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30/9/2007WHO study on PPD for urban and rural
population 1
Assessing prevalence and determinants of PPD Pakistani population
Presenter: Dr. Rozina Farhad MistryAga Khan Health Service Pakistan
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PAKISTAN-SHARE OF THE WORLD 2005
POPULATION: 153 MILLION ( 2.37%)
WOMEN IN RH GROUP: >33 million
CHILDREN IN <5: >22 million
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Countries HDI Countries HDI
Canada 4 China 94
United States 8 Kyrgystan 110
Cyprus 30 Sao Tome 123
Poland 37 India 127
Mexico 53 Ghana 131
Brazil 72 Cameroon 141
Georgia 97 Pakistan 142
Peru 85 Bangladesh 138
Turkey 88 Sierra Leon 177
Ecuador 100
COUNTRIES ACCORDING TO THE HUMAN DEVELOPMENT INDEX 2004
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2005 - OTHER HARD FACTS - MILLIONS
•POPULATION LIVING BELOW POVERTY LINE = 35.5
•POPULATION WITH NO ACCESS TO SAFE
WATER FOR DRINKING = 56.9
•POPULATION WITH ONE ROOM HOUSE = 57.9
•POPULATION WITH NO SANITATION = 78.2
•ADULT LITERATCY RATE = 57.4%.
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University ofCentral As ia
The Aga KhanUniversity
IMAMAT
THE AGA KHAN DEVELOPMENT NETWORK
Economic Deve lopment CultureSocial Development
Age Khan Fund forEconomic Development
Aga KhanFoundation
The Aga Khan Trustfor Culture
Tour ism PromotionServices
IndustrialPromotion Services
Aga KhanEducation Services
Aga Khan Awardfor Architecture
Historic CitiesSupport Programme
Fi nancialInstitutions
Aga KhanHealth Services
Education andCulture Programme
Aga Khan Building andPlanning Services
Aga Khan Program for Is lamic Architectureat Harvard University and Massachuset ts
Institute of Technology
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Primary•To assess prevalence of postpartum depression (PPD) among postpartum mothers in urban area (Karachi) and in the rural (Northern Areas) of Pakistan using the screening tool of Edinburgh Postpartum Depression Scale (EPDS).
Secondary•To assess any differences in health and growth outcomes of children of the mothers diagnosed as having PPD versus the mothers without it.
Primary•To assess prevalence of postpartum depression (PPD) among postpartum mothers in urban area (Karachi) and in the rural (Northern Areas) of Pakistan using the screening tool of Edinburgh Postpartum Depression Scale (EPDS).
Secondary•To assess any differences in health and growth outcomes of children of the mothers diagnosed as having PPD versus the mothers without it.
Research Questions
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Definition of Post Partum Depression
• DSM IV defines Postpartum depression as a form of severe depression after delivery that requires treatment.
• Studies state that postnatal depression is a psychological disorder which occurs within six weeks after childbirth
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• After delivery:• 50%-75% of the new mothers
experience "baby blues" • 10% of these women develop a
longer-lasting depression • one in 1,000 women develop the
more serious condition called postpartum psychosis
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ICD 10 diagnostic criteria for PPD
i) At least two of the following features must be present for at least two weeks: • A depressed mood for most of the day• Loss of interest or pleasure in
activities that are normally pleasurable, such as playing with the baby
• Tiredness, decreased energy, and fatigue
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ii) Any four of the following should be present:
• Loss of confidence and self esteem• Feelings of guilt and blaming oneself• Recurrent thoughts of suicide or death,
including that of the child• Difficulty in concentration• Agitation or lethargy• Sleep disturbance• Appetite disturbance
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PPD-WHY SHOULD WE BE CONCERNED
WHY?WHY?????
WHY?WHY?????
Mother suffering from PPD is unable to do things she needs to do every day
Only 20% seek Rx. The remaining individuals remain either undiagnosed, misdiagnosed, or seek no medical assistance .
In the absence of Rx, PPD can get worse and last for as long as a year.
PPD is a serious condition, it can be effectively treated with antidepressant medications and counseling
PPD has consequences for the physical and psycho-social development of children.
Infants show growth retardation at several time points in the first year of life
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Rationale for the study
• Widely different PPD rates have been documented for developing countries
• Scarce country specific data
• Advocacy for incorporating early diagnosis and management of PPD mother and her baby
• To develop culturally appropriate interventions to create awareness about impact of PPD on mothers and children
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Biological factors
Socio environmental
factors
Obstetric related factors
Post Partum Depression
Impact On maternal
Health
Impact onGrowth outcome
of Children
CONCEPTUAL FRAMEWORK
Child related factors
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• Cross sectional study with simple random sampling
• Study Sites:
a) Karachi (urban setting) Three women and children hospital of Aga
Khan Health Service, Pakistan
b) Gilgit and Ghizer district in the Northern
Areas (rural setting).
STUDY DETAILS
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Actual sample surveyed Total: 1256Urban: 720Rural : 536
Response rate Urban: 97.5% Rural : 95.7%
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Data collection instrument
• The instrument used in the study had two sections:
• General information section• Developed on the basis of log of factors
identified from various studies
• Edinburgh post partum depression scale
RESULTS
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General Socio-demographic charecteristics of the population
26.51
2.23
1.98
1.95
8.07
21.94
26.8
3.07
2.87
2.77
11.13
18.84
0 5 10 15 20 25 30
Age in years
Number of Pregnancies
Number of Live Births
Number of alive children
Persons in the house
Age at marriage
Rural
Urban
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61
191 195197
166
83
221
57
5 8
72
00
50
100
150
200
250
Ultra Low Low Middle High Don’tKnow
Noresponse
Comparative analysis of socio-economic status
KarachiNorth
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Method of assessing nutritional status
% Malnourished
Urban Area
n=720*
Rural Area
n=536*
Overalln=125
6*
Weight for Age Z-scores % < -2
o 95% CI
3.3%(2.2, 5.0)
1.3%(0.6, 2.8)
2.5%(1.7, 3.5)
Weight for Length (height) Z-scores
% < -2o 95% CI
4.5%(3.1, 6.3)
2.2%(1.1, 4.3)
3.7%(2.7, 5.0)
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31%
40%
19%
9%
1%
0% 5% 10% 15% 20% 25% 30% 35% 40%
Immediately afterdelivery
Within first 2 hoursof delivery
Within first 24hours of delivery
After 24 hours ofdelivery
Never breast fed
Breast feeding practice in the combined sample
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ANALYTICAL FINDINGS
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Statistical analysis• SA was done using SPSS-10.0
• Frequencies and percentages of the variables was calculated
• Logistic regression analysis was performed to assess the significance of the variables by taking PPD either present or absent as a binary variable
• P value of <0.05 was considered significant
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Prevalence of depressive symptoms
650
70
475
61
0
100
200
300
400
500
600
700
800
Urban Rural
Developed PPD
Not developed PPD
(11.4%)
(9.7%)
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21.8
19.5
20.6
18
18.5
19
19.5
20
20.5
21
21.5
22
Urban Rural Combined
Family history of depression
Percentages
OR=2.66P<0.001
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Variables Total Positive (%) OR P-value
Any health problem during ANC
YesNo
157 (12.5)1099 (87.5)
15.39.7
1.67 0.033*
Delivery assisted byUnskilled Skilled
128 (10.2)1128 (89.8)
16.49.8
1.82 0.029
Place of deliveryHomeHospital/ Clinic
141 (11.2)1115 (88.8)
15.69.8
1.71 0.033*
Complications during deliveryYesNo
237 (18.9)1019 (81.1)
19.48.3
2.64 < 0.001*
Type of deliveryCaesarean section Vaginal delivery
216 (17.2)1040 (82.8)
14.49.6
1.58 0.038*
OBSTETRIC RELATED CONTRIBUTORY FACTORS OF PPD
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SOCIO-ENVIRONMENTAL CONTRIBUTORY FACTORS OF PPD
Variables Total Positive (%) OR P-value
Husband/ family feelings about pregnancy
Upset Happy
14 (1.1)1242 (98.9)
28.610.2
3.51 0.049
Personal feeling after deliveryStressful Relaxed
28 (2.2)1228 (97.8)
08 28.610.0
3.59 0.006*
Performing daily workingStressfully Calmly
619 (49.3)637 (50.7)
24.36.1
1.33 < 0.001*
Support from Husband /Others in daily work
HusbandOthers
466 (37.1)790 (62.9)
38 (8.2)93 (11.8)
1.50 0.042
Breast feedAfter 24 hours Within 24 hours
119 (9.5)1137 (90.5)
16.89.8
1.87 0.017*
Gender of babyGirl Boy
615 (49.0)641 (51.0)
12.28.7
1.45 0.045*
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Child related contributory factors of PPD
Variable
Mother with PPD
Mothers without PPD
p-value(n=131) (n=1124 )
Mean Birth Weight of babies (kg.) 2.91 3.02 0.01*
Mean Current Weight (kg.) 4.22 4.37 0.03*
% of mothers reported illness of their baby during preceding 2
weeks
47 % 26 % <0.001
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Comparison Of Significant Contributory Factors Of PPD Between Rural And Urban Cohorts
9
21.8
15.6
12.5
14.6
24
14.1
18
13.9
19.5
13.8
24.8
12.5
25.4
25.9
16.4
0 10 20 30
Low S.E. structure
F.H. of depression
Any health problems duringANC
Complication during delivery
Operative delivery
Stressful routine w orking
Breast feeding >24 hours
Baby suffering from illness
PercentageRural
Urban
0.126
0.746
0.891
0.560
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Factors that were not found to be contributory in the urban and the rural population
• Age of the mother (less than 20 years)
• Parity• History of child death• Family structure: nuclear/extended• Education of parents• Planned or unplanned delivery• Married more than once
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CONCLUSION
• Our study has highlighted that the prevalence of PPD is:• almost similar (10.4%) to that found in the
developed and many developing country setting
• PPD is more prevalent in rural then in urban population
• While there are many common determinants of PPD, there are also determinants which vary in urban and rural setting of Pakistan
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• A very strong association of PPD exists with the biological factor (family history of mental illness), obstetric and child growth related parameters
• Our study confirms that babies born to mothers vulnerable to PPD exhibit signs of lagging on the growth parameters as early as in 4-6 weeks of baby’s age.
CONCLUSION
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RECOMMENDATIONRECOMMENDATION
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CREATE SUPPORTIVE ENVIRONMENT
• More awareness programs are needed to reduce stigma attached to diagnosis of mental illness
• The roles of father and mother need to be redefined from their traditional boundaries into creating a more supportive environment.
• More awareness need to be created amongst the family member for extending additional social support to the new mothers.
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DEVELOP PERSONAL SKILLS
• Women and young girls need to learn to prepare themselves for different stages of life, to diagnose the condition and seek help at the right time.
• Birth preparedness should be an integral component of the reproductive health strategy
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REORIENT HEALTH SERVICES
• Midwifery, Nursing, and medical education should develop capacity in skilled birth providers about diagnoses, management and counseling skills on PPD
• Health care providers need to be trained to act as an enabler, mediator and advocate for implementation of policies and strategies that will support a mother suffering from PPD
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REORIENT HEALTH SERVICES
• Screening of mother for PPD should be instituted at 4-6 weeks of post natal period
• Unskilled birth attendants (TBAs) should be trained in early diagnosis and referral at the right time for PPD.
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STRENGTHEN COMMUNITY ACTION
• Support groups and networks need to be established for PPD mothers from where she and her husband should be able to get the support required to deal with this condition.
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HEALTH PUBLIC POLICY
• Promote Multisectoral interventions for destigmatizing mental illness in Pakistani society
• Media should be encouraged to bring about social change through challenging the traditional role of husbands in child rearing
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FUTURE STUDIES
• Assessment of prevalence of Ante-natal depression
• Prospective study of babies born to PPD mother upto two years of age
• Qualitative studies to understand the underlying norms of the societies related to gender preferences
• Further analysis of differential impact of socio-economic status on the occurrence of PPD
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STRENGTHS OF THE STUDY
• Estimated PPD prevalence both in rural and urban areas.
• Also assessed the impact of PPD on child growth parameters as early as 4 -6 weeks of age;
• Wide representation of the population from various socio-economic class
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Limitation of our study
• The cases identified at risk of PPD with >12 score or equal to 12 score were not clinically evaluated to confirm the diagnosis.
• It was not possible to undertake advanced statistical analysis such as multivariate analysis
• Findings cannot be generalized to the entire rural population of Pakistan because of the ethnically different population living in different rural areas of Pakistan.
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• Ms. Laila Khalfan• Dr. Abid Hoosein• Mr. Rasool Bux• Mr. Intisar Siddiqui• Mr. Shamsu Rehman• Field teams and staff of AKHS, P• Board of AKHS, P
Acknowledgment
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Thanks and Questions Thanks and Questions Please !Please !