy.

The strongest association in this study was with social support. In this study, women with high social support were 0.26 times as likely as women with low social support to experience antenatal depression. Similarly, women with moderate social support were 0.27 times as likely as women with low social support to experience antenatal depression. The association between social support and depression during pregnancy has been confirmed by studies from both developing and developed countries. These studies have shown that social support plays a buffering role from stressful life events by providing resources, support and strength during pregnancy [21, 39]. Much related to the absence of social support is the presence of intimate partner violence during pregnancy. In this study, although very few women (about 4%) reported ever been beaten during the current pregnancy, there was a significant association between intimate partner violence and depression during pregnancy, as has been found in several previous studies [26, 27].

Household level food insecurity is another important associated factor with depressed mood in pregnancy. About 41% of women in this study reported food insecurity, which can be one main cause of stress in life. Consequently, women reporting food insecurity are nearly five times as likely as food secure women to report depressive symptoms during pregnancy. Food insecurity is a major problem in Ethiopia and the study area in particular [20]. Moreover, this study took place in the summer months of June and July and in rural Ethiopia, these are times when most households run out of food, and food insecurity tends to be high during this season. Studies have also indicated that the effects of food insecurity extend beyond the nutritional effects and include anxiety and depression [20].

Our result indicates that socio-demographic factors such as age, parity, place of residence and wealth were not associated with prenatal depression. Similarly, the association between education and depressive symptoms was attenuated once the effects of other socio-demographic and obstetric factors were controlled for. Although such factors were found to be associated in some previous studies [17, 25], a systematic review proved that such factors (age, parity, socio-economic status, and education) were not significant in multivariate models in majority of the studies included in the review [34].

Overall, our study found a high level of depressive symptoms among pregnant women in the study area. Although the study lacks clinical validation, the EPDS has been validated in several settings among pregnant women and is found to be a valid screening instrument for depressive symptoms during pregnancy. As shown above, much of these stressful life experiences may stem from the socio-economic context in which women live such as food insecurity, intimate partner violence and unwanted pregnancy. Understanding the factors that buffer the effects of stressful life events on depression in pregnancy is important. This study demonstrated that social support during pregnancy plays such a buffering role against depression. It is therefore important to screen for depression during pregnancy and provide appropriate counseling during routine prenatal care visits. The WHO has made such recommendations, integration of mental health into primary health care settings in developing countries [50]). In conclusion, enabling women to meet their reproductive goals and interventions that encourage social support in pregnancy help a lot in reducing mental health problems such as depression.

^a Analysis of 2011 EDHS data for pregnant women showed that 32% of pregnancies were not intended. But, for births in the five years before the survey, 25% of them were reported as unintended.

^b Data from DSS registration for the year 2012.

^c Kebele is the smallest administrative unit in Ethiopia.