Perinatal Depression in Rural Ghana: Burden, Determinants, Consequences, and Impact of a Community-Based Intervention.

The relative lack of research in mental health in low and middle income countries is symptomatic of the 10/90 gap in general health research where only 10% of the world’s expenditure on health research is dedicated to the poorest 90% of the world’s population. Globally there has been modest declines in both maternal and child deaths but there are still wide disparities between developed and developing countries; as the total number of under 5 deaths has declined, from 11.6 million in 1990 to 7.2 million in 2011, the proportion of deaths occurring in sub-Saharan Africa has increased from 33% in 1990 to 49% in 2011, and the region also bears the biggest burden (>50%) of maternal deaths. Innovations to reducing this burden are urgently needed in parallel with intensified efforts to increase coverage of proven effective maternal and child health interventions. One such innovation might be to include a focus on eliciting contextual determinants, and preventing and/or treating perinatal depression that is depression occurring during pregnancy or after birth, since there is some evidence suggesting that this is associated with adverse effects on infant health and development, and maternal health. This thesis is designed to add to this sparse evidence base by providing data on the burden of antenatal and postnatal depression in rural Ghana, examining determinants of this burden, investigating the links between perinatal depression and maternal and child health outcomes, and evaluating whether a home-visits intervention had reduced this burden. The research was undertaken within seven contiguous districts of the Brong Ahafo region of Ghana between January 2008 and July 2009. All women of reproductive age in these districts were part of a surveillance system supporting two randomised controlled trials that involved 4-weekly visits by resident fieldworkers who collected data on socio-demographics, obstetric histories, pregnancies, births, deaths and infant and maternal health. The research for this PhD involved training the surveillance field workers to also administer the depression module of the Patient Health Questionnaire screening tool (PHQ-9) to pregnant women and recently delivered mothers between 4-12 weeks after birth. 21135 pregnant women and 18356 recently delivered women were screened for depression, 13929 of whom were screened at both time points. The prevalence of postnatal depression (PND) was 3.8% (95% CI 3.5%, 4.1%), comprising 0.1% (95% CI: 0.08%-0.1%) who met criteria for major depression and 3.7% (95% CI: 3.4%-3.9%) for minor depression. The prevalence of antenatal depression (AND) was much higher 9.9% (95% CI: 9.5%-10.3%); 12.5% of these cases persisted into the postnatal period and accounted for 34.4% of postnatal cases. The following determinants were identified for antenatal depression: maternal age 30 years or older, never married, lower wealth status, non-Catholic religion, non-indigenous ethnicity, unplanned pregnancy, and previous pregnancy loss. And the following were identified for postnatal depression: never married, non-indigenous ethnicity, AND, season of delivery, peripartum/postpartum complications, newborn ill-health, still birth or neonatal death. Determinants were similar for ‘new’ cases of postnatal depression and for cases where depression was also detected antenatally. AND was found to be associated with the following consequences: prolonged labour, postpartum complications, peripartum complications, CS/instrumental delivery, severe newborn illness, and bed net non-use during pregnancy. PND was associated with increased risk of infant mortality up to six months (rate ratio [RR], 2·83 (1·56-5·16) and 12 months (RR, 1·79 (1·04-3·09) of age. Postnatal depression was also associated with increased risk of infant morbidity. Home-visits by community volunteers aimed at preventing neonatal deaths had no impact on attenuating prevalence of postnatal depression (relative risk [RR] 0.99 (95% CI 0.65, 1.50; p=0.96). This is the first large cohort study in SSA to provide evidence of determinants and consequences of perinatal depression, rather than studying the more general common mental disorder which include depression. The conclusions reached in this PhD are:1) Most risk factors of postnatal depression relate to adverse birth outcomes of the mother and/or baby, whereas those of antenatal depression are sociodemographic and pregnancy-specific, 2) Both antenatal and postnatal depression may have deleterious effects on the health of the mother and/or on child health and survival, 3) A case for clinical interventions for depression is established both during pregnancy and after birth, 4) Though often self-limiting, tackling antenatal depression could prevent up to a third of the burden of postnatal depression, 5) The timely implementation of such interventions using existing primary care structures may provide an important adjunct to improving maternal health and child health and survival efforts

Predictors of spontaneous remission and recovery among women with untreated perinatal depression in India and Pakistan

Abstract Background Mothers with perinatal depression can show different symptom trajectories and may spontaneously remit from depression, however, the latter is poorly understood. This is the first study which sought to investigate predictors of spontaneous remission and longer-term recovery among untreated women with perinatal depression. Methods We analysed data from two randomised controlled trials in women with perinatal depression in India and Pakistan. Analyses were restricted to women in the control groups who did not receive active treatment. Generalised estimating equations and logistic regressions were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs), adjusting for within-person correlation. Results In multivariable analyses, remission was associated with a husband who is not working (adjusted OR, aOR = 2.04, 95% CI 1.02–4.11), lower Patient Health Questionnaire-9 score at baseline (aOR = 0.43, 95% CI 0.20–0.90 for score of ≥20 vs. 10–14) and better social support at baseline (aOR = 2.37, 95% CI 1.32–4.27 for high vs. low social support). Conclusions Women with low baseline severity may remit from perinatal depression with adequate social support from family and friends. These factors are important contributors to the management of perinatal depression and the prevention of clinical worsening, and should be considered when designing low-threshold psychological interventions. </jats:sec

Implementing effective community-based surveillance in research studies of maternal, newborn and infant outcomes in low resource settings

BACKGROUND: Globally adopted health and development milestones have not only encouraged improvements in the health and wellbeing of women and infants worldwide, but also a better understanding of the epidemiology of key outcomes and the development of effective interventions in these vulnerable groups. Monitoring of maternal and child health outcomes for milestone tracking requires the collection of good quality data over the long term, which can be particularly challenging in poorly-resourced settings. Despite the wealth of general advice on conducting field trials, there is a lack of specific guidance on designing and implementing studies on mothers and infants. Additional considerations are required when establishing surveillance systems to capture real-time information at scale on pregnancies, pregnancy outcomes, and maternal and infant health outcomes. MAIN BODY: Based on two decades of collaborative research experience between the Kintampo Health Research Centre in Ghana and the London School of Hygiene and Tropical Medicine, we propose a checklist of key items to consider when designing and implementing systems for pregnancy surveillance and the identification and classification of maternal and infant outcomes in research studies. These are summarised under four key headings: understanding your population; planning data collection cycles; enhancing routine surveillance with additional data collection methods; and designing data collection and management systems that are adaptable in real-time. CONCLUSION: High-quality population-based research studies in low resource communities are essential to ensure continued improvement in health metrics and a reduction in inequalities in maternal and infant outcomes. We hope that the lessons learnt described in this paper will help researchers when planning and implementing their studies

Sustained effectiveness and cost-effectiveness of Counselling for Alcohol Problems, a brief psychological treatment for harmful drinking in men, delivered by lay counsellors in primary care: 12-month followup of a randomised controlled trial

Background Counselling for Alcohol Problems (CAP), a brief intervention delivered by lay counsellors, enhanced remission and abstinence over 3 months among primary care male attendees with harmful drinking in a setting in India. We evaluate the sustainability of the effects after treatment termination, the cost-effectiveness of CAP over 12 months, and the effects of the hypothesized mediator of ‘readiness to change’ on clinical outcomes. Methods and Findings Male primary care attenders aged 18-65 screening with harmful drinking on the Alcohol Use Disorders Identification Test (AUDIT) were randomized to either CAP plus Enhanced Usual Care (EUC) (n=188) or EUC alone (n=189), of whom 89% completed assessments at 3 months and 84% at 12 months. Primary outcomes were remission and daily standard ethanol consumed in the past 14 days; and the proposed mediating variable was readiness to change at 3 months. CAP participants maintained the gains they showed at the end of treatment through the 12-month follow-up, with the proportion with remission (AUDIT<8: 54.3% vs 31.9%; aPR 1.71 [95% CI 1.32-2.22]; p<0.001) and abstinence in the past 14 days (45.1% vs 26.4%; aOR 1.92 [95% CI 1.19-3.10]; p=0.008) being significantly higher in the EUC plus CAP group than in the EUC alone group. They also fared better on secondary outcomes including recovery (AUDIT<8 at 3 and 12 months: 27.4% vs 15.1%; aPR 1.90 [95% CI 1.21-3.0]; p=0.006); and percent of days abstinent (mean% [SD] 71.0 [38.2] vs 55. 0 [39.8]; AMD 16.1 [95% CI 7.1-25.0]; p=0.001). The intervention effect for remission was higher at 12 months compared to that at 3 months (aPR 1·50 [95% CI 1·09–2·07]. There was no evidence of an intervention effect on Patient Health Questionnaire-9 score, suicidal behaviour, percentage days of heavy drinking, Short Inventory of Problems score, WHO Disability Assessment Schedule II score, days unable to work, and perpetration of intimate partner violence. Economic analyses indicated that CAP was dominant over EUC alone, with lower costs and better outcomes; uncertainty analysis showed a 99% chance of CAP being cost-effective per remission achieved from a health system perspective, using a willingness to pay threshold equivalent to one month’s wages for an unskilled manual worker in Goa. Readiness to change levels at 3 months mediated the effects of CAP on mean daily drinking at 12 months (Indirect effect -6.014, 95% CI -13.99- to -0.046). Serious adverse events were infrequent and prevalence was similar by arm. The methodological limitations of this trial are the susceptibility of self-reported drinking to social desirability bias, the modest participation rates of eligible patients, and examination of mediation effects of only one mediator and in only half of our sample. Conclusions CAP’s superiority over EUC at the end of treatment was largely stable over time and mediated by readiness to change. CAP provides better outcomes at lower costs from a societal perspective

The Healthy Activity Program lay counsellor delivered treatment for severe depression in India: systematic development and randomised evaluation

BACKGROUND: Reducing the global treatment gap for mental disorders requires treatments that are economical, effective and culturally appropriate. AIMS: To describe a systematic approach to the development of a brief psychological treatment for patients with severe depression delivered by lay counsellors in primary healthcare. METHOD: The treatment was developed in three stages using a variety of methods: (a) identifying potential strategies; (b) developing a theoretical framework; and (c) evaluating the acceptability, feasibility and effectiveness of the psychological treatment. RESULTS: The Healthy Activity Program (HAP) is delivered over 6-8 sessions and consists of behavioral activation as the core psychological framework with added emphasis on strategies such as problem-solving and activation of social networks. Key elements to improve acceptability and feasibility are also included. In an intention-to-treat analysis of a pilot randomised controlled trial (55 participants), the prevalence of depression (Beck Depression Inventory II ⩾19) after 2 months was lower in the HAP than the control arm (adjusted risk ratio = 0.55, 95% CI 0.32-0.94,P= 0.01). CONCLUSIONS: Our systematic approach to the development of psychological treatments could be extended to other mental disorders. HAP is an acceptable and effective brief psychological treatment for severe depression delivered by lay counsellors in primary care

Evaluating the implementation of community volunteer assessment and referral of sick babies: lessons learned from the Ghana Newhints home visits cluster randomized controlled trial.

A World Health Organization (WHO)/United Nations Children's Fund (UNICEF) (2009) joint statement recommended home visits by community-based agents as a strategy to improve newborn survival, based on promising results from Asia. This article presents detailed evaluation of community volunteer assessment and referral implemented within the Ghana Newhints home visits cluster-Randomized Controlled Trial (RCT). It highlights the lessons learned to inform implementation/scale-up of this model in similar settings. The evaluation used a conceptual framework adopted for increasing access to care for sick newborns and involves three main steps, each with a specific goal and key requirements to achieving this. These steps are: sick newborns are identified within communities and referred; families comply with referrals and referred babies receive appropriate management at health facilities. Evaluation data included interviews with 4006 recently delivered mothers; records on 759 directly observed volunteer assessments and 52 validation of supervisors' assessments; newborn care quality assessment in 86 health facilities and in-depth interviews (IDIs) with 55 mothers, 21 volunteers and 15 health professionals. Assessment accuracy of volunteers against supervisors and physician was assessed using Kappa (agreement coefficient). IDIs were analysed by generating and indexing into themes, and exploring relationships between themes and their contextual interpretations. This evaluation demonstrated that identifying, understanding and implementing the key requirements for success in each step of volunteer assessment and referrals was pivotal to success. In Newhints, volunteers (CBSVs) were trusted by families, their visits were acceptable and they engaged mothers/families in decisions, resulting in unprecedented 86% referral compliance and increased (55-77%) care seeking for sick newborns. Poor facility care quality, characterized by poor health worker attitudes, limited the mortality reduction. The important implication for future implementation of home visits in similar settings is that, with 100% specificity but 80% sensitivity of referral decisions, volunteers might miss some danger signs but if successful implementation must translate into mortality reductions, concurrent improvement in facility newborn care quality is imperative

Coping strategies of women with postpartum depression symptoms in rural Ethiopia: a cross-sectional community study

Background: Most women with postpartum depression (PPD) in low- and middle-income countries remain undiagnosed and untreated, despite evidence for adverse effects on the woman and her child. The aim of this study was to identify the coping strategies used by women with PPD symptoms in rural Ethiopia to inform the development of socio-culturally appropriate interventions. Methods: A population-based, cross-sectional study was conducted in a predominantly rural district in southern Ethiopia. All women with live infants between one and 12 months post-partum (n = 3147) were screened for depression symptoms using the validated Patient Health Questionnaire, 9 item version (PHQ-9). Those scoring five or more, ‘high PPD symptoms’, (n = 385) were included in this study. The Brief Coping with Problems Experienced (COPE-28) scale was used to assess coping strategies. Construct validity of the brief COPE was evaluated using confirmatory factor analysis. Results: Confirmatory factor analysis of the brief COPE scale supported the previously hypothesized three dimensions of coping (problem-focused, emotion-focused, and dysfunctional). Emotion-focused coping was the most commonly employed coping strategy by women with PPD symptoms. Urban residence was associated positively with all three dimensions of coping. Women who had attended formal education and who attributed their symptoms to a physical cause were more likely to use both problem-focused and emotion-focused coping strategies. Women with better subjective wealth and those who perceived that their husband drank too much alcohol were more likely to use emotion-focused coping. Dysfunctional coping strategies were reported by women who had a poor relationship with their husbands. Conclusions: As in high-income countries, women with PPD symptoms were most likely to use emotion-focused and dysfunctional coping strategies. Poverty and the low level of awareness of depression as an illness may additionally impede problem-solving attempts to cope. Prospective studies are needed to understand the prognostic significance of coping styles in this setting and to inform psychosocial intervention development