Prevalence and Predictors of Postpartum Depression: Northwest Ethiopia

Background Postpartum depression is an umbrella, which encompasses several mood disorders that follow childbirth within 6 weeks. Screening for postpartum depression would improve the ability to recognize these disorders and enhance care that ensures improved clinical outcomes. Early identification of postpartum depression is important in order to plan for implementation strategies that allow for timely treatment and support of women with postpartum depression. Objective To determine the prevalence and associated factors of postpartum depression among women who gave birth in the last six weeks in Gondar town, Northwest Ethiopia, 2018. Methods A community based cross-sectional study was conducted among 526 women who gave birth in the last 6 weeks from July 1 to 30, 2018 in Gondar town. Cluster sampling technique was used. Data were collected by semi-structured and pretested questionnaire and entered into epi-Info version 7.0 and then analyzed by SPSS version 20.0. Both bivariate and multivariable logistic regression model were fitted. Adjusted odds ratio with 95% confidence interval has been computed and variables with p-value <0.05 were considered statistically significant. Results The prevalence of postpartum depression among 526 postnatal women was 25% (95% CI: 21, 28). Abortion history (AOR = 1.79, 95% CI: 1.07, 2.97), birth weight <2.5 kg (AOR = 3.12, 95% CI: 1.78, 5.48), gestational age below 36 weeks (AOR = 2.18, 95% CI: 1.22, 3.88) unplanned pregnancy (AOR = 2.02, 95% CI: 1.24, 3.31), relatives' mental illness (AOR = 1.20: 1.09–3.05), had no antenatal visit (AOR = 4.05, 95% CI: 1.81, 9.05), had no postnatal visit (AOR = 1.82, 95% CI: 1.11, 3.00) were factors significantly associated with postpartum depression. Conclusion and Recommendations. The prevalence of PPD was found to be higher. Variables like abortion history, low birth weight, gestational age below 36 weeks, unplanned pregnancy, relatives' mental illness, had no antenatal visit, and had no postnatal visit were predisposing factors to postpartum depression. Preventive measures to avoid low birth weight and pregnancy complications are also identified as proactive ways to reduce postpartum depression. Early identification and treatment of depression during ANC and postpartum care can mitigate the impact of PPD on the mother-baby dyad. Emphasis must be given women to have ANC and PNC follow up.


Introduction
Postpartum depression is a very common problem, which occurs in women of childbearing age within 6 weeks of childbirth, but is o en unrecognized or undiagnosed and a significant public health burden [1]. Risk factors for postpartum depression include social stressors, such as poverty, intimate partner violence, history of pregnancy loss, unintended pregnancy, and these variables have adverse effects on maternal health [2]. An important distinction that makes postpartum depression unique from other depression disorders is that it is marked by prominent anxiety components [3]. e problem of postnatal depression not only has immediate adverse effects on the mother, her newborn, child, and the family but can also lead to long-term morbidity of chronic or recurring depression [4].
Current models of postpartum care in developed countries originated in the beginning of the 20 th century in response to the high maternal and neonatal mortality rates of the time [5]. Untreated postpartum depression can have adverse long-term effects. In addition to the maternal risk from chronic depression, offspring may exhibit emotional, behavioral, cognitive, and interpersonal impacts associated with their mother's depression [6].
Four million births occur in the world annually; approximately forty percent of new mothers are affected with different types of postpartum mood disorders including depression symptoms before and during pregnancy [7]. e relevance of this research on PPD establishes not only the regional prevalence of the disorder but identifies proactive approaches to both identify the disorder and modify the complications of PPD. e endpoint is to mediate the impact of PPD on the mother and child dyad, the family, and the community. e prevalence of postpartum depression varies from 1.9% to 82.1% in developing countries [8]. Global studies show differing prevalence rates, with researchers in Canada reporting a prevalence of 40% [9], and in Jamaican 56% and 34% depression prevalence during prepartum and postpartum periods, respectively [9]. Studies show that the prevalence of postpartum depression is 9.2% in Sudan [10]. In addition, in a study carried out in eastern Tigray zone, Ethiopia, the prevalence of major depression at six weeks postpartum was 19% [11].
e effects of postnatal depression on the mother, her marital relationship, and her children make it an important condition to diagnose, treat, and prevent. e provision of care will vary depending on the socio-demographic and obstetric factors. Globally, PPD prevalence and associated risk factors are important to identify, especially in low and middle income countries. e aim of this research is to translate this information to health care workers and to women in order to improve care related to PPD. e identification of the magnitude and risk factors that determine postpartum depression will help health care providers and other concerned bodies to suggest the diagnosis and interventions to be designed for the neglected postpartum depression. Postpartum depression is a neglected problem. It causes a lot to maternal ill health, jeopardizes the newborn health, and quite o en destablizes the family. e study will also provide greater inputs to the government and program managers for designing of programs, proper implementation, and evaluation of their contribution for the achievement of the new adopted agenda as Sustainable Development Goals (SDGs) in relation with postpartum depression.

Study Design & Period.
A community based crosssectional study design was conducted from July 1 to 30, 2018.

Study Area.
The study was conducted in Gondar town which is located 750 km from Northwest of Addis Ababa, the capital city of Ethiopia. According to the 2017 population projection, the total population size of Gondar town was estimated to be 338,646. From the total population of Gondar city 23.58% were women in the reproductive age group. The city has one comprehensive specialized hospital, 8 health centers, and three private maternity specialty clinics that give maternity services and one private primary hospital.

Source Population.
All women who gave birth in Gondar town.

Study Population.
All women who gave birth in the last 6 weeks prior to the study period and reside more than 6 months in the selected Kebele of Gondar town.

Inclusion
Criteria. All mothers who gave birth 6 weeks prior to the data collection period at the selected kebeles of Gondar city.

Sample Size Estimation.
e sample size was determined by considering the assumptions for single proportion formula.
Sample size was =519 but I have got 7 additional participants in the cluster. e final sample size was 526.

Sampling
Procedure. Gondar town has a total of 21 kebeles. e reference population was homogeneous, we use those 21 kebeles as a cluster; from these 8 kebeles were selected randomly using the lottery method. en from each selected clusters, we took all women who gave birth in the last six weeks. en the data collector used map and location of the urban health extension workers to get selected mothers as shown in the following ( Figure 1). Obstetric variables: parity, premature labor, unplanned pregnancy, losing or hospitalizing a baby, mode of delivery, pregnancy complication or illness, stressful life event during pregnancy, experienced death of baby, and undesired fetal sex. Previous psychiatric history: history of depression and family history of psychiatric problems, and social support. Social support: poor husband support, domestic violence, child birth without the presence of any relatives, unsatisfactory relationship with mother-in-law, unsatisfactory relationship with husband.

History of Depression.
Women who had mental illness that can interfere with a person's life. Sever feelings of sadness, hopelessness, and loss of interest in activities.

Happy Spouse.
Happy relationship/marriage with husband.

Data Collection Tools and
Procedures. Data were collected through pretested semi-structured face to face interview. e semi-structured questionnaires were prepared in local language, Amharic, to make it simple and understandable. One diploma midwifery student in each kebele for data collection and two BSc midwifery supervisors, total of 8 data collectors and 2 supervisors were recruited.

Data Quality Control.
e questionnaire was prepared in English, and then translated to Amharic (local language) and back to English to maintain consistency of the tool. Training was provided for data collectors and supervisors for one day about the purpose of the study and techniques of data collection. e trained data collectors were supervised during data collection and each questionnaire was checked for completeness in a daily basis. Data entry was conducted and it was cross checked. e questionnaire was pretested to check the response, language clarity, and appropriateness of the questionnaire, while the pretest was done outside study area at Maksegnit city with 5% of sample size. At the end of the pretest depending on its outcome, the correction measures were under taken.
2.9.6. Data Processing and Analysis. Data cleaning was performed to check for accuracy, completeness, consistencies, and missed values and variables. A er the data had been checked for completeness and accuracy, it was coded manually and then entered to Epi Info version 7.0 and exported to Statistical Package of Social Science (SPSS) version 20 for analysis. Descriptive statistics was performed on numerical value, standard deviation, frequencies, proportion to describe study population in relation to dependent and independent variables. Binary logistic regression was used to identify statistically significant independent variables and independent variables having -value less than 0.2 will go to multivariable logistic regression for further analysis. Adjusted odds ratio with 95% confidence interval was used to determine the degree and direction of association between covariates and the outcome variable. To adjust for confounding variables, a multivariable logistic regression was done, model fitness was checked using Hosmer-Lemeshow goodness of fit test, and a -value <0.05 with 95% confidence interval for odds ratio (OR) was used to determine significance.
2.9.7. Ethical Clearance. Ethical clearance was obtained from the Institutional Review Board (IRB) of University of Gondar on behalf of the Ethics Review Committee of the department of midwifery. A letter of cooperation was obtained from Gondar town health office. e reasons why the research was to be done was explained to the study subjects; informed consent was obtained from each study subject a er explanation of the purpose of the study, and involvement (to be participant) was a er their complete consent. Any mother who was not willing to participate in the study was not forced to participate, no personal identifications were included in the data sheet, and all data taken from the participants were kept strictly confidential and used only for the study purpose. According to this study, the odds of developing postpartum depression among women who ever had abortion were nearly two times than those who had no abortion history (AOR = 1.79, 95% CI: 1.07, 2.97).
In the current study, women who had low birth weight (<2.5 kg) new born were three times more likely to develop postpartum depression as compared to their counter parts (AOR = 3.12, 95% CI: 1.78, 5.48).
In this statistical analysis, respondents who gave birth below 36 weeks of gestational age were two times more likely to develop postpartum depression as compared to women who delivered at gestational age of 36 or more weeks (AOR = 2.18, 95% CI: 1.22, 3.88).
It was noted that unplanned pregnancy has been associated with the development of postpartum depression.

Depression Related Characteristics of Respondents.
Among the respondents, 46 (8.7%) of them had relatives with a mental illness history. Out of these, 60% of the women reported that her mother had mental illness problem. Sixty-three (12%) of the respondents had history of depression. Nearly three quarters of the candidate's husband (76%) were happy with their current marital status (Table 3).

Social-Support Related Characteristic of Respondents.
Among the respondents, 19.2% of them were abused by their husbands. e common type (71.3%) of the abuse was verbal in kind. Most of the women relatives (88.8%) were present in health facilities in the indexed child birth. On the other hand, (55.3%) the respondents had happy relationship with their husband's family (Table 4).

Prevalence of Postpartum Depression.
From the entire respondents the prevalence of postpartum depression was found to be 25% (95% CI: 21-28) as shown in Figure 2.

Factors Associated with Postpartum Depression.
e bivariate logistic regression analysis revealed that husband's occupation, income, live children, women who had abortion history, weight of newborn infant, gestational age at birth, planned pregnancy, complication during last pregnancy, ANC visit, PNC visit, history of relatives' mental illness, previous history of depression, happy with spouse, and relatives present at health facilities in the indexed delivery had association of postpartum depression at -value less than 0.2.
Concerning multivariable logistic regression analysis, abortion history, birth weight, gestational age, planned pregnancy, ANC visit, history of relatives' mental illness, and women who had PNC visit were found to be significant associated factors of postpartum depression at -Value <0.05.  respondents who had unplanned pregnancies were two times than those women who had planned pregnancies (AOR = 2.02, 95% CI: 1.24, 3.31). Participants who did not have antenatal visits were exposed to postpartum depression development. e study revealed that respondents who did not have antenatal visits were four times more likely to be depressed compared to those who had antenatal follow-up (AOR = 4.05, 95% CI: 1.81, 9.05). ere is also a strong relationship between postnatal visit and postnatal depression. In this study, the odds of developing postpartum depression among respondents who did not have postnatal visits were nearly two times more likely to be depressed than those who had postnatal visits (AOR = 1.82, 95% CI: 1.11, 3.00). e report also declared that the odds of developing postpartum depression among participants whose relatives had mental illness history were 1.2 times more likely to be depressed than those whose relatives did not have mental illness history (AOR = 1.20, 95% CI: 1.09, 3.05) ( Table 5).

Discussion
e aim of this study was to assess the prevalence and associated factors of postpartum depression among women who gave birth in Gondar town, Ethiopia. e study evidenced that the prevalence of postpartum depression was found to be 25%. is finding is in accordance with studies conducted in Iran-23.2% [12] and 28.1% in the Trabzon province [13]. However, the reports of the current study were found to be higher compared to studies done in Canada 8.69% [14], New Delhi 12.75% [15], Kampala-Ugandan urban primary health care 6.1% [16], Gujarati 12.5% [1], Harare Ethiopia 13% [17], and 19% prevalence in the eastern zone of Tigray [11]. e possible explanation might be the differences in study setting and type of design utilized. e other difference might be 68.2% of the respondents in this study were secondary and above by education. Higher educational levels for mothers may contribute to reporting postpartum depression, as they are aware of their depression and are empowered to report the symptoms. is also attributes that women with good educational level may have intellectual skills and better copying strategies.
On the other hand, the estimate of postpartum depression in the current study was lower than the study conducted in Victoria South Australia 38.3% [18], Nepal University Hospital 29% [19], Rawalpindi General Hospital 33.1% [20], in Cape-Town 45.1% [21], in Turkey 32.1% [12], and 48.6% in Karachi, Pakistan [22]. e higher prevalence may be related to the site of delivery, as many studies listed were conducted in university hospitals and regional referral centers. e findings may also be impacted by those patients who have access to care and those who seek care for depression in the postpartum period. e other explanation might be due to socio-cultural differences of respondents. It is vital to consider the role of culture and the impact patient's beliefs and the cultural support for receiving help for postpartum depression.
Women who ever had abortion, birth weight below 2.5 kg, gestational age below 36 weeks, planned pregnancy, antenatal visit, relatives who had mental illness, and postnatal visit were in Canada [23].
is could be that depressed or anxious women may have exaggerated pessimistic concerns about the health of their newborn compared with those women who are psychologically well. Lastly, it might be due to the reason that low birth weight is likely to cause women to feel depressed for the newborn and to feel that she has failed to fulfill the baby's needs during her life span of pregnancy.
In this statistical analysis, respondents who gave birth below 36 weeks of gestational age were two times more likely to be depressed compared to those who gave birth at gestational age of 36 or more weeks. is finding is supported by a study conducted in Canada [23], Istanbul, Turkey [12], Arabic women [24], and Harare, Ethiopia [11]. e study might be due to the uncertainty about the survival of the newborn and doubts about one's capacity to cope with the care of an abnormal or ill newborn child.
It was noted that unplanned pregnancy has been associated with the development of postpartum depression. e odds of developing postpartum depression among respondents who had unplanned pregnancies were two times more likely to be depressed compared those whose pregnancies were planned. e result was supported with studies conducted in Uganda, and Nigeria [11,25], Istanbul, Turkey [26], Kuwait [1], and Harare, Ethiopia [11]. e possible explanation might be because in African cultures child bearing was so widely desirable that issues of whether a baby was wanted never arose, even though individual women might not be psychologically or economically prepared for pregnancy. An unplanned baby's birth is likely to affect the whole life and career plans of a woman. is unplanned life course may predispose women to develop depression in her postpartum period. factors significantly associated with development of postpartum depression.
According to this study, the odds of developing postpartum depression among respondents who ever had abortion were nearly two times more likely to be depressed compared to those who had no abortion history. is report was supported by studies conducted at Gujarati postpartum women [1] and rural southern Ethiopia [2]. is might be because of the fact that women who had abortion will pose different psychosocial problems and they might regret for fear of complication development during their life of pregnancy. e study revealed that the odds of developing postpartum depression among respondents whose new born child with low birth weight were three times more likely to be depressed as compared those who had high birth weight (≥2.5 kg) of new born. is report was in accordance with studies conducted  postnatal visits were nearly two times more likely to be depressed compared to those who had postnatal visits. Although assumed that accessing care would lead to increased diagnosis of postpartum depression, the postpartum visits may in fact provide guidance, reassurance, and appropriate referrals that are unavailable to those who do not seek care. Health care professionals have an ability to both educate and empower mothers as they care for their babies, their families, and themselves.
e report also declared that the odds of developing postpartum depression among participants whose relatives had mental illness history were 1.2 times more likely to be depressed compared to those whose relatives did not have mental illness history. is finding was in accordance with studies conducted in Istanbul, Turkey [26], Bahraini [1], and Arba Minch, Ethiopia. e links between genetic pre-disposition to mood disorders, considering both nature and nurture are important to address. PPD may be seen as a "normal" condition for those Participants who did not have antenatal visits were exposed for development of postpartum depression. e study revealed that respondents who did not have antenatal visits were four times more likely to be depressed compared to those who had antenatal follow-up. is report was in agreement with studies conducted at north Carolina, Colorado [27], Khartoum, Sudan [28] and Gondar University Hospital, Ethiopia [29]. e study results may be affected by the care given during the antenatal care visits, where counseling and anticipatory guidance is given by care providers to expectant mothers. e care may build maternal self-esteem and resiliency, along with knowledge about normal and problem complications to discuss at care visits. Mothers who value ANC care may also have different views on their right to mental and physical wellness, including access to care.
ere is also a strong relationship between postnatal visit and postnatal depression. In this study, the odds of developing postpartum depression among respondents who did not have to Gondar town administrative office and kebele leaders for their endless hospitality and commitment to make this project possible. ey would also like to extend their appreciation to the study participants, supervisors, and data collectors.
who are acquainted with relatives with mood disorders, especially during the childbearing years. Family history of mental illness can be easily elicited in the ANC first visit history. is information targets women who may have additional PPD risks and need special attention during the postnatal period.

Conclusion and Recommendation
e prevalence of postpartum depression was found to be higher compared to the national target value. Factors that are associated with increased PPD include women who have had abortion history, low birth weight newborn, gave birth prematurely, had unplanned pregnancy, had no ANC follow up, and had no PNC follow up. Women at increased risks also had relatives with mental health histories, and those with previous history for depression were more likely to have postpartum depression a er their birth.
Early identification and treatment of depression during postpartum care can mitigate the impact of PPD on the mother-baby dyad. Emphasis must be given women to have ANC and PNC follow-up. Data Availability e data used to support the findings of this study are available from the corresponding author upon request.

Conflicts of Interest
e authors declare that they have no conflicts of interest.

Authors' Contributions
Eyerualem Desta dra ed the proposal. Mengstu Melkamu analyzed the data and dra ed the paper. Both Mengstu Melkamu and Haymanot Alem approved the proposal with some revisions, participated in data analysis, and revised subsequent dra s of the paper. All authors read and approved the final manuscript. ese authors contributed equally to this work.