6B Women's Mental Health- Murray

8/11/2019 6B Women's Mental Health- Murray

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Postnatal Depression in Central

VietnamLinda Murray, PhD

University of Tasmania


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Global Epidemiology of PND

Prevalence estimates range from 1020 % worldwide

Prevalence of 19.8% in low and middle income countries (LMIC)

< 10% of low and middle income countries have data available

Australia had a prevalence of 16% (2008)

To date, only two studies published in Vietnam which estimatedprevalence of 33% (Ho Chi Minh City) and 29% (Hanoi)

PND has been associated with poorer infant health anddevelopmental outcomes and increased infectious disease in LMIC

Anoop et al, 2004; Fisher et al, 2004;2010; 2012;Halbreich & Karkun, 2006; OHara, 1994; Fisher et al, 2012;UNFPA & WHO, 2008; Beyondblue, 2008


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Study Aims

To add insight into the prevalence of PND in Vietnam

To explore whether PND in Central Vietnam is strongly

linked to cultural factors (both risk and protective), such

as son preference and traditional confinement practices

To investigate associations between high EPDS scores

and infant health outcomes

To identify family and social determinants to assist in the

design of mental health interventions


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Study Design

Systematic

LiteratureReview

Qualitative Research

Participatory qualitative research with health

workers and postpartum women

- Focus group activities:12 healthworkers

- In-depth interviews: 17 health

professionals; 20 (10 rural, 10 urban)

postpartum women

Quantitative Research

- Pilot of quantitative questionnaire

- Cross-sectional survey of 431 women 4

weeks6 months postpartum

Dissemination of Findings


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Exploratory Qualitative Research

What would cause a woman to become depressed afterhaving a baby?

Concept mapping groups (n=12)

Iterative in-depth interviews (n=37)

Participants:

Maternal health specialists

Psychiatrists

Midwives and nurses

Traditional medicine specialists

Postpartum Women


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Concept Mapping Process

1. Brainstorm a list of statements

2. Sort the statements into meaningful groups

3. Rate the statements on a 5 point likert scale

- Is this statement likely to cause PND

- Is this statement likely to protect against PND

- Is this statement important to study4. Analyse using Concept Systems

5. Present and discuss the analysis as a group


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Statements in Clusters

Cluster Statements

1. Economic

Situation

2 Worry about losing employment (applies to professionals)

11 Lost opportunities for promotion (e.g after third child)

1 Economic difficulty

9 Loss of income post delivery

10 Sufficient financial resources

4 Less time for social activities

2. Family Aspects25 Informational support from relatives and family

44 Happy/harmonious family21 Supportive husband

22 Gender of the baby is the one they desired

3. Society and

Friendship

26 Support from the reproductive health program

40 Good atmosphere

43 Help of the neighbourhood

46 Support from mothersfriends

4. Mothers

Emotions and

Worry

34 Single mother

31 Husband very concerned about the gender of the baby

5 Gender of the baby the parents dontwant

33 Gender of the baby the mother didntwant

39 Disappointment because the gender is different to the ultrasound

10 Lack of confidence about place in the community (e.g after third child)

3 Worry about physical appearance after delivery


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Statements in Clusters Continued...

5. Negative

Stressors

14 Husband isntloyal38 Grandparents dontaccept the baby and send it to an orphanage

30 Husband is rude, drinks, and goes out a lot

13 Lack of care, concern and help from relatives

35 A family member has recently died

45 The family observes traditional customs the mother doesnt want to

follow

6. Babys Health 6 Stillbirth15 The baby has a congenital disability

18 Poor health of the baby

32 Baby difficult to nurse

17 Worry about enough milk for the baby

42 Healthy baby

24 The baby is feeding well

7. Mothers Health 19 The mother has a history of mental illness8 Obstetric complications (e.g postpartum haemorrhage)

37 Caesarean wound infection

12 Other physical disease during pregnancy and delivery36 Pain and fatigue after delivery

7 Pain during delivery

8. Protective

Factors

16 Sleeplessness due to the baby

28 Regular diet

29 Sufficient relaxation, wakes up late

27 Physical activity for avoiding stress

41 Mother doesntsmoke or drink coffee or alcohol

23 The mother has enough time to take care of the baby


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Point Map


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Cluster Map


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Most Likely to Cause PND


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Most Likely to Protect Against PND


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Son Preference

Obstetrician: I had a patient, a woman who is a teacher, she had the firstbaby but unfortunately she is a girl, so after delivery she calls this

postnatal depression because the woman didnt like to contact with otherpeople. She just lies, her back to the baby and doesnt want to eat, she

didnt want to eat and didnt want to talk to other people, because of thegender.

Linda: And what about the husband?

Obstetrician:Because when she was pregnant and she took an ultrasoundand the doctor said that this was a boy and the husband was very hopeful,but after delivery the baby was a girl. So the husband was a little bitdisappointed and it made the woman feel bad.


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Tradition and change in Confinement Practices

When we have babies we think if women dont keep warm or go to work toosoon when we get older we will have some diseases like a stomach ache orheadache...the mother tells the daughter and everybody does that yeah. But

now, the daughter...knows its not necessary but I have to do that or mymother will not be happy.Nurse Educator


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Quantitative Survey (n = 431 mothers)

Dependent Variable

Edinburgh Postnatal Depression Scale (Vietnamese)

(continuous variable)Independent Variables

- Socio Economic Status and infant gender

- Obstetric Factors

- Traditional birth/confinement Practices- Social Support

- Maternal Competence and Self Esteem

- Infant Health


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Study SitesThua Thien Hue Province


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Urban Survey Sites


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Urban Health Centre


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Rural Survey Sites


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Rural Health Centre


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Demographic Characteristics

The women were;

Mostly aged 30 or less (64%)

93% attended some years of

secondary school; but less

than 1 in 5 had been to college

or university

Nearly all were married (97%)

Only one in five (21%) workedin a job that provided paid

maternity leave


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Prevalence of PND (EPDS cut off 12)

Urban (n = 216) Rural (n = 215) Total (n = 431)

20.4% (n = 44) 15.8% (n = 34) 18.1% (n = 78)


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Traditional Confinement Practices


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Bivariate Analysis of Confinement Practices and

Depression


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Is son preference linked with PND?


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Social Influences on PND


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Infant Health and PND

Associations between:

Diarrhoea

Breastfeeding problems

Amount child cries


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Multivariable Generalised Linear Models: EPDS Score

Variable P value Variable P value

Classed as poor 0.39 Frightened ofFamily

0.013

Husbands

employment

0.036 Frightened of

Husband

0.006

Food insecurity 0.007 Violence in past12 months


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Multivariable Generalised Linear Models: WHO5

Wellbeing

Variable P value Variable P value

Location 0.015 Family reaction togender (MIL)

0.004

Classed as poor 0.009 Frightened of

family

0.008

Food insecurity 0.055 Violence in past 12months


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Strengths and Limitations

Strengths Sequential exploratory mixed methods design

Triangulation and community participation

Community based survey randomised at district and commune level

Limitations Translation of qualitative data

Refusal rate of 40.5%

Insufficient statistical power to analyse family structure and infant genderin multiparous women

Unable to establish antenatal mental health history of participants


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Conclusions

Postnatal depression was common (18.1%) and at the upper

end of international averages (10%-20%)

Qualitative narratives indicated a link between sonpreference/infant gender and maternal depression

However, this study did not find that female gender was

strongly linked to PND, including where the mother hadconsecutive female children and no son.

It does appear that family reaction to infant gender is

somewhat linked with maternal wellbeing


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Conclusions

What we see in Vietnam is PND as a universal reaction to family, child andrelationship adversity

Many traditional confinement practices were associated with higher EPDSscores (e.g. Not washing, cotton wool in ears; lying over heat etc).

However, multivariable analysis revealed that the strongest influences onmothers mental health were inter-partner violence, being frightened offamily members, food insecurity and low social integration

Also mothers with higher EPDS scores reported breastfeeding problemsand infant diarrhoea

Contrary to some prior research, it may be that PND is only minimallyinfluenced by culture-bound practices including son preference


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www.utas.edu.au


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ReferencesAnoop, S., Saravanan, B., Joseph, A., Cherian, A., & Jacob, K. S. (2004). Maternal depression and low

maternal intelligence as risk factors for malnutrition in children: a community based case-control study

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Massachusetts: Jones and Bartlett Publishers.

Beyondblue. (2009).Beyond Blue Australia. Retrieved January 21, 2009, from http://www.beyondblue.org.au/.

Brockington, I. F. (1996).Motherhood and Mental Health. Oxford: Oxford University Press.

Cox, J. L., Holden, J.M., Sagovsky, R. (1987). Detection of Postnatal Depression: Development of the 10 item

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Bursac, Z., Gauss, C. H., Williams, D. K., & Hosmer, D. W. (2008). Purposeful selection of variables in

logistic regression. Source Code for Biology and Medicine, 3(17), 1-8.

Fisher, J. R. W., Morrow, M. M., Ngoc, N. T. N., & Anh, L. T. H. (2004). Prevalence, nature, severity and

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Fisher, J., Cabral de Mello, M., Patel, V., Rahman, A., Tran, T., Holton, S., & Holmes, W. (2012). Prevalence

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and depressive symptoms.Journal of Affective Disorders, 91, 97-111.
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ReferencesPatel, V., Weiss, J. A., Chowdhary, N., Naik, S., Pednekar, S., Chatterjee, S., . . .

Kirkwood, B. (2011). Lay health worker led intervention for depressive and anxiety

disorders in India. impact on clinical and disability outcomes over 12 months.

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health on infant growth in low income countries: new evidence from South Asia.

British Medical Journal, 328(7443), 820-823.

Trochim, W. M. K. (1989). An introduction to concept mapping for planning and

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UNFPA, & WHO. (2008).Maternal mental health and child development in low and

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