Introduction
There is a high prevalence of common mental disorders (CMDs; ie anxiety and depression) in women of reproductive age in low and middle income countries (LMICs) [
1], yet their impact on reproductive behaviours has been largely neglected. There is evidence from high-income countries that depression is associated with increased rates of unintended pregnancy in young adulthood and shorter pregnancy spacing [
2‐
4]. Depression and stress have also been found to be associated with lower rates of contraceptive use and choice of less effective methods, mostly in clinical samples from North America [
5,
6]. There is lack of replicating studies from LMICs but recent evidence showed that high CMD symptoms postpartum were associated with subsequent unmet need of contraception in a sample of women in rural Ethiopia [
7].
Most literature on determinants for unmet need for contraception in LMICs has focused on socio-demographic characteristics of the women or factors pertaining to knowledge and access to family planning services [
8]. Nevertheless, women often cite concerns about contraceptive side effects or health related reasons for not using contraception as well as lack of regular sexual intercourse [
9]. It is estimated that mitigating unmet need for contraception in developing regions could avert over 50 million unintended pregnancies, thereby preventing the deaths of 70,000 women from pregnancy-related causes annually [
10]. Despite progress in improving access to contraception, striking inequalities still exist across countries and among vulnerable populations [
11]. Acknowledging the challenge, the 2030 Agenda for Sustainable Development includes under Goal 3 to ‘ensure universal access to sexual and reproductive healthcare services, including family planning, by 2030’ [
12].
The relationship between poor mental health before pregnancy and subsequent use of contraception has not been investigated in high fertility, high unmet need for contraception settings. For this study, we aimed to investigate if depression is associated with unplanned pregnancy and use of contraception in a cohort of pregnant women in rural Malawi, we hypothesized that symptoms of depression at preconception (here considered to be the year before pregnancy) are associated with a higher risk of unplanned pregnancy and nonuse of contraception at the point of conception and in the postpartum period, independently of other known determinants.
Discussion
In our study, depression symptoms were most prevalent before and during pregnancy with around one fifth of women reporting high level of symptoms at antenatal interview but significantly lower numbers reporting symptoms at later stages. We found that a self-reported history of depression in the year before pregnancy is associated with inconsistent use of contraception at the time of conception, higher risk of unplanned and ambivalent pregnancies, no use of contraception despite no desire for a further pregnancy in the early postpartum period as well as reduced use of modern contraceptive method at 28 day post-partum. These results remained significant after adjusting for socio-demographic factors known to impact on women’s access to and use of family planning and depression symptoms in pregnancy. Although the point estimates were similar and in the same direction at 6 months and 12 months, the differences were not significant.
In our cohort less than a third of women were using modern contraceptive methods in the early postpartum with the majority relying on lactational amenorrhea as their main contraceptive method. Whereas the number using modern methods increased in subsequent months, to over two thirds using modern contraceptive methods at 12 months, a significant proportion still relied on traditional methods and reported no contraception use despite no desire for a further pregnancy at this time point. Our findings show that women with a history of depression in the year before pregnancy are at increased risk of a subsequent unplanned pregnancy.
Our study adds to the growing literature on unmet need for contraception amongst women with mental health disorders. Studies from high income countries and mostly from clinic-based samples have previously highlighted an association between depression and stress and contraceptive non-use and reduced odds of consistent contraceptive use, especially when using withdrawal, condoms, and birth control pills compared to women without symptoms [
5,
6,
24]. A recent study using primary care data linked with obstetrics and gynecology records in the US has also reported that women with mental health disorders have increased odds of Long-Acting Reversible Contraception removal [
25]. In those settings, suggested mechanisms underlying this association are that psychological distress may negatively impact the decision making and risk assessment abilities of women with regards to contraceptive behavior [
26,
27]. An alternative possible mechanism is that women with depression may be more susceptible to perceive somatic side effects of hormonal contraception and therefore discontinue use more readily [
28]. Globally, side effects are the most common reason for women to discontinue contraception [
29] however no studies exist investigating if women with depression experience find it harder to tolerate side effects and therefore discontinue more readily. IPV has also been shown to be associated with a reduction in women’s use of contraception [
30] and could be an important confounder, however our results remained significant after adjusting for disclosure of abuse in past year. The vast majority of women in our cohort were Christian and the religious recommendation in this setting is to return to sexual activity following childbirth. There may be differences in how women adopt contraceptive methods depending on their religious beliefs but this could not be explored in this study.
Whereas much research has recently focused on the hormonal contraception effects on mood with no consistent results [
31] and a large body of evidence supports an association between unintended pregnancies and perinatal depression [
32], little is known about how depression may impact on use and choice of contraceptive methods, particularly in low income settings. A recent study from rural Ethiopia reported that women with high depression symptoms in the late postpartum have higher unmet need for contraception [
7]. Similarly to our study the relationship seemed to have a temporal element, with a relationship seen between high depression symptoms at 12 months and unmet need for contraception at 2.5 years but not at 3.5 years. Variations in the temporal gradients may be partly explained by the timings when women are more likely to experience depression symptoms. Whereas in this study from Malawi women had a higher prevalence of depression symptoms during pregnancy than at any other times during the cohort, in the Ethiopian study women showed higher rates of depression symptoms in the early postpartum period. Contextual differences in how women access social support and experience adversity in different parts of their reproductive life may play a role in the prevalence of depression and further studies are required to explore potential mechanisms.
To our knowledge this is the first study to investigate the role of depression before pregnancy on contraceptive use at conception and in the early postpartum, in a low income setting. Our results have important implications as traditionally family planning programmes have focused on increasing access to modern contraceptive methods with little consideration how different groups of women such as adolescents [
33], or women experiencing psychological distress may benefit from more targeted interventions in order to have their reproductive rights met. There is growing evidence that merely increasing access will not reach every woman and focus on improving the quality of the family planning programs and develop targeted interventions for women not currently reached with the current models are necessary [
29]. Our results also highlight the need for general services, including family planning services, to integrate mental health care into all general health care services as per ambition of the World Health Organization mental health Gap Action Programme [
34], Common mental disorders are prevalent in women of reproductive age in LMICs [
1] and failing to address them may have long term impact on women’s health, choices and opportunities.
Strengths of our study include the large, representative sample of women from a rural setting in a low-income country, the use of locally validated measures of pregnancy intention and of depression in the pregnancy and the postpartum period and the prospective design with high rates of follow-up. Our study also has several potential limitations. It relies on self-reported data for symptoms of depression in the year before conception and use of contraception and may be subjected to reporting bias. We were also unable to explore the reasons behind contraceptive choices. Whereas we collected data on pregnancy intentions we lacked information on side effects. We can also not exclude that other confounders not used in our models may play a significant role in our hypotheses.
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