Antenatal Depression and Associated Factors among Pregnant Women Attending Antenatal Care Service in Kochi Health Center, Jimma Town, Ethiopia

Background Antenatal depression has immense public health importance, as it can adversely affect both the mother and child health. The problem contributes to the disease burden in both developed and developing countries. Despite this, it is less investigated and not getting the necessary attention in the study setting. Objective The aim of the study was to assess the prevalence of antenatal depression and associated factors among women attending antenatal care (ANC) service in Kochi Health Center, Jimma town, southwest Ethiopia, 2019. Method Institutional based cross-sectional survey was conducted on 314 pregnant women attending Kochi Health Center from February 15 to April 15, 2019. A systematic random sampling technique was used to include the study participants. Antenatal depression was assessed using the Patient Health Questionnaire (PHQ-9) tool. Data was collected through face-to-face interviews using a pretested and structured questionnaire. Descriptive statistics was done to summarize the dependent and independent variables. Moreover, the chi-square test analysis was done to determine the association between the outcome and explanatory variables. Results A total of 314 pregnant women participated in the study, making a response rate of 96.7%. The study has revealed a total of 52 (16.6%) of the respondent had antenatal depression. A chi-square test of independence analysis showed a significant association between antenatal depression and marital status, family history of depression, pregnancy planning, history of abortion, social support, and intimate partner violence (P < 0.00001). Conclusion The study has shown that the prevalence of antenatal depression was high and associated with multiple psychosocial, clinical, and obstetric factors. Therefore, screening pregnant women for depression and the provision of necessary mental health services is recommended to mitigate the adverse health outcome of the problem.


Introduction
Globally, more than 350 million people of all ages suffer from depression, and more women are affected by depression than men [1,2]. According to the World Health Organization (WHO), depression is projected to become the second leading contributor to the global burden of disease by 2020 [3].
Common mental disorders such as depression are one of the public health problems of the developing world. Studies have shown that depression and substance abuse are rampant, overwhelmingly disabling, follows chronic courses when untreated, and can lead to increased morbidity and mortality [4,5].
Depressed women are more likely to have unhealthy practices during pregnancy, poor nutrition due to a lack of appetite, poor weight gain, and risk for intrauterine growth. Depressed women are less compliant with prenatal care and feel less invested in the care toward their pregnancy [6][7][8].
Antenatal depression is a condition that describes a range of physical and emotional changes that many women can have during pregnancy. Some of these symptoms include fatigue, crying, hopelessness, anxiety, problems concentrating, changes in appetite, sleeping difficulty, lack of interest in daily activities, and suicide. It is estimated that 25-35% of pregnant women have depressive symptoms, and 20% of them may meet the diagnostic criteria for major depression at some time during pregnancy [9,10].
It is a multifaceted illness that has varying consequences for a woman's mental health, physical health, the family's functioning, and her children's [11][12][13]. Antenatal depressive symptoms have the potential to impact negatively upon health service utilization and thereby contribute to increased perinatal complications, adverse pregnancy outcomes, and maternal mortality [14,15].
Untreated depression during pregnancy has been also associated with poor pregnancy and birth outcomes such as maternal preeclampsia, low birth weight, smaller head circumference, increased risk of premature delivery, increased surgical delivery interventions, and lower Appearance, Pulse, Grimace, Activity, and Respiration(APGAR) scores and is considered to be the strongest risk factor for postpartum depression [16][17][18].
In the developing world, antenatal depression is a critical public health problem because of its intergenerational impact on the mother, infants, and children [19]. One in three to one in five women in developing countries has a significant mental health problem during pregnancy and after childbirth [20,21]. In terms of regional distributions, high rates of mental health problems in pregnant women and mothers have been reported from Africa [22].
Many studies which have done in the topic area in Ethiopia were from the different regions of the country, having the knowledge of socio-cultural-economic difference among the regions in the country; this study will give an insight towards antenatal depression and associated factor among pregnant women attending ANC service in Jimma town, southwest Ethiopia. Despite national and international organizations focus on maternal mental health, antenatal depression remains a neglected issue in healthcare systems and given low priority in the study setting. Moreover, there is a paucity of evidence on antenatal depression. Indeed, better evidence is needed to support greater priority to mental health care and to design appropriate interventions. Additionally, the findings of this study will serve as a baseline for further research in the area.

Study Area and Period.
Kochi Health Center is located in Jimma town, which is found in Oromia regional state, southwest of Ethiopia, 352 km far away from the capital city, Addis Ababa. The health center is owned by the government and serving almost ten kebeles (lowest administrative unit) in the town. The health center has started health service in December 2000 and provides services such as outpatient treatment, ANC service, maternal and child health service, delivery service, antiretroviral therapy service, HIV/AIDS prevention from mother to child service, and public health services with an outreach program for a total of 11503 population in the catchment area. During the study, there were 1287 pregnant women who had ANC follow-up in the health center. The study was conducted from February 15 to April 15, 2019.

Study Design and Population.
The institution-based cross-sectional study design was conducted on randomly sampled pregnant women attending ANC services during the study period.

Sampling Technique and Procedure.
A systematic random sampling technique was used to include pregnant women attending the Kochi Health Center ANC clinic during the data collection period. The periodic interval was calculated using the formula K = N/n, where K is a periodic interval, N is the total population, and n is the estimated sample size, accordingly, K = 1287/325; approximately, every fourth pregnant women attended ANC service during the data collection period was included in the study.

Data Collection Tools and Procedures.
Data were collected by five trained midwives through a face-to-face interview. A structured questionnaire was developed through reviewing available relevant literature adapted from previous similar studies. The instrument includes items related to sociodemographic, antenatal depression, social support, obstetric and clinical parameters, intimate partner violence, and substance-related characteristics. Patient health questionnaire (PHQ-9) was used to screen antenatal depression symptom severity; accordingly, PHQ-9-score of 0-4 indicates minimal depression, 5-9 mild depression, 10-14 moderate depression, 15-19 moderately severe depression, and 20-27 as severe depression. A score of 10 and above is considered as a cutoff score for depression [23]. PHQ-9 has acceptable reliability and validity for the screening of antenatal depressive symptoms and for measuring the severity of depressive symptoms among Ethiopian pregnant women [24]. Maternity Social Support Scale (MSSS) was used to measure the respondent's social support status. The tool is a five-point Likert scale with a total maximum score of 30. Each item was rated as 5 for always, 4 for most of the time, 3 for some of the time, 2 for rarely, and 1 for never. Accordingly, social support was classified into three categories: high social support (scores [24][25][26][27][28][29][30], medium social support [18][19][20][21][22][23], and low social support (below 18) categories [21]. Intimate partner violence was measured by intimate partner violence scale; intimate partner violence was considered if a pregnant woman reported one of the following during the current pregnancy: husband/partner have done things to scare or intimidate on purpose or threatened to hurt someone they care about or hit, slapped, or thrown something that could 2 Journal of Pregnancy hurt her or forced or pressured to have sexual intercourse when she did not want to [25,26]. Obstetric and clinical parameters in this study include pregnancy planning, gravidity, parity, trimester, history of abortion, history of stillbirth, perceived complication during a previous pregnancy, having currently known medical illness, and currently taking medication. A family history of depression was assessed with the question: Is there any family member who has a diagnosis of depression? Substance use in this study includes frequent use of alcohol, khat (a local stimulant drug), tobacco, and cannabis. Moreover, substance use was measured by the WHO Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) screening tool. Accordingly, lifetime use was considered when a pregnant woman used any of the above-listed substances ever in her life, and the current use was considered when the pregnant woman used any of the above-listed substances within the last three months [27]. The English version of the questionnaire was translated into local language Amharic and Afaan Oromo and back translated into English to ensure its consistency by independent language experts of the field. Finally, the Amharic and Afaan Oromo versions of the questionnaire were used to collect the required data.
2.6. Quality Control Measures. Regular supervision was made by the data collection supervisors to ensure all necessary data were properly collected. Each day of data collection, the filled questionnaires were checked manually first for completeness 3 Journal of Pregnancy and consistency then inserted into the computer twice. A pilot test was conducted to identify the impending problems on data collection tools on 5% of respondents at the Bochobore Health Center; the necessary correction of the questionnaire was done accordingly to the pilot test result; the data collected during pilot test were not included in the analysis of the main study.
2.7. Data Process, Analysis, and Presentation. The collected data were cleaned, coded, and entered into the Epi-data version 3.1 data entry software and exported to the Statistical Package for the Social Sciences (SPSS) version 20 statistical software for analysis. Descriptive statistics were done to summarize the dependent and independent variables. A chisquare test of association was performed to identify factors associated with the outcome variable. Finally, variables with a P value of less than 0.05 were considered to have a statistically significant association with the outcome variable. The final result was organized through text narration and table form.
2.8. Ethical Consideration. The study was reviewed and approved by the Institutional Review Board (IRB) of Jimma University. Furthermore, permission was obtained from the Kochi Health Center for data collection. Participants were fully informed about the aims of the study, and written informed consent was sought before the interview. Privacy and confidentiality were ensured throughout the process of the study.
This study was conducted in accordance with the Declaration of Helsinki.

Social Support Status of the Respondent.
Approximately one-third 94 (29.9%) of the total respondents reported as they have good friends who always support them, and nearly half of the participants described as their husband or partner who always helps them a lot. Additionally, two-thirds of the respondents were reported as having a conflict with their husband or partner sometimes 109 (34.6), and about 141 (44.9%) replied as feeling always controlled by their husband or partner (Table 3).

Intimate Partner Violence Status of the Respondent.
A total of 53 (16.9%) of the study participants reported that their husband or partner has done things to scare or intimidate them, and nearly one-fifth 61 (19.4%) of the respondents described that they were hit, slapped, or thrown something that could hurt them by their husband or partner. Moreover, 16 (5.1%) reported that they were forced or pressured by their husband or partner to have sexual intercourse when they did not want to (Table 4).

Factors Associated with Antenatal Depression.
A chisquare test of independence has revealed statistically significant association between antenatal depression and marital

Discussion
This study was conducted to assess the prevalence and factors associated with antenatal depression among pregnant women attending ANC service in Kochi Health Center, Jimma, Ethiopia.
The study has revealed that 52 (16.6%) of the pregnant woman had antenatal depression during the current pregnancy. This result is nearly similar to 16% in the longitudinal study done in the US [28] but much lower than 31.9% in the  Journal of Pregnancy study done in Saudi Arabia [29], 42.7% in Pakistan [30], and 15 to 65% in a systematic review done globally [31]. On the contrary, the finding of this study is higher than 9.18% and 12.3% in the study done in Mumbai and Bengaluru, India, respectively [32,33], and 14.2% in Rio de Janeiro, Brazil [34]; this may be because a better health service provision of the countries compared to Ethiopia. The finding of this study is almost similar to 15.9% in Southern KwaZulu-Natal, South Africa [35], 17.9% in the Dubti Hospital Afar region [21], and 15.2% in Aneded woreda, Amhara Region, Ethiopia [36]. But the result is lower than 24.3% in a systematic review and meta-analysis in South Asia [37], 24.5% in Abeokuta North Local Government Area in Nigeria [38], 21.5% in the findings from, 21.28% in a systematic review and metaanalysis in Ethiopia [22], and 23.5% in another systematic review and meta-analysis in Ethiopia [8], Hawassa [39], and 24.9% in Addis Ababa [40]. The finding is much lower when it compared to 47% in rural South Africa [41] and 37.6% in Rwanda [42]; this variation may be explained by the difference in the socio-cultural-economic status of the countries, the difference in the study tool used, cutoff point scores, and the sample size used. In this study, marital status was found to have a significant association with antenatal depression; this is similar with the studies done in Poland [43], Abeokuta North Local Government Area, Nigeria [38], Mombasa city, Kenya [44]; a systematic review and meta-analysis in Ethiopia [8]; another systematic review in Ethiopia [8]; and the national health survey Ethiopia [45], Anended woreda in Amhara Region Ethiopia [36], and Ankesha district, Awi zone, North West Ethiopia [46]. This could be because the psychological, physical, and economic support by the partner could play a significant role in reducing the risk of depression during pregnancy [47].
Similarly, family history of depression was associated with antenatal depression; this finding is similar with the studies done in Dare Salam Tanzania [48]; an umbrella review on the global burden of antenatal depression [31], the study was done in Arba Minch [49] and Mizan Aman [50]. This could be explained by the role of genetics and psychosocial support system of the family dynamics that could contribute to the development of depression during pregnancy [51].
In the current study, pregnancy planning was found to have an association with antenatal depression similarly; consistent findings were reported from the study done in Hyderabad, Pakistan [52], and Nigeria [38] and a systematic review in Ethiopia [8], Aneded woreda, North West Ethiopia [36], Addis Ababa [53], Hawassa [39], and Awi zone, North West Ethiopia [46]. This showed that psychological preparedness and readiness to conceive might be a contributing factor to depression during gestation.
In this study, social support was associated with antenatal depression; similar findings were reported from the study done in the USA [54], KwaZulu-Natal, South Africa [35], and Kenya [44]; a systematic review and meta-analysis conducted in Ethiopia [22]; and another systematic review in Ethiopia [8] and Hawassa, Ethiopia [39]. This might be explained by social support that has been shown to promote mental health and acts as a buffer against depression [55], so lack of social support could be implicated for the high risk of depression during pregnancy.
A significant association was found between intimate partner violence and antenatal depression; similar reports were obtained from the studies done in Hyderabad, Pakistan [52], and KwaZulu-Natal, South Africa [35]; a case-control study in Kenya [44]; and a systematic review and metaanalysis conducted in Ethiopia [22] and Aneded woreda, North West Ethiopia [36]. This could reveal that psychological, physical, and sexual abuse by the intimate partner particularly during pregnancy could lead to depressive symptomatology.
This study has found the association between history of abortion and antenatal depression; similar findings were reported from the study done in the US [56], Netherlands [57], China [58], Japan [59], and Hawassa [39]. Having a history of spontaneous abortion could have strong psychological sequelae. This will ultimately induce fear, uncertainty, worry, and anxiety and further increase the risk of depression during subsequent pregnancies [47].

Conclusions
The prevalence of antenatal depression among pregnant women attending ANC service in Kochi Health Center was high and significantly associated with marital status, family history of depression, pregnancy planning, history of abortion, social support, and intimate partner violence. Integration of mental health service with ANC follow-up service and screening pregnant women for possible depression has paramount importance for a healthy pregnancy and prevention of the possible adverse health outcomes on the mother and the fetus.

Data Availability
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Conflicts of Interest
The authors declared that they have no conflicts of interest.