Prevalence of Antenatal Depression and Associated Factors among Pregnant Women Attending Antenatal Care at Dubti Hospital: A Case of Pastoralist Region in Northeast Ethiopia

Background Globally, depression affects an estimated 10 % to 20% of women during pregnancy. There is limited evidence on antenatal depression in Northeast Ethiopia. This study aimed to assess prevalence of antenatal depression and associated factors among Dubti Hospital Antenatal care attendants. Methods Institution based cross-sectional study was conducted among 363 Antenatal care attendants at Dubti Hospital from March 07 to May 07, 2016. Beck's Depression Inventory tool was used to collect data. Data were entered into Epi-Data 3.1 and analyzed using SPSS 20. Bivariable and multivariable logistic regression analyses were fitted. Variables having p value < 0.05 were considered as statistically significant. Results A total of 357 pregnant women were interviewed. The prevalence of antenatal depression was 17.9% [95% CI (14.0, 22.0%). Pregnancy planning [AOR: 0.04; 95% CI (0.014, 0.114), social support [AOR: 0.21; 95% CI (0.07, 0.66), and marital conflict [AOR: 6.45; 95% CI (2.1, 17.9)] were significantly associated with antenatal depression. Conclusions Nearly one in five pregnant women had depression. Marital conflict, pregnancy planning, and social support were significant predictors of antenatal depression. Dubti Hospital should strengthen its effort on prevention of unplanned pregnancy. Healthcare workers in antenatal care unit have to deal with marital conflict and social support as part of their routine investigation to avoid complications through early detection of antenatal depression.


Introduction
Antenatal depression is defined as the occurrence of a depressive episode in women during pregnancy. The World Health Organization (WHO) ranked depression as a single largest contributor to global disability in 2015. Depression has been reported more common among female population group as compared to male population group [1]. Depression affects an estimated 10 % to 20% of pregnant women worldwide. Depression is more prevalent among women in low-and middle-income countries compared to those women in high income countries [2]. The prevalence of antenatal depression varies across different parts of the world. It has been reported to be 47% in rural South Africa [3], 39.5% in Tanzania [4], 28.5% in China [5], 14.9 % in Italy [6], 13.8% in Sabah Malaysia [7], 13.2 % in Germany [8], and 10.9% in Turkey [9]. In Ethiopia, the prevalence of antenatal depression is reported to be 31.2% in Adama Hospital [10], 31.1 % in Maichew [11], 29.5 % in Sodo district of Gurage Zone [12], 24.9% in Addis Ababa Public Health Centers [13], 23% in Gondar University Hospital [14], and 11.8% in Debretabor Town [15].
Antenatal depression is a significant predictor for postnatal depression [16][17][18][19][20][21][22]. Beyond the woman, it is also an independent risk factor for offspring depression up to age of 18 [23]. Antenatal depression is associated with operative delivery and preeclampsia [24], preterm birth [25,26], and low-birth weight [25]. But, it is not associated with pregnancy loss or infant death [12]. Women with depressive symptoms had an increased risk of having more nonscheduled ANC visits and increased number of emergency healthcare visits 2 Depression Research and Treatment for pregnancy-related emergencies [12]. Increased depressive symptoms are also associated with no engagement in favorable health practices during pregnancy [27]. A cohort study in Malaysia revealed that women with antenatal depression were more likely to stop breast feeding before six months than their counterparts [28].
Previous studies have indicated that some of the most common risk factors for antenatal depression include younger age, low income, unemployment, single marital status, low educational status, psychiatric histories, use of substances, lack of social support, marital conflict, multigravidity, less number of parities, more number of children, unplanned pregnancy, history of abortion, and a history of obstetric complications [2,3,5,6,10,11,13,15,[29][30][31][32][33]. The Government of Ethiopia has launched and enforced a mental health strategy (2012/13-2015/2016) which aimed to provide mental health services at all levels of the existing health system including health posts. However, still there is a gap in mainstreaming a mental health service with the routine maternal health services, like antenatal care in the country. Previous studies have been conducted in Central and Northwest Ethiopia reporting different findings about antenatal depression. There is limited evidence regarding the prevalence and associated factors of antenatal depression in Northeast part of Ethiopia. Therefore, this study aimed to assess the prevalence and associated factors of depression among pregnant women attending antenatal care at Dubti Hospital in Afar Regional State, Northeast Ethiopia.

Study Design, Area, and
Period. An institution based cross-sectional study was conducted at Dubti Hospital. The hospital is located 10 km far from Samara, the capital city of Afar National Regional State. It is one of the six hospitals in the region, which offers a full range of healthcare services including antenatal care and mental health services. Apart from other services, the hospital provides a routine antenatal follow-up care for pregnant women. An evidence reported from the hospital showed that a total of 4560 pregnant women receive antenatal care annually from this hospital [34]. The study was conducted from March 07 to May 07, 2016.

Sample Size Determination and Sampling Procedure.
A sample size of 363 was calculated using a single population proportion formula: Assumptions. n is required sample size, Z is critical value for normal distribution at 95% confidence level (1.96), d = 0.05 (5% margin of error), P=31.2% (proportion of pregnant women having antenatal depression) [10], and an estimated nonresponse rate is 10%. First, pregnant women at any trimester of pregnancy who were attending antenatal checkup at Dubti Hospital during the study period were included. Then, systematic random sampling technique was used to select every other pregnant woman. Pregnant women who were seriously ill and unable to hear and/or speak were excluded from the study.

Data Collection Process and Instrument.
Data were collected using a pretested-interviewer administered structured questionnaire. The questionnaire was prepared first in English and translated into Amharic and then back to English to check for its consistency. The Amharic version of the questionnaire was used to collect the data.
Two female diploma nurses and one BSc public health professional were recruited as data collectors and supervisor, respectively. The data collectors and supervisor were trained for two days on the study objective and data collection process. The questionnaire was pretested on 5% of the sample size at Aysaita Hospital, and amendments on the questionnaire were made accordingly. Intensive supervision was done by the supervisor and principal investigator throughout the data collection period.

Study Variables.
The dependent variable in this study was antenatal depression. Beck's Depression Inventory Version-II (BDI-II) was administered to detect depression.
BDI is a reliable and valid measure of depression in a range of populations in most of the countries in the world including Ethiopia. It consists of 21 items, and each of the items describes a specific symptom of depression. Each statement is scored on a 4-point scale (0 to 3) and a total score is obtained by summing the ratings for each statement. Therefore, the total score ranges from 0 to 63 [35]. Then, a score of 17 and above was used as a cutoff point to detect antenatal depression in this study [7,9]. Finally, pregnant women who scored 17 and above were coded as "1" and those who scored less than 17 were coded as "0" for regression analysis.
The independent variables were socioeconomic characteristics (maternal age, educational status, marital status, occupation, and average family monthly income), obstetric factors (gravidity, parity, number of children, history of abortion, history of stillbirth, history of pregnancy complication, and pregnancy planning), psychosocial factors (social support and relationship with partner), history of a depressive disorder (in the women and family), and substance use. Average family monthly income was defined based on minimum Ethiopian monthly wage of 21 USD [36] that was about 500 Ethiopian birr during the study period.
In this study, ever use of substance was defined as pregnant women who had used a psychoactive substance at least once in their lifetime and using psychoactive substance within 30 days preceding the study as current use of substance.
Social support was measured using the Maternity Social Support Scale (MSSS) developed by Webster and colleagues [37]. The scale contains six items and includes questions on family support, friendship network, help from spouse, conflict with spouse, feeling controlled by spouse, and feeling unloved by spouse. Each item was measured on a five-point Likert scale and a total score of 30 was possible. Social support was classified into three categories: high social support (for scores [24][25][26][27][28][29][30], medium social support (18)(19)(20)(21)(22)(23), and low social support (below 18) categories.

Data
Processing and Analysis. The data were checked for completeness and consistencies. Data were also cleaned, coded, and entered into Epi-Data software version 3.1 and then exported to SPSS version 20 statistical package for analysis. The crude odds ratios with 95% confidence interval were estimated in the binary logistic regression analysis to assess the association between each independent variable and the outcome variable. Variables with 푝 value <0.25 in the bivariable logistic regression analysis were considered in the multivariable logistic regression analysis. The Hosmer-Lemeshow goodness-of-fit with enter procedure was used to test for model fitness. Adjusted odds ratios with 95% confidence interval were estimated to assess the strength of the association, and variables with 푝 value <0.05 were considered significant factors.

Sociodemographic Characteristics of the Study Participants.
A total of 357 pregnant women were included in the study, resulting in a response rate of 98.3%.
The mean (±SD) age of participants was 25.97 (±5.61) years with a range of 16 years to 43 years. Three hundred fortyfive (96.6%) and 205 (57.4%) women were married and had attended formal education, respectively. Almost 90 percent of study participants had reported that they earn an average family monthly income of more than 500 Ethiopian Birr (the minimum Ethiopian wage during that time) (Table 1).

Obstetric Characteristics.
More than three-fourth (76.2%) of pregnant women were in either the second or third trimester during the time of the study. Two hundred eighty-four (79.6%) of the women had planned their current pregnancy. Of 221 women who had a history of pregnancy, 55(24.9%) had a history of complication during previous pregnancy ( Table 2).  (Table 3).

Psychoactive Substance
Use. Twenty-one (5.9%) of the study participants had used alcohol at least once in the last 30 days. None of the participants had reported current khat chewing. None of the study subjects had used tobacco and shisha in their life time (Table 4).

Factors Associated with Antenatal Depression.
The prevalence of antenatal depression was 17.9% (95% CI: 14.0 -22.0%). Bivariable logistic regression analysis showed that maternal education, average family monthly income, history of complication in previous pregnancy, pregnancy planning, social support, marital conflict, and previous history of depression were statistically associated with antenatal depression at 푝 value <0.05 (Table 5).
In multivariable logistic regression analysis marital conflict, pregnancy planning, and social support were found to be significantly associated with antenatal depression at 푝 value <0.05 (Table 5).
Those women who had marital conflict were about six times more likely to have antenatal depression as compared to those who had no marital conflict [AOR=6.45(2.1, 17.9)]. Women who had planned their current pregnancy [AOR=0.04(0.01, 0.11)] were 96% less likely to have antenatal depression as compared to women who had no planned pregnancy. Compared to women who had low social support, women who had medium social support [AOR=0.21 (0.07, 0.66)] were 79 % less likely to have antenatal depression.

Discussion
Mental well-being is a fundamental component of WHO's definition of health. Good mental health enables people   [38]. The prevalence of antenatal depression in this study was lower than the findings from rural South Africa (47%) [3], Tanzania (39.5%) [4], Adama Hospital (31.2%) [10], Addis Ababa Public Health Centers (24.9%) [13], and Gondar University Hospital (23%) [14]. However, it was higher than the finding in Debretabor town (11.8%) [15]. This could be due to the sociodemographic and economic differences. The geographic and cultural variations might also attribute such differences among these studies. In addition, the measurements used to ascertain the outcome variable might differ. Beck's Depression Inventory (BDI), Edinburgh Postnatal Depression Scale (EPDS), and Patient Health Questionnaire (PHQ) were used in these studies which might give a varied estimate of the prevalence of antenatal depression in such studies. With regard to the determinants of antenatal depression, this study has found out that the factors significantly associated were marital conflict, pregnancy planning, and social support.
The existence of marital conflict was found to be a significant factor associated with antenatal depression. Those women who had marital conflict were about six times more likely to have antenatal depression as compared to women who had no marital conflict. This finding was consistent with previous studies [2,4,10,13]. This might be illustrated in  such a way that the physiological and psychological changes occurring during pregnancy might influence women to seek out close partner support without which it may increase the probability of antenatal depression. The increase in women's sexual problems during the early months of pregnancy might affect partnership characteristics, which in turn contributes to antenatal depression. A study conducted in Korea [39] showed that antenatal depression was associated with bad marital communication and marital dissatisfaction. Those women who had planned their current pregnancy were 96% less likely to have antenatal depression as compared to those women who had no planned pregnancy. This finding was consistent with other studies [7,30,40,41]. This is possibly because women who had planned pregnancy might be well prepared financially, psychologically, and socially for the phenomena of pregnancy and childbearing practice.
Women who had medium social support were 79% less likely to have antenatal depression as compared to those women who had low social support. Similar finding was reported from other studies [10,18,[29][30][31][32][33]. This might be explained that social support from women's partner, family, and friends might help them confront stressful life events by receiving emotional, material, and informational supports during pregnancy.
This study might have the following limitations. Since the study was hospital based, pregnant women with depression, who do not seek antenatal care service at Dubti Hospital, would not be caught. Beck's Depression Inventory is a screening tool. Therefore, making a diagnosis of antenatal depression based on this scale without the gold standard psychiatric examination could be difficult. The objective of this study was also to assess prenatal depression rather than postnatal depression. Hence, follow-up study may come up with comprehensive pictures of the problem among both pregnant and postpartum women.

Conclusions
Nearly one in five pregnant women attending antenatal care at Dubti Hospital had antenatal depression. Marital conflict, pregnancy planning, and social support were found significantly associated with antenatal depression. Therefore, Dubti Hospital should strengthen its effort on prevention of unplanned pregnancy. In addition, healthcare workers at the antenatal care clinic have to deal with marital conflict and social support as part of their routine assessment to avoid the complications through early detection of antenatal depression.

Data Availability
The data used to support the findings of this study are available from the corresponding author upon request.

Conflicts of Interest
Authors declared that they have no conflicts of interest.

Authors' Contributions
Yihalem Abebe Belay conceived, designed the study, supervised the data collection, and performed the data analysis and interpretation. Nurilign Abebe Moges, Fetuma Feyera Hiksa, Kassahun Ketema Arado, and Misgan Legesse Liben assisted in designing the study, data analysis, and data interpretation. Yihalem Abebe Belay, Nurilign Abebe Moges, and Misgan Legesse Liben drafted the manuscript. All authors read and approved the final manuscript.