|ORIGINAL RESEARCH REPORT
|Year : 2022 | Volume
| Issue : 2 | Page : 49-56
Screening for postpartum depression by health-care workers in Kaduna, North-Western Nigeria: A cross sectional study
Amina Mohammed-Durosinlorun1, Nafisatu Mamoon2, Bashir A Yakasai3
1 Department of Obstetrics and Gynaecology, Faculty of Clinical Sciences, Kaduna State University/Barau Dikko Teaching Hospital, Kaduna, Nigeria
2 Department of Family Medicine, 44 Nigerian Army Reference Hospital, Kaduna, Nigeria
3 Psychiatry, College of Medicine, Faculty of Clinical Sciences, Kaduna State University/Barau Dikko Teaching Hospital, Kaduna, Nigeria
|Date of Submission||23-Sep-2021|
|Date of Acceptance||15-Jan-2022|
|Date of Web Publication||13-Jun-2022|
Dr. Amina Mohammed-Durosinlorun
Department of Obstetrics and Gynaecology, Faculty of Clinical Sciences, College of Medicine, Kaduna State University/Barau Dikko Teaching Hospital, Kaduna
Source of Support: None, Conflict of Interest: None
Background: Postpartum depression (PPD) can be associated with adverse maternal/neonatal outcomes and screening leads to increased recognition and earlier initiation of management before more complications set in. Objectives: The objective of the study was to determine practices and attitudes towards screening for PPD among health care workers in Kaduna. Methods: The study was a cross-sectional descriptive study. Participants were health-care workers providing care for pregnant women. A pretested semi-structured questionnaire was used for data collection. Information collected included biodemographic data, professional and hospital characteristics, knowledge, views, and practices related to PPD screening. Data were summarized using cross table and frequency tables. Chi-square or Likelihood Ratio test was used as appropriate. A P < 0.05 was considered statistically significant. Results: There were 202 respondents. The mean age of participants was 34.49 ± 9.95 years. Majority of the participants had experience of 1–5 years (53, 26.2%), worked in secondary (80, 39.6%), and public (168, 83.2%) facilities. Most participants “Sometimes” or “Never” screened women for PPD (184, 91.1%), while 18 participants (8.9%) “Always” or “Often” screened for PPD. Facility level and cadre were significantly associated with routine screening for PPD (P < 0.05). Only about 10% were aware of the use of validated questionnaires as screening tools. Overall, one hundred and seventy-six participants (87.1%) had a good attitude toward screening for PPD. Religion and ethnic group were significantly associated with attitudes toward PPD screening. Conclusion: Most respondents do not routinely screen women for PPD and are not very familiar with screening tools but had good attitudes toward PPD screening.
Keywords: Health workers, Kaduna, Nigeria, postpartum depression, screening
|How to cite this article:|
Mohammed-Durosinlorun A, Mamoon N, Yakasai BA. Screening for postpartum depression by health-care workers in Kaduna, North-Western Nigeria: A cross sectional study. J Clin Sci 2022;19:49-56
|How to cite this URL:|
Mohammed-Durosinlorun A, Mamoon N, Yakasai BA. Screening for postpartum depression by health-care workers in Kaduna, North-Western Nigeria: A cross sectional study. J Clin Sci [serial online] 2022 [cited 2022 Aug 10];19:49-56. Available from: https://www.jcsjournal.org/text.asp?2022/19/2/49/347245
| Introduction|| |
Depression is a mood disorder occurring more in women than men, especially during the reproductive-age years. Postnatal depression is a common form of depression in the peripartum period, occurring in over 11% of women. Prevalence in Nigeria is variable, 14%–44%.,,,,,
The exact etiology of postpartum depression (PPD) is not known but it has been associated with several risk factors during pregnancy such as stress, lack of social support, previous and family history, preterm delivery, and other complications of pregnancy.
PPD can be associated with adverse maternal and neonatal outcomes such as reduced breastfeeding rates, poor maternal and infant bonding, increased suicide and infanticide rates, impaired child cognitive development and social relationships.,,,,,
PPD is, unfortunately, underdiagnosed and untreated with more than 50% of women never getting diagnosed despite the availability of cost-effective treatment modalities using drugs and behavioral therapies.,
Screening leads to increased recognition of depression, and earlier initiation of management before more complications set in. Professional medical bodies recommend that health-care providers (HCPs) screen for depressive symptoms at least once during pregnancy or postpartum, using a validated screening tool.
With high rates of poverty and other competing health challenges, PPD may be overlooked in this environment, and few studies have investigated the attitudes and practices of HCPs toward PPD screening. Hence, the aim of this study was to determine screening practices and attitudes for PPD among health care workers in Kaduna.
| Methods|| |
The study was carried out in Kaduna, a state in North-Western Nigeria with 23 local government areas (LGAs) and lies 10°20'N 7°45'E with a Sudan Savannah type of vegetation. Its population in 2018 was estimated to be 8.9 million, with an almost equal ratio of males to females. The main ethnic group is Hausa Fulani being with over 50 other ethnic groups. The population is mainly rural with farming as the main occupation. The state has a lot of educational institutions. There are numerous government and private health facilities at all levels of care to cater for the health of its citizens.
The study was a cross-sectional descriptive study involving the administration of a semi-structured questionnaire.
Participants for the study were health-care workers (HCWs) drawn from primary, secondary, and tertiary health-care facilities, as well as government-owned (public) and privately owned hospitals.
Consenting health-care workers currently working in Kaduna and providing care for pregnant women or women in the puerperium were included in the study.
Undergraduate students still in school but attending to pregnant women were excluded.
An a priori power analysis was conducted using G*Power3 to measure how expectations compare to actual observed data using Chi-square statistic, with a medium effect size (d = 0.50) and an alpha of. 05. The result showed that a minimum total sample size of 143 was required to achieve a power of 0.80.
A pretested semi-structured questionnaire adapted from previous studies was used for data collection. Pretesting was done by administering 10 questionnaires to health-care workers at the Barau Dikko Teaching Hospital, with face and content validation done by two gynecologists and one physician/mental health specialist). Information collected included bio-demographic data, professional and hospital characteristics, knowledge, views, and practices related to PPD screening.
Five questions were used to calculate a PPD attitude score: (1) Is PPD common? (2) Is screening for PPD effective? (3) Does screening for PPD improve the detection rate? (4) Does screening for PPD result in early treatment? (5) Will screening for PPD be easy difficult?. The possible responses; Don't know, No or Yes were scored as 0, 1, and 2, respectively. An aggregate score of ≥5 was considered “good” attitude while <5 was considered “poor” attitude.
Data were analyzed with IBM SPSS (IBM SPSS Statistics; Armonk, NY, USA) software version 22. Data were summarized using crosstable and frequency tables. Chi-square or Likelihood Ratio test was used as appropriate, to check for statistically significant association between the dependent and independent variables. A P < 0.05 was considered statistically significant.
Ethical approval for the study was gotten from the Kaduna State Ministry of health and informed consent from participants. The nature of the study posed very little risk to participants.
| Results|| |
The study was carried out between September 2019 to January 2020. We gave out more questionnaires than required to cover for attrition. Two hundred and fifty questionnaires were distributed and 202 retrieved, giving a response rate of 80.8%.
The mean age of participants was 34.49 ± 9.95 years. Majority were aged 20–29 years (70, 34.7%), Muslim (105, 52%), Hausa/Fulani (84, 41.6%), and married (132, 65.3%) [Table 1].
Participants were mainly nurses (92, 45.5%) with others being doctors and community HCWs, and their specialties are shown in [Table 2]. More of the participants had postgraduation experience of 1–5 years (53, 26.2%) and worked in secondary (80, 39.6%) and public/government-owned (168, 83.2%) health-care facilities as shown in [Table 2].
|Table 2: Professional and facility characteristics of health-care workers|
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Most participants (92, 45.5%) felt PPD was not a common illness, but screening for PPD would be effective (109, 54%), improve detection rates (162, 80.2%), and lead to early initiation of treatment (163, 80.7%).
Regarding screening practices, most participants “Sometimes” or “Never” screened women for PPD (184, 91.1%), while 18 participants (8.9%) “Always” or “Often” routinely screened for PPD [Table 3]. The facility level (primary, secondary, or tertiary health-care facility) and cadre/type of health worker were significantly associated with routinely screening for PPD (P < 0.05) [Table 4].
|Table 3: Attitudes and practices of health-care workers toward screening for postpartum depression|
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Most participants (86, 42.6%) were not sure of the methods used to screen for PPD, with only about 10% being aware of the use of validated questionnaires as screening tools. Others mentioned the importance of taking a detailed history and close observation of the patient, used alone or in combination, as screening methods [Table 3].
Most (123, 60.9%) felt that screening for PPD would not be difficult. However, some felt the poor health-seeking behavior of women in our environment, especially for postnatal care and increased workload for staff would be barriers to screening for PPD, among others.
A lot of the participants (128, 63.4%) felt they were not properly trained to screen for PPD. They also felt that the antenatal period (101 respondents) and immediate postpartum period before a woman was discharged from the hospital (126 respondents) were the best times to screen for PPD [Table 3]. A lot of the participants (103, 51%) were not sure of who was best suited to screen women for PPD, while others mentioned HCWs including nurses and doctors.
One hundred and ten participants (54.5%) indicated that they sometimes followed up to see if women had treatment after screening, while up to 73 participants (36.1%) never did so. Being unaware that something is wrong (82, 40.6%), shame and stigma (50, 24.8%), and being too busy (35, 17.3%) were some of the reasons why participants felt that women would not come for follow-up.
Overall, one hundred and seventy-six participants (87.1%) had a good attitude toward screening for PPD while 26 (12.9%) had poor attitudes [Figure 1]. Religion (P value 0.019) and ethnic group (P = 0.001) were significantly associated with attitudes toward PPD screening [Table 5].
|Figure 1: Attitude of participants toward postpartum depression screening|
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|Table 5: Attitude of participants toward postpartum depression screening|
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| Discussion|| |
This is one of the few studies that have examined the attitude and practices of health workers toward PPD screening. Being healthy involves not only physical health but also mental, psychosocial health, and emotional wellbeing. Mental health is usually neglected, and in our environment, a lot of women may not go to a hospital except when they are pregnant, making it an ideal time for a lot of medical interventions including screening for PPD, especially as pregnancy is a risk factor for depression.
Most participants felt PPD was not a common illness but that screening would still be effective. PPD symptoms such as changes in sleep and appetite patterns may be masked by physiological pregnancy and postpartum changes, with dire consequences.
In this study, a low number of participants (8.9%) “Always” or “Often” screened women for PPD, while the majority (91.1%) “Never” or “Sometimes” routinely screened for PPD. This means most health workers in this study do not routinely screen women for PPD and so cases can be missed. This is much lower than an American survey of obstetricians that found 44% of respondents “Often” or “Always” screened for PPD, 41% “Sometimes” screened for PPD, and 15% “Never” screened for depression. An American survey of certified nurse-midwives/certified midwives reported that 25.1% “Always” screen, and 58.5% “Usually” screen women for depression.
The facility level and cadre of health workers were significantly associated with routine screening for PPD [Table 4], with those in secondary and tertiary facilities more likely to screen than their counterparts at primary levels of care. Doctors were also more likely to screen women for PPD than nurses and community health workers. Perhaps this may have something to do with better awareness. A few of the nurses were attending to pregnant women despite specializing in other fields like ear, nose, and throat, probably because of staff shortages. Another study and found that providers documented their patients' PPD screening in only 39% of visits with nurse practitioners having the highest rate of documentation (94%), than nurse midwives (67%) and physicians (42%). The type of doctor may also be important, and in one study, screening rates among pediatricians are even lower; 8% of pediatricians routinely screened mothers for depressive symptoms. In an Israeli online survey of 224 pediatricians and family practitioners, the family practitioners were significantly more willing to screen for PPD than the pediatricians.
Most respondents (42.6%) in our study were not sure of how to screen for PPD and only about 10% of respondents were aware of the use of validated questionnaires as screening tools. This is in contrast to another Nigerian study where 64.0% were aware of a validated questionnaire, the EPDS (Edinburg Postnatal Depression Scale) to screen for PPD. The EPDS is the most commonly used validated tool, a 10-item self-report scale designed to assess the presence and severity of depressive symptoms but is limited by its sensitivity and specificity. In the study by LaRocco-Cockburn et al., 32% of respondents used a validated screening tool administered by HCW, and 16% used a validated patient self-report test. In another study, only 22% of providers reported using a validated tool for PPD screening, indicating that the majority did so with either unvalidated tools or informal assessments., This is similar to our study where respondents also mentioned the importance of taking a detailed history and close observation as screening methods for PPD. Several studies have confirmed that informal or no assessment of PPD is ineffective and results in fewer detection rates than when formal screening is done.,, Universal depression screening in outpatient settings significantly improves detection rates compared to routine care (35.4% and 6.3%).
Lack of time and training were barriers to PPD screening identified by respondents. This is similar to findings from other studies.,,,,,,,, In Cameroun, a study reported participants' knowledge on depression was generally low, and less than half (49.1%) had prior training in mental health during their undergraduate studies. Other studies also found that community health-care professionals reported a lack of mental health training but identified a need for it.,
Most respondents in this study felt that the antenatal period and immediate postpartum period before a woman was discharged from the hospital were the best times to screen for PPD. This is similar to the study done in southern Nigeria where almost all of the respondents claimed that PPD tendency can be detected during pregnancy. Other studies suggest that the optimal time to screen for PPD is at the first postnatal visit. As mothers are naturally worried about their children and hopefully seek newborn care, pediatric appointments may also be an opportunity to screen for PPD, so collaboration between obstetric pediatric is crucial.,,
About 54.5% of our respondents indicated that they sometimes followed up to see if women had treatment after screening. This is much lower than another study done where 75% of women screening positive for PPD were referred to a psychiatry unit for further evaluation.
One of the reasons why respondents felt women do not come for follow-up or get screened for PPD was that the women were unaware that something is wrong. This is collaborated by one small study showing that <20% of women with PPD had reported any symptoms to a HCP.
Most respondents (87.1%) had a good attitude toward PPD screening with religion and ethnic group being significantly associated with attitudes toward PPD screening. It was not surprising that respondents felt stigma and shame of mental illness are additional barriers to access to mental health care and screening, perpetuated by traditional/religious beliefs and prejudices, and is similar to other studies.,, Mothers may not seek help because they are reluctant to be identified as having PPD. In other studies, the type of provider was associated with attitude to PPD screening; family practitioners had more favorable attitudes than pediatricians.
The study had several limitations which should be considered when interpreting the results. This study had a cross-sectional design, making a causal relationship for attitudes and practices toward PPD screening difficult to determine. The nonrandom sampling method means results may not be a representation of the population of HCW. There may have been some responder bias.
| Conclusion and Recommendations|| |
Most respondents do not routinely screen women for PPD and are not very familiar with PPD screening tool. This means a window of opportunity to screen for PPD is being missed in this vulnerable population. The HCW, however, had good attitudes toward PPD screening. While further studies are required, we recommend adequate staffing and correct placements and continuous preservice and in-service training/retraining of HCPs to improve screening for PPD. Community awareness and health education on mental health issues will help reduce stigma and encourage disclosure of symptoms.
We wish to acknowledge all the nurses and doctors who assisted with the distribution and collection of questionnaires at different health facilities.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]