SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA PREVALENCE AND DETERMINANTS OF POSTPARTUM DEPRESSION IN FIRST-TIME MOTHERS AT KORLE BU TEACHING HOSPITAL BY LYDIA AFIA AYISI (10932919) THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PUBLIC HEALTH (MPH) DEGREE. JANUARY, 2023 University of Ghana http://ugspace.ug.edu.gh i DECLARATION I, Lydia Afia Ayisi, declare that except for other people's studies which have been duly acknowledged, this dissertation is the result of my original research undertaken under supervision and that it has neither in whole nor in part been presented for another degree in this university or elsewhere. LYDIA AFIA AYISI PROFESSOR AMOS LAAR (STUDENT) (SUPERVISOR) DATE: 30TH AUGUST, 2023 DATE: 30TH AUGUST, 2023 University of Ghana http://ugspace.ug.edu.gh ii DEDICATION This dissertation is dedicated to my children Adepa and Keita-Asher, who continue to teach me the intricacies of motherhood. You inspire me to reach for greater heights. I also dedicate this piece of work to all first-time mothers all over the world. A day at a time, motherhood does get better with time! University of Ghana http://ugspace.ug.edu.gh iii ACKNOWLEDGEMENT My heartfelt gratitude goes first and foremost to God Almighty for sustaining me throughout this programme and bringing me this far. My sincere appreciation also goes to my supervisor, Professor Amos Laar for his indispensable direction and for seeing to the successful completion of this work. To my interim supervisor, Dr. John Ganle for his immeasurable support, guidance, and assistance. For always ready to listen to me and offer advice. I would also like to extend my gratitude to my family; my husband Mr. Selorm Xatse and children Ewoenam Elyanna Adepa Xatse and Selorm Keita-Asher Xatse for being a pillar of support and motivation to me on this journey. My immense gratitude also goes to all the first-time mothers who availed themselves to be part of this study, without whom this work wouldn’t have been successful. Thank you for sharing your experiences, fears, and hopes about motherhood with me. And to everyone who contributed in one way or the other to the successful completion of this dissertation, I am eternally grateful. University of Ghana http://ugspace.ug.edu.gh iv ABSTRACT Background: Although postpartum depression (PPD) in mothers has been extensively studied, little is known about the rates, correlates, and effects of postpartum depression in first-time mothers. The main objective of this study was to determine the prevalence and correlates of postpartum depression in first-time mothers within 6 months of childbirth at Korle Bu Teaching Hospital (KBTH). Methods: A cross-sectional quantitative study was carried out between November 2022 and December 2022. Consecutive sampling technique was used to select participants. In all, 150 first-time mothers who were attending the postnatal/child welfare clinic at Korle Bu Teaching Hospital were recruited and interviewed. The Edinburgh Postnatal Depression Scale (EPDS) and a structured questionnaire were used for data collection. Descriptive analyses were done using frequency tables. Bivariate analysis (using chi-square) was done to determine the associations between independent (explanatory) variables and the outcome variable. Simple logistic regression was used to test for the strength of associations between the explanatory variables and the outcome variable. Multivariable logistic regression analysis was used to control for confounders and identify the determinants of PPD. Results: Overall, the prevalence of postpartum depression was 19.3%. Only 16% of the mothers received health professional counselling on PPD during antenatal. Age, employment status, divorced/separated recently, monthly expenditure, planned/expected pregnancy, number of antenatal visits attended, type of delivery, length of hospital stay after delivery, maternal anxiety, having a baby with special needs, previous history of depression, partner reliability and having an abusive partner were factors significantly associated with PPD. However, after adjusting for confounders, age (AOR=0.08, CI: 0.01-0.75) and maternal anxiety University of Ghana http://ugspace.ug.edu.gh v (AOR=16.93, CI: 2.31-123.84) were the only two factors that strongly predicted postpartum depression. Conclusion: This study has shown that the prevalence of postpartum depression in first-time mothers at Korle Bu Teaching Hospital is relatively high. This presents a significant public health concern that requires prompt action as it impacts not just the health and well-being of mothers, but also that of their children and families. There is a need for urgent measures for early detection and diagnosis, including counselling and psychosocial support both at home and in medical facilities. Further research, preferably using mixed-methods design may provide elucidation on not only the magnitude of the problem or its correlates but also the effects of postpartum depression and the lived experiences of first-time mothers. University of Ghana http://ugspace.ug.edu.gh vi TABLE OF CONTENTS DECLARATION ------------------------------------------------------------------------------------------ I DEDICATION ------------------------------------------------------------------------------------------- II ACKNOWLEDGEMENT ----------------------------------------------------------------------------- III ABSTRACT --------------------------------------------------------------------------------------------- IV TABLE OF CONTENTS ------------------------------------------------------------------------------ VI LIST OF TABLES -------------------------------------------------------------------------------------- XI LIST OF FIGURES ------------------------------------------------------------------------------------ XII LIST OF ABBREVIATIONS ----------------------------------------------------------------------- XIII CHAPTER ONE ----------------------------------------------------------------------------------------- 1 INTRODUCTION --------------------------------------------------------------------------------------- 1 1.0. BACKGROUND ------------------------------------------------------------------------------------- 1 1.1 PROBLEM STATEMENT ---------------------------------------------------------------------------- 3 1.2 OBJECTIVES ---------------------------------------------------------------------------------------- 6 1.2.1 General Objective --------------------------------------------------------------------------- 6 1.2.2 Specific Objectives -------------------------------------------------------------------------- 6 1.3 RESEARCH QUESTIONS ---------------------------------------------------------------------------- 6 1.4 JUSTIFICATION FOR THE STUDY ------------------------------------------------------------------ 7 1.5 CHAPTER SUMMARY AND DISSERTATION OUTLINE ------------------------------------------- 9 CHAPTER TWO ---------------------------------------------------------------------------------------- 10 LITERATURE REVIEW ------------------------------------------------------------------------------ 10 2.0 INTRODUCTION ----------------------------------------------------------------------------------- 10 University of Ghana http://ugspace.ug.edu.gh vii 2.1 THE CONCEPT OF POSTPARTUM AFFECTIVE DISORDERS -------------------------------------- 10 2.1.1 Baby Blues ---------------------------------------------------------------------------------- 10 2.1.2 Postpartum Psychosis ---------------------------------------------------------------------- 11 2.1.3 Overview of Postpartum Depression ---------------------------------------------------- 11 2.2 ASSESSMENT AND DIAGNOSIS ------------------------------------------------------------------ 12 2.2.1 Standardized Interviews ------------------------------------------------------------------- 12 2.2.2 Self-Report Questionnaires --------------------------------------------------------------- 12 2.2.3 Clinician-Rated Scales --------------------------------------------------------------------- 13 2.2.4 Diagnosis ------------------------------------------------------------------------------------ 13 2.3 COMPARISONS BETWEEN SCREENING INSTRUMENTS ----------------------------------------- 14 2.4 CHILD OUTCOMES -------------------------------------------------------------------------------- 16 2.5 MATERNAL OUTCOMES -------------------------------------------------------------------------- 17 2.6 PREVENTION AND TREATMENT OF POSTPARTUM DEPRESSION ------------------------------- 17 2.7 PREVALENCE OF POSTPARTUM DEPRESSION IN FIRST-TIME MOTHERS ---------------------- 18 2.8 FACTORS ASSOCIATED WITH POSTPARTUM DEPRESSION ------------------------------------- 20 2.8.1 Sociodemographic factors ----------------------------------------------------------------- 20 2.8.2 Obstetric, Maternal and infant-related factors ------------------------------------------ 21 2.8.3 Psychosocial, Clinical & Psychological factors ---------------------------------------- 22 2.8.4 Cultural factors ----------------------------------------------------------------------------- 23 2.9 CONCEPTUAL FRAMEWORK --------------------------------------------------------------------- 24 2.10 CHAPTER SUMMARY AND OUTSTANDING GAPS IN LITERATURE ---------------------------- 30 CHAPTER THREE ------------------------------------------------------------------------------------- 32 METHODOLOGY -------------------------------------------------------------------------------------- 32 3.0 INTRODUCTION ----------------------------------------------------------------------------------- 32 3.1 STUDY DESIGN ------------------------------------------------------------------------------------ 32 University of Ghana http://ugspace.ug.edu.gh viii 3.2 STUDY AREA -------------------------------------------------------------------------------------- 32 3.3 STUDY POPULATION ------------------------------------------------------------------------------ 35 3.3.1 Inclusion criteria ---------------------------------------------------------------------------- 36 3.3.2 Exclusion criteria --------------------------------------------------------------------------- 36 3.4 SAMPLE SIZE DETERMINATION ------------------------------------------------------------------ 36 3.5 SAMPLING PROCEDURE -------------------------------------------------------------------------- 37 3.6 Data collection methods ------------------------------------------------------------------ 37 3.7 INSTRUMENT FOR DATA COLLECTION ---------------------------------------------------------- 38 3.8 PRE-TEST ------------------------------------------------------------------------------------------ 40 3.9 DATA PROCESSING AND ANALYSIS ------------------------------------------------------------- 40 3.10 VARIABLES -------------------------------------------------------------------------------------- 41 3.10.1 Outcome variable ------------------------------------------------------------------------- 41 3.10.2 Independent (Explanatory) Variables -------------------------------------------------- 41 3.10 QUALITY ASSURANCE -------------------------------------------------------------------------- 43 3.11 ETHICAL ISSUES --------------------------------------------------------------------------------- 43 3.12 Chapter Summary ------------------------------------------------------------------------ 45 CHAPTER FOUR --------------------------------------------------------------------------------------- 46 RESULTS ------------------------------------------------------------------------------------------------ 46 4.1 INTRODUCTION ----------------------------------------------------------------------------------- 45 4.2 BACKGROUND AND SOCIODEMOGRAPHIC CHARACTERISTICS OF FIRST-TIME MOTHERS - 46 4.3 PREVALENCE OF POSTPARTUM DEPRESSION -------------------------------------------------- 50 4.3.1 Classification of PPD in respondents by severity -------------------------------------- 50 4.3.2 Classification of PPD in respondents by possibility/probability --------------------- 51 4.3.3 Postpartum depression status by some selected characteristics of respondents ---- 52 University of Ghana http://ugspace.ug.edu.gh ix 4.4 OBSTETRIC, MATERNAL AND INFANT, CLINICAL AND PSYCHOLOGICAL CHARACTERISTICS OF RESPONDENTS -------------------------------------------------------------------------------------- 54 4.4.1 Obstetric characteristics of respondents ------------------------------------------------- 54 4.4.1.1 Pregnancy and Antenatal-related characteristics of respondents --------------- 54 4.4.1.2 Delivery history of respondents ----------------------------------------------------- 54 4.4.2 Maternal and infant-related characteristics --------------------------------------------- 56 4.4.3 Clinical and psychological characteristics of respondents ---------------------------- 59 4.5 FACTORS ASSOCIATED WITH POSTPARTUM DEPRESSION ------------------------------------- 60 4.5.1 Background and sociodemographic factors associated with postpartum depression ------------------------------------------------------------------------------------------------------- 60 4.5.2 Obstetric factors associated with postpartum depression ----------------------------- 64 4.5.3 Maternal and Infant-related factors associated with postpartum depression ------- 66 4.5.4 Clinical and Psychological factors associated with postpartum depression -------- 68 4.5.5 Spousal and Social support factors associated with postpartum depression -------- 69 4.6 DETERMINANTS OF POSTPARTUM DEPRESSION ------------------------------------------------ 70 4.6.1 Associations between factors associated with PPD at the bivariate level and Postpartum depression (Simple Logistic Regression analysis) ----------------------------- 70 4.6.2 Determinants of PPD ----------------------------------------------------------------------- 72 CHAPTER FIVE ---------------------------------------------------------------------------------------- 76 DISCUSSION ------------------------------------------------------------------------------------------- 76 5.1 INTRODUCTION ----------------------------------------------------------------------------------- 76 5.2 SUMMARY OF FINDINGS -------------------------------------------------------------------------- 76 5.3 BACKGROUND AND SOCIODEMOGRAPHIC CHARACTERISTICS OF RESPONDENTS AND POSTPARTUM DEPRESSION. -------------------------------------------------------------------------- 77 5.4 PREVALENCE OF POSTPARTUM DEPRESSION IN FIRST-TIME MOTHERS ---------------------- 78 University of Ghana http://ugspace.ug.edu.gh x 5.5 FACTORS ASSOCIATED WITH POSTPARTUM DEPRESSION ------------------------------------ 79 5.6 STRENGTHS AND LIMITATIONS OF THE STUDY ------------------------------------------------ 82 5.7 CHAPTER SUMMARY ----------------------------------------------------------------------------- 83 CHAPTER SIX ------------------------------------------------------------------------------------------ 84 CONCLUSION AND RECOMMENDATIONS --------------------------------------------------- 84 6.1 CONCLUSION -------------------------------------------------------------------------------------- 84 6.2 RECOMMENDATION ------------------------------------------------------------------------------ 85 REFERENCES ------------------------------------------------------------------------------------------ 87 APPENDIX ---------------------------------------------------------------------------------------------- 96 APPENDIX I: CONSENT FORM ----------------------------------------------------------------- 96 APPENDIX II: DATA COLLECTION TOOLS ------------------------------------------------- 99 APPENDIX III: ETHICAL CLEARANCE ----------------------------------------------------- 112 University of Ghana http://ugspace.ug.edu.gh xi LIST OF TABLES Table 1: Background and Sociodemographic characteristics of respondents (n=150) ............ 48 Table 2: Obstetric characteristics of respondents .................................................................... 55 Table 3: Maternal and infant-related characteristics of respondents ....................................... 58 Table 4: Clinical and psychological characteristics of respondents ........................................ 60 Table 5: Association between sociodemographic characteristics and postpartum depression (Bivariate Chi-Squared Analysis) ............................................................................................ 62 Table 6: Association between Obstetric characteristics and postpartum depression (Bivariate Chi-Squared Analysis) ............................................................................................................. 65 Table 7: Association between maternal and infant-related characteristics and postpartum depression (Bivariate Chi-Squared Analysis) .......................................................................... 67 Table 8: Association between Clinical and Psychological characteristics and postpartum depression (Bivariate Chi-Squared Analysis) .......................................................................... 69 Table 9: Association between Spousal and Social support characteristics and postpartum depression (Bivariate Chi-Squared Analysis) .......................................................................... 70 Table 10: Factors associated with postpartum depression and Determinants of PPD ............. 73 University of Ghana http://ugspace.ug.edu.gh xii LIST OF FIGURES Figure 1: Conceptual framework showing possible factors that are associated with postpartum depression. Source: Author’s own construct based on review of literature ............................. 25 Figure 2: Prevalence of Postpartum Depression (PPD) ........................................................... 50 Figure 3: Classification of PPD by severity ............................................................................. 51 Figure 4: Classification of PPD by possibility/probability ...................................................... 52 Figure 5: Depression status by selected characteristics of respondents ................................... 53 University of Ghana http://ugspace.ug.edu.gh xiii LIST OF ABBREVIATIONS PPD Postpartum Depression KBTH Korle Bu Teaching Hospital EPDS Edinburgh Postnatal Depression Scale CWC Child Welfare Clinic DSM Diagnostic and Statistical Manual ANC Antenatal Care BDI Beck Depression Inventory CES-D Center for Epidemiological Studies Depression GHQ General Health Questionnaire PDSS Postpartum Depression Screening Scale PRQ Pregnancy Risk Questionnaire PRAMS Pregnancy Risk Assessment Monitoring System PHQ Patient Health Questionnaire PROM Patient-Reported Outcome Measure SVD Spontaneous Vaginal Delivery CS Caesarean Section University of Ghana http://ugspace.ug.edu.gh 1 CHAPTER ONE INTRODUCTION 1.0. Background The postpartum period is a difficult period of adjustment after childbirth, and nearly one in ten women develop postpartum depression. (Inekwe & Lee, 2022). Depression that develops after having a baby is known as postpartum depression (PPD). Unlike “baby blues”, which is the feeling of worry, sadness, and tiredness after childbirth, postpartum depression symptoms are more pronounced, persist longer, and typically do not resolve on their own (Centers for Disease Control and Prevention [CDC], 2022). Early postpartum depression symptoms detection and treatment are essential for the mother, child, and family's general health. When left untreated, postpartum depression symptoms can harm a child's development in both the short and long term, disrupt the home environment, and have a substantial impact on the bonding between a mother and her newborn (Suri & Altshuler, 2012). According to Azad et al., (2019), postpartum depression is a severe public health issue and is known to negatively impact both the physical and cognitive growth of the child as well as the mother's perinatal health. One of the major mental and public health problems, postpartum depression is a non-psychotic mood or mental disease that starts within the first four to six weeks after childbirth and can last up to one year, with the first six months being when it is most severe, where mothers are at a high risk of developing it (Alam et al., 2021; Inekwe & Lee, 2022; O’Hara & Mc Cabe, 2013). University of Ghana http://ugspace.ug.edu.gh 2 It presents with disabling symptoms which include changes in sleeping and eating patterns, fatigue, social withdrawal, sadness, crying, anxiety, guilt, loneliness, stress, and exhaustion (Coast, Leone, Hirose, & Jones, 2012). This makes it difficult for mothers to care for themselves and their babies, which in turn impacts the physical, social and cognitive development of the child negatively (Haithar, Kuria, Sheikh, Kumah, & Vander, 2018). Postpartum disorders however serious they are, have been underrecognized and undermanaged for various reasons. According to Suri & Altshuler (2012), this is partly because pregnant women receive little or no education about the risk of postpartum psychiatric illnesses, and many times symptoms go undetected by obstetricians. Also, some women are made to believe that these symptoms are normal with postpartum and would eventually resolve on their own. Furthermore, women who have depressive symptoms frequently don't seek professional assistance because they feel guilty for feeling downcast at a time when they should be joyous. Other reasons which may explain the underdiagnosis of postpartum depression are the fear of abandonment and lack of support owing to the stigma new mothers face upon disclosure of their insecurities and depressive symptoms (Mughal, Azhar, & Siddiqui, 2021). Meanwhile, studies show that the social support a woman receives after delivery, coupled with her maternal feeling of self-efficacy as a parent has the potential of influencing her mental status (Abdollahi, Agajani-Delavar, Zarghami, & Lye, 2016a). While the postpartum period can be a time of joy and positive expectations, it can also be a time of difficulty, stress, and increased vulnerability (Biaggi, Conroy, Pawlby, & Pariante, 2016). This is because mothers go through numerous psychological and physical alterations and face many challenges during this period (Khatun et al., 2018). This makes it a very University of Ghana http://ugspace.ug.edu.gh 3 challenging time for mothers, and new mothers are required to learn quickly to adapt to this new role of motherhood. While this may be difficult for most mothers, first-time mothers may particularly have a harder time adapting to the mother’s role, and so are more vulnerable to postpartum depression, whose symptoms can make motherhood take on a rather frustrating turn (Abdollahi et al., 2016). Findings from a study show that women with prior children showed a markedly lower prevalence of postpartum depression than first-time mothers across all age groups (UVAHealth, 2022). Evidence from a recent study in Dhaka city, Bangladesh also found that the probability of postpartum depression among first-time mothers was 2.08 times higher compared to others who were second-time or more (Alam et al., 2021). These investigations, among others, demonstrate that first-time mothers have a higher risk of developing postpartum depression. However, there is a scarcity of data exploring postpartum depressive symptoms in first-time mothers globally, especially in LMICs, precisely Sub- Saharan African countries, including Ghana. This suggests the need for more experimental studies on the subject in places like Ghana. 1.1 Problem Statement Depression is the leading contributor to the global burden of disease (Rahman, Surkan, Cayetano, Rwagatare, & Dickson, 2013) and found to have adverse effects on families and caregivers (Reynolds & Patel, 2017). A mother’s sensitivity, attachment, and parenting style are critical for the healthy development of the cognitive, social, and behavioral skills of her infant (Brummelte & Galea, 2016). University of Ghana http://ugspace.ug.edu.gh 4 Evidence shows that maternal depression, which includes postpartum depression, is linked to poor outcomes in infants such as undernutrition in the first year of life, higher rates of diarrheal and febrile diseases, and early cessation of breastfeeding (Guo et al., 2013; Okronipa et al., 2012; Ystrom, 2012). Research shows that about 1 in 8 women with a recent live birth experience symptoms of PPD. Estimates of the number of women affected by PPD differ by age, race/ethnicity, and state (Centers for Disease Control and Prevention, 2022). Approximately, 10–15% of women are affected by PPD (Brummelte & Galea, 2016). The prevalence of postpartum depression ranges from approximately 10% to 30% depending on the criteria used for diagnosis (Brummelte & Galea, 2016). The period prevalence of depression among women within the first postpartum year is 21.9% (Wisner et al., 2013). Globally, postpartum depression (PPD) has been reported to affect 10–20% of women (Brummelte & Galea, 2016; Fisher et al., 2012). Over the years, PPD has received attention because of its detrimental effects on both maternal and child health. Alterations in maternal hormones; steroid and peptide alter the hypothalamic pituitary adrenal (HPA) and hypothalamic pituitary gonadal (HPG) axes and subsequently affect maternal mood which in turn impairs mother-infant interaction. It is reported that mothers with PPD often exhibit less sensitivity and attachment, and harsher or more disturbed parenting behaviors, which may contribute to adverse child outcomes in their children (Brummelte & Galea, 2016). The global prevalence of PPD ranges from 0.5% to 60.8%, with lower percentages in high- income countries (6-13%) compared to about 20% in low-and-middle-income countries University of Ghana http://ugspace.ug.edu.gh 5 (LMICs) (Alam et al., 2021; Fisher et al., 2012). Studies show high prevalence rates in the majority of African countries than in high-income countries. For instance, PPD prevalence was reported to be 9.7% in Zambia, 33% in Zimbabwe, Nigeria (13.2%), Ethiopia (13.7%), Morocco (17.9%), South Africa (20.0%), Malawi (30.4%), Burkina Faso (44.0%) with lowest rates reported in Uganda (7.1%) (Parsons, Young, Rochat, Kringelbach, & Stein, 2011). Studies in Ghana reveal the prevalence of postpartum depression ranges from 7% to 32.6% (Anokye, Acheampong, Budu-Ainooson, Obeng, & Akwasi, 2018; Cadri, Aziz, Gyan, & Adomah-Afari, 2020; Saeed & Wemakor, 2019; Weobong et al., 2014). A recent study at Korle Bu Teaching Hospital found the prevalence of postpartum depression at 2 weeks postpartum to be 41.1% among mothers younger than 20 years and above 35 years (Sefogah, Samba, Mumuni, & Kudzi, 2020). While there is existing literature on postpartum depression in Ghana, there is however little information on the prevalence and correlates of depression in first-time mothers in Ghana (Saeed & Wemakor, 2019). Also, very little data exists on postpartum depression at the Korle Bu Teaching Hospital. Even though studies show a higher risk of PPD in first-time mothers than in other new mothers, there is still a paucity of data that examine PPD among first-time mothers in African countries like Ghana. To the best of my knowledge, this will be the first study on PPD in first-time mothers in Ghana. Therefore, this study aims to close this gap by examining the prevalence and correlates of PPD among first-time mothers at Korle Bu Teaching Hospital- a quaternary hospital in Ghana. University of Ghana http://ugspace.ug.edu.gh 6 1.2 Objectives The objectives of the study were divided into general and specific objectives 1.2.1 General Objective The general objective of the study was to determine the prevalence and correlates of postpartum depression in first-time mothers within 6 months of childbirth at Korle Bu Teaching Hospital. 1.2.2 Specific Objectives The specific objectives were to: 1. Estimate the proportion of first-time mothers within 6 months of childbirth with postpartum depression symptoms at the Korle Bu Teaching Hospital. 2. Describe the characteristics (e.g., obstetric, maternal, infant, clinical, and psychological) of first-time mothers within 6 months of childbirth attending postnatal/child welfare clinic (CWC) at the Korle Bu Teaching Hospital. 3. Identify the factors associated with postpartum depression in first-time mothers within 6 months of childbirth attending postnatal/CWC at the Korle Bu Teaching Hospital. 1.3 Research questions To achieve the research objectives above, the following research questions were investigated: 1. What proportion of first-time mothers attending postnatal/CWC at Korle Bu Teaching Hospital have postpartum depression symptoms? 2. What are the characteristics (e.g., obstetric, maternal, infant, clinical, and psychological) of first-time mothers attending postnatal/CWC at the Korle Bu Teaching Hospital with postpartum depression? 3. What are the factors associated with postpartum depression in first-time mothers attending postnatal clinic/CWC at the Korle Bu Teaching Hospital? University of Ghana http://ugspace.ug.edu.gh 7 1.4 Justification for the study Postpartum depression poses substantial health risks to both mother and baby (Sinclair, 2013). Globally, depression accounts for the largest proportion of the burden associated with mental or neurological disorders in women of child-bearing age (Murray et al., 2012). Maternal depression is the second leading cause of disease burden in women worldwide, following infections and parasitic diseases. It can lead to suicide, which is a leading cause of mortality in women of childbearing age and has long-term negative effects on the physical and cognitive development of infants (Rahman et al., 2013). According to Epperson (1999), the risk for PPD may be greatest for first-time mothers because they hold high expectations regarding childbearing but have no personal experience with which to compare their experiences. Postpartum depressive mood and self-care action were reported to be significantly related to fatigue in a study of first-time mothers of which a high proportion was found to have depressive mood (Khatun et al., 2018). New mothers tend to normalize depressive symptoms because they may be unable to recognize that what they are experiencing is PPD. They may also do so for fear of being judged as exhibiting maternal responses that are unfitting for motherhood (Logsdon, Foltz, Scheetz, & Myers, 2010). First-time mothers especially are less likely to seek help due to the seeming stigma attached to depression and so may hesitate to report depressive symptoms (Mughal et al., 2021). This often results in first-time mothers feeling more isolated and unequipped to deal with the multiple changes associated with the postpartum period, which can negatively impact their health status and parental efficacy (Pessagno & Hunker, 2013). University of Ghana http://ugspace.ug.edu.gh 8 Untreated PPD accompanied by fear and the lack of maternal experience in first-time mothers can lead to a host of maladaptations for both mother and baby which may lead to decreased mother-child bonding, severe social isolation, reduced maternal ability to care for the infant, reduced rate of identifying infant cues and increased incidence of developmental delay in infants (Reich, Silbert-Mazzarella, Spence, & Spiegel, 2005). Given the detrimental effects of PPD on both mothers and infants, epidemiological studies are required to implement early prevention and intervention measures. Although few studies have been conducted on PPD in first-time mothers, they were mostly done in Asia and other countries, which are not contextually fit for Ghana. To date, no study has investigated PPD, its determinants, or associated factors among first-time mothers in Ghana. Therefore, bridging this gap may contribute to guiding how the healthcare team plans care for first-time mothers in Ghana, improve the quality of their self-care, and develop their self-efficacy to protect their health and care for their newborns. Also, knowledge of the factors associated with postpartum depression in first-time mothers, its predictors or determinants, can help early identification of women at increased risk of affective disorders, and also provide a basis for early intervention. The results of this study may advance understanding and practice as well as aid healthcare professionals in correctly evaluating, screening for, and spotting early depressive symptoms in first-time mothers. It could also pave a way for policymakers to prioritize and subsequently include maternal mental health into maternal and child health care programmes and policies, and also to integrate mental health screening into routine primary care for pregnant and postpartum women and to follow up this screening with treatment or referral and with follow- up care. University of Ghana http://ugspace.ug.edu.gh 9 More so, the findings of this study would also serve as an important body of literature for upcoming scholars. 1.5 Chapter Summary and Dissertation Outline The above chapter provided a background to the study. The problem and the need for doing this study in Ghana were both extensively described in the chapter. This was followed by an outline of the objectives of the study and research questions, as well as the justification for the study. The dissertation’s remaining sections are organized as follows; The second chapter examines existing literature on postpartum depression with a particular emphasis on the factors associated with it. The study's methodology will be covered in detail in chapter three. The observations and outcomes are presented in Chapter four. Chapter five will detail a discussion of the findings and results, while chapter six finishes with pertinent recommendations. University of Ghana http://ugspace.ug.edu.gh 10 CHAPTER TWO LITERATURE REVIEW 2.0 Introduction This chapter discusses in general terms the concept of postpartum depression, its prevalence, diagnosis, and treatment, its causes, and contributing factors, as well as the various screening procedures used to identify postpartum depressive symptoms. Also presented is the conceptual framework that will serve as the study's compass. 2.1 The concept of postpartum affective disorders Affective / mood disorders are mental disorders that affect the emotional state of a person (Molly Burford, 2021). Baby blues, postpartum depression, and puerperal psychosis are three common mood disorders in women following childbirth. The mildest of these three is baby blues, whiles puerperal psychosis is the most severe (MGH Center for Women’s Mental Health, 2018). 2.1.1 Baby Blues “Baby blues” is a term used to describe mild mood symptoms that affect women after giving birth. It occurs early postpartum, around 2 to 5 days after childbirth, and lasts around 10 days to approximately 2 weeks. Crying episodes, changes in appetite, exhaustion, fatigue, sleep disturbance, restlessness, confusion, and sadness are some of its symptoms (CDC, 2022; Mughal et al., 2021). Unlike PPD whose symptoms are more intense, persistent, and severe, baby blues have little impact on daily activities or a mother's capacity to care for her child, and symptoms usually University of Ghana http://ugspace.ug.edu.gh 11 resolve spontaneously on their own within a few days, without sequelae (CDC, 2022; Meltzer- Brody, 2011). 2.1.2 Postpartum Psychosis Postpartum psychosis is a psychiatric emergency that occurs within the first few days or weeks after delivery, with a potential risk of suicide and infanticide. It is an acute start of depressive or manic psychosis where the puerperal woman can experience serious symptoms such as unusual behavior, hallucinations, agitation, numerous nights of sleep deprivation, and delusions (Mughal et al., 2021). It is rare, the severest of psychiatric illnesses during the postpartum period, and affects 1 to 2 women out of 1000 after childbirth (MGH Center for Women’s Mental Health, 2018). 2.1.3 Overview of Postpartum Depression Mughal et al. (2021) describe PPD as a significant depressive episode that occurs at the beginning of pregnancy or within four weeks of birth. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) recognizes postpartum depression as a condition when a patient has a major depressive episode concurrent with the peripartum start but does not recognize it as a distinct disease. In addition to having a history of childbirth, PPD exhibits similar signs and symptoms as non- puerperal depression. Depressed mood, altered sleep and eating patterns, loss of interest, feelings of worthlessness, an inability to focus, as well as anxiety and suicidal thoughts are some of the symptoms (Mughal et al., 2021). Others may cry more frequently than usual, feel angry, isolate themselves from loved ones, feel numb or detached from their child, worry that they may injure their child, feel guilty about not being a good mother, or have doubts about their capacity to care for their child (CDC, 2022). Delusions and hallucinations (voices saying University of Ghana http://ugspace.ug.edu.gh 12 to harm infant) are some examples of the psychotic symptoms that certain patients may experience (Mughal et al., 2021). Risk factors for PPD include lack of social support, prior depression, stressful life events, a family history of depression, having multiples, such as twins or triplets, being a teenage mother, preterm labor and delivery (before 37 weeks), pregnancy and birth complications, and difficulty in conceiving. Postpartum depression, however, can also happen to women who had a healthy pregnancy and delivery (CDC, 2022). It is estimated that over 40% of women will experience their first depressive episode during the postpartum period. (Wisner et al., 2013). During the first postpartum year, depression is prevalent in women at a rate of 21.9%. 2.2 Assessment and Diagnosis To measure depressive symptomatology, both general and postpartum-specific depression measures have been used. Among the instruments used are Self-report questionnaires, Standardized interviews, and Clinician-rated assessments (Stone et al., 2015). 2.2.1 Standardized Interviews Among the standardized interviews are the Schedule of Affective Disorders and Schizophrenia (SADS), Structured Clinical Interview for DSM-IV-R (SCID), Standard Psychiatric Interview (SPI), and Present State Examination (PSE). 2.2.2 Self-Report Questionnaires There are numerous self-reported assessments available to evaluate depressive symptoms and track treatment effectiveness. Typically, participants are asked to rate the frequency or University of Ghana http://ugspace.ug.edu.gh 13 seriousness of depression symptoms on these questionnaires; They cannot, however, be used to diagnose depression, thus respondents who score highly should be followed up with a clinical evaluation (Ogoe, 2018). Self-report questionnaires include, but are not limited to; the Beck Depression Inventory (BDI), Self-Report Questionnaire (SRQ), Hospital Anxiety and Depression Scale (HADS), Center for Epidemiological Studies Depression Scale (CES-D), General Health Questionnaire (GHQ), Depression Adjective Checklist (DACL), Postpartum Depression Screening Scale (PDSS), Profile of Mood States (POMS), Pitt Depression Scale, Zung Self-Rating Depression Scale (ZSDS), Patient Health Questionnaire (PHQ), and the Edinburgh Postnatal Depression Scale (EPDS). They cannot, however, be used to diagnose depression. 2.2.3 Clinician-Rated Scales The Hamilton Rating Scale for Depression (HRSD) and the Montgomery-Asberg Depression Rating Scale (MADRS) are some examples of clinical-rated scales for PPD. 2.2.4 Diagnosis A diagnosis of postpartum depression is made when at least five depressive symptoms last for at least two weeks. In addition to the five symptoms, which may include: Depressed mood (subjective or observed) present most of the day, Psychomotor retardation or agitation, Loss of interest or pleasure, most of the day, Insomnia or hypersomnia, Loss of energy or fatigue, Worthlessness or guilt, Suicidal ideation or attempt and recurrent thoughts of death, Impaired concentration or indecisiveness and Change in weight or appetite (weight change 5% over 1 month), the diagnosis must include either depression or anhedonia (loss of interest) (Mughal et al., 2021). University of Ghana http://ugspace.ug.edu.gh 14 2.3 Comparisons between Screening Instruments To identify potential PPD cases, a range of self-report screening techniques are utilized in clinical practice and research. The most popular self-report measures for PPD identification are the Edinburgh Postnatal Depression Scale (EPDS) and the Beck Depression Inventory (BDI), which have 10 and 21 items, respectively. The DSM-IV diagnostic criteria are the foundation of the Patient Health Questionnaire (PHQ-9), a nine-item depression screening tool that is frequently used in clinical settings to identify probable instances of depression and has also been validated in perinatal populations (Davis, Pearlstein, Stuart, O'Hara, & Zlotnick, 2013). Davis et al. (2013) assessed the accuracy of the BDI in 534 perinatal women at various time points. Based on the time period examined, the BDI's Receiver Operating Characteristic (ROC) values ranged from 0.8 to 0.9, making it equivalent to diagnostic interviews for identifying PPD. The best cut-off point for the BDI, however, was found to vary according to the perinatal time period, according to this study. In the same study, the diagnostic validity of the Pregnancy Risk Assessment Monitoring System (PRAMS)-6, PHQ-9, PRAMS-3D, and PRAMS-3A were evaluated against the Hamilton Rating Scale for Depression and the Structured Clinical Interview for DSM-IV (SCID). The PRAMS-6, PHQ-9, PRAMS-3D, and PRAMS-3A all demonstrated a fair degree of accuracy in identifying PPD. Sidebottom, Harrison, Godecker, and Kim (2012) found that, using a PHQ-9 cutoff of 10, the sensitivity and specificity rates for a diagnosis of depression were 85 percent and 84 percent, respectively, and for a sub diagnosis, they were 75 percent and 88 percent, respectively. University of Ghana http://ugspace.ug.edu.gh 15 Depressive symptoms in the postpartum period have been evaluated using a variety of methods. Nevertheless, some of these tools weren't created expressly to measure PPD. This is true of the General Health Questionnaire (GHQ), the Inventory of Depressive Symptomatology (IDS), the Zung Self-Rating Depression Scale (Zung SDS), the Center for Epidemiological Studies Depression Scale (CES-D), and the Beck Depression Inventory (BDI and BDI-II). These are, in reality, tools for measuring the discomfort that is related to and connected with general depressive symptoms. Additionally, some techniques haven't had their psychometric qualities well described and others haven't been used very often when measuring depressed symptoms. Conversely, a number of other researchers have put particular screening techniques to the test in order to look into depressive illnesses. These are the Edinburgh Postpartum Depression Scale and the Postpartum Depression Screening Scale (PDSS) (Zubaran, Schumacher, Roxo, & Foresti, 2010). Out of four screening instruments that were assessed in a systematic review, the Postpartum Depression Screening Scale (PDSS) and the Edinburgh Postnatal Depression Scale (EPDS) both demonstrated significant sensitivity and specificity. When used in various cultural situations, however, none of screening the tools could be deemed perfect (Zubaran et al., 2010). According to Sultan et al., (2022), the EPDS is the best Patient-Reported Outcome Measure (PROM) currently in use to screen for postpartum depression in mothers. These findings indicate that the EPDS should be utilized by clinicians and in upcoming research studies to screen for maternal postpartum depression because it was the PROM that performed the best and was most thoroughly examined in various healthcare settings. The EPDS has ten screening questions for postpartum depression, and the results are given as a total score between 0 and University of Ghana http://ugspace.ug.edu.gh 16 30 (lower scores indicate less postpartum depression). Using a different cutoff value will affect the EPDS's sensitivity and specificity. According to a thorough study of 58 investigations (including non-obstetric studies), the EPDS's combined sensitivity and specificity are maximized at a cutoff value of 11 or higher. 2.4 Child outcomes Postpartum depression has detrimental effects on child outcomes. It has been linked to critical factors that affect a child’s survival such as poor infant nutritional status, diarrhea, and respiratory illness, as well as worse outcomes concerning the physical and psychological development of the child (Mughal et al., 2021). It has been discovered that children of women who experienced postpartum depression display noticeable behavioral alterations, decreased cognitive growth, and early start of depressive disorders. More so, these children frequently struggle with social interaction problems and obesity (Mughal et al., 2021). A study by researchers at the University of Michigan suggests that, for efforts to improve infant growth, health, and nutritional status, and reduce child mortality in less-developed countries to succeed, they must address the mental health of new mothers (Sinclair, 2013). They noted that children with mothers who are depressed in low- and middle-income nations (LMINs) are almost twice as likely to be underweight and to experience growth stunting. According to Mughal et al. (2021), children of mothers who have untreated depression can develop behavioral and emotional problems. Common effects of PPD on child outcomes are delays in language development. Others include sleeping problems, excessive crying, eating difficulties, attention-deficit/hyperactivity disorder (ADHD), early onset of depressive illness, obesity, and dysfunction in social interactions. University of Ghana http://ugspace.ug.edu.gh 17 2.5 Maternal outcomes Maternal outcomes of PPD include poor maternal-infant bonds, failure of breastfeeding, negative parenting practices, and marital discord. If not treated promptly, PPD can lead to chronic depressive disorder. Even if treated, patients still stand the risk of future episodes of major depression (Mughal et al., 2021). Postpartum depression makes mothers less concerned about their infants, hence do not respond positively when they cry, make gestures, or make eye contact. As a result of their inability to properly care for their child, the mothers stop breastfeeding. Making personal adjustments is difficult for mothers who are experiencing postpartum blues. However, due to mothers' poor care and refusal to breastfeed, babies can be fussy and easily injured. In addition, postpartum mothers lack the motivation to breastfeed their infants, which hinders their development and growth. Compared to babies who do not receive breast milk, those who are breastfed by their mothers will have a stronger immune system (Handini & Puspitasari, 2021). 2.6 Prevention and treatment of postpartum depression Prevention strategy includes any method that lowers an individual's risk of contracting a disease or condition (primary prevention), stops or slows the progression of a disease or condition through early detection and treatment (secondary prevention), or stops or slows the progression of a disease or condition and lessens the disability that results from it through the treatment of an already-existing disease (tertiary prevention). This is considered a preventive intervention (Molyneaux, Trevillion, & Howard, 2015). University of Ghana http://ugspace.ug.edu.gh 18 Depression is treatable, and most people who receive treatment recover from it (CDC, 2022). Early detection and treatment for PPD symptoms are crucial to guarantee the mother, child, and family’s well-being. Treatment of PPD requires a multimodal approach, taking into consideration education, psychotherapy, support, pharmacological and biological treatment options. It is imperative to consider the role of breastfeeding when pharmacological treatment is considered (Suri & Altshuler, 2012). An investigation employed brief group therapy as an evidence-based treatment for first-time mothers at risk for postpartum depression. It was discovered that mothers who took part in the brief group psychotherapy intervention saw a decline in their scores on the Edinburgh Postnatal Depression Scale, decreasing their risk for PPD (Pessagno & Hunker, 2013). 2.7 Prevalence of postpartum depression in first-time mothers Few studies have been conducted on PPD in first-time mothers globally. In a study determining the prevalence and the associations that exist between structural social support and functional support in first-time mothers, the prevalence of PPD was found to be 13.2% and 9.8% at 6 weeks and 12 weeks postpartum respectively using the EPDS cutoff of >11 (Leahy-Warren, McCarthy, & Corcoran, 2011). In another study examining the correlates of PPD in first-time mothers without prior psychiatric contact, the prevalence of PPD was reported as 10.3% at five days and 6.4% at 6 weeks University of Ghana http://ugspace.ug.edu.gh 19 postpartum using the EPDS cut-off ≥12 (Sylvén, Thomopoulos, Kollia, Jonsson, & Skalkidou, 2017). Findings from a study on perinatal parenting stress, anxiety, and depression outcomes in first- time mothers and fathers show a prevalence of 17.1% in first-time mothers at 3 months and 9.4% at 6 months using an EPDS cut-off of > 13 (Vismara et al., 2016). Results from a study assessing the relationships between postpartum fatigue, depressive mood, self-care agency, and self-care action of first-time mothers in Bangladesh reveal depressive mood in 73.4% of the participants at EPDS ≥9 (Khatun et al., 2018). A study of Chinese first-time mothers and fathers on depression, social support, and perceived stress reported PPD prevalence of 13.8% in first-time mothers (Gao, Chan, & Mao, 2009). Abdollahi et al. (2016), found the incidence of depression in first-time Iranian mothers at three months postpartum to be 10.7% using the EPDS cut-off score of > 12. Campbell & Cohn (1991) found the prevalence of PPD in first-time mothers to be 9.3% using the modified Research Diagnostic Criteria for depression. In a prospective cohort study of older first-time mothers who conceived naturally or through assisted reproductive technology, the prevalence of major depressive disorder was 7.9% (McMahon et al., 2011). University of Ghana http://ugspace.ug.edu.gh 20 2.8 Factors associated with postpartum depression 2.8.1 Sociodemographic factors According to Fiala et al. (2017), a range of sociodemographic characteristics, such as the mother's age, marital status, number of children, educational attainment, the child's sex, and length of connection with partner have the ability to affect postpartum depression in postpartum women. However, their investigation found no strong correlation between these characteristics and postpartum depressive symptoms in postpartum women. Results from a study on first-time Japanese mothers showed that current age and the EPDS score were inversely related (β = −.185, p < .0001) (Torashima et al., 2022). Another study indicated that compared to adult mothers with lower or greater levels of resources, postpartum depression was significantly more prevalent among first-time teenage mothers. (Lanzi, Bert, & Jacobs, 2009). No correlation was found between a first-time mother's age, her living arrangement with the baby's father, her employment status, or her level of education and her mood (Kristensen et al., 2018). In a study, socioeconomic status, past histories of depression and PPD, history of stressful situations, family support, preference for a male child, and unintended pregnancy were statistically significant factors associated with PPD (p 0.05) (Ahmed, Elbeh, Shams, Malek, & Ibrahim, 2021). University of Ghana http://ugspace.ug.edu.gh 21 According to a study by Goyal, Gay, Lee, & Jose (2010), postpartum depressive symptoms are more likely to occur in first-time mothers with socioeconomic traits such as being unmarried, having low education, being unemployed, and having a low income. 2.8.2 Obstetric, Maternal and infant-related factors Though the postpartum period is recognized as a vulnerable time for maternal mental health in high-income countries, the situation is entirely different in low-income nations where the majority of the people perceive symptoms of depression as spiritual or personal problems rather than as a psychiatric disorder that could be treated (Sinclair, 2013). High-risk pregnancies which may result in emergency cesarean section and hospitalizations during pregnancy or after delivery are maternal factors associated with PPD. Infant-related factors may include meconium passage, umbilical cord prolapse, preterm or low birth infant, and low hemoglobin (Mughal et al., 2021). Poverty (Coast et al., 2012), neonatal complications, no support from husband, joblessness, being a first-time mother, and unplanned pregnancy are factors found to be correlated with PPD (Alam et al., 2021). Results from a parallel randomized control trial of PPD among first-time mothers show preterm birth, lack of pain relief during labour, low attendance of the midwife in the delivery room, impromptu caesarean section, low Apgar score, unpreparedness for hospital discharge, inadequate knowledge about breastfeeding, none or minor breastfeeding in the early postpartum period, poor or fair self-rated mental health, and uncertain or weak attachment to the newborn child as factors associated with PPD (Maimburg & Væth, 2015). University of Ghana http://ugspace.ug.edu.gh 22 Higher PPD symptoms were substantially correlated with difficulties with breastfeeding (coefficient 0.77, 95% CI: 0.02, 1.53). Hospitalization during pregnancy and unexpected pregnancies were other problems linked to an EPDS score (Koutra et al., 2018). PPD risk factors have also included previous infant loss and pregnancy-related issues such as low hemoglobin levels during birth (Goshtasebi et al., 2013). Postpartum depression is more likely to occur in mothers whose newborns had medical conditions, were born prematurely, or have difficult temperaments. When compared to women who had intended pregnancies, those who had unwanted pregnancies had a higher rate of postpartum depression (6.7% vs. 4.3%, p<0.05). However, after adjusting for covariates, unplanned pregnancy was no longer linked to postpartum depression (adjusted OR 1.41; 95% CI 0.91–2.1) (Abbasi, Chuang, Dagher, Zhu, & Kjerulff, 2013). 2.8.3 Psychosocial, Clinical & Psychological factors Lack of social support, smoking during pregnancy, and domestic violence in the form of spousal sexual, physical, and verbal abuse are risk factors for developing PPD (Mughal et al., 2021). A study of first-time mothers shows perceived social isolation, maternal parental self-efficacy, and marital satisfaction stress exposure as contributing factors to PPD (Abdollahi et al., 2016). History of anxiety and depression, dissatisfaction with the baby’s gender, negative attitude toward the baby, premenstrual syndrome (PMS), and history of sexual abuse are unending risk factors of postpartum depression (Mughal et al., 2021). University of Ghana http://ugspace.ug.edu.gh 23 In a recent study, anxiety, marital dissatisfaction, stress, insufficient/ lack of social support, financial difficulties, and single parenting were identified as psychosocial determinants of PPD (Paddy et al., 2021). High levels of depressive symptoms in the postnatal period are strongly related to having experienced domestic abuse, according to Howard, Oram, Galley, Trevillion, & Feder (2013). Postpartum depression is significantly influenced by antenatal depression and anxiety, previous mental illness, an unhappy marriage, stressful life events, a disliking toward pregnancy, and a lack of social support. Dysfunctional marriages and life difficulties are important factors that put women at risk for PPD in both developed and developing countries. Other psychological factors that raise the incidence of PPD include stress related to childcare and poor attitudes toward pregnancy (Norhayati, Nik, Asrenee, & Wan, 2015). According to studies, women who have a history of mental illness are more likely to have postpartum depression (Suri & Altshuler, 2012). Prior depression is the greatest risk factor for PPD (Wisner et al., 2013). 2.8.4 Cultural factors Postpartum confinement, in which women are held indoors for a month, is a custom among Taiwanese women. Women receive assistance with home duties, special diet, and protection from harsh weather during this time. According to Chien et al. (2012), this postpartum confinement period is linked to a lower risk of having PPD. However, this same practice contributes to a higher incidence of PPD among Singaporean women (Chee et al., 2005). University of Ghana http://ugspace.ug.edu.gh 24 2.9 Conceptual framework Below is the conceptual framework of the study. It shows the factors that could contribute to PPD which include sociodemographic factors, socioeconomic factors, obstetric factors (pregnancy & antenatal-related factors and delivery history), maternal and infant-related factors, spousal & social support, and clinical & psychological factors. University of Ghana http://ugspace.ug.edu.gh 25 Figure 1: Conceptual framework showing possible factors that are associated with postpartum depression. Source: Author’s own construct based on review of literature Postpartum Depression Sociodemographic factors • Age • Employment • Educational level • Residence • Marital status • Religion Socioeconomic factors • Family income • Monthly expenditure • Work conditions • Recent home relocation • Divorced/separated • Loss of job • Spousal and social factors etc. Obstetric factors • Gravidity • Gestational age antenatal was started • Number of ANC visits • Type of delivery • Gestational age at birth • Complications during pregnancy Clinical factors • Previous history of depression • Family history of mental disorder • Health professional counselling/education on PPD Maternal & Infant- related factors • Sex of baby • Baby’s age • Birth weight • Length of hospital stay • Breastfeeding problems • Infant’s health status • Maternal health status etc. Psychological factors • Intimate partner violence • Childcare stress • Pressure from others related to childcare University of Ghana http://ugspace.ug.edu.gh 26 Socio-demographic factors include: • Age • Employment • Educational level • Residence • Marital status • Religion Socio-economic factors • Monthly family income • Work conditions • Financial difficulties • Financial dependence • Monthly expenditure • Recent home relocation • Divorced/separated • Death of a loved one • Loss of job • Cultural practices and beliefs Obstetric factors (This comprises of Pregnancy and antenatal-related factors and Delivery history) Pregnancy and antenatal-related factors • Gravidity • Unplanned/unexpected pregnancy University of Ghana http://ugspace.ug.edu.gh 27 • Complications in pregnancy • Previous miscarriage(s) • Antenatal care (ANC) attendance and number of visits • Past infertility treatment • Health professional counselling on PPD during ANC • Gestational age ANC was started • Previous knowledge about PPD Delivery history • Gestational age at birth • Type of delivery • Number of babies delivered • Time breastfeeding was initiated after delivery • Length of hospital stay Psychological factors • Intimate partner violence (IPV) • Childcare stress • Pressure related to childcare Maternal and infant-related factors • Length of hospital stay after delivery • Baby’s age • Baby’s sex • Baby’s sex expected • Baby’s weight at birth University of Ghana http://ugspace.ug.edu.gh 28 • Maternal health status • Ill baby • Breastfeeding problems • Baby’s health status • Temperament of baby Spousal and social support • Partner reliability • Marital relationship satisfaction • Relationship with parents and parents-in-law • Intimate partner violence (IPV) • Family and social support Clinical factors • Previous history of depression • Family history of mental disorder • Health professional counselling/education on PPD. The conceptual framework implies that a variety of sociodemographic factors, including maternal age, occupation/employment, educational level, place/ type of residence, marital status, and religion may affect the occurrence of postpartum depressive symptoms. It is thought that age can influence a woman's preparation to give birth and that mothers are most prepared to support and care for their infants between the ages of 20 and 30. Paramedics believe that between the ages of 20 and 30 is best because there is the least chance of developing medical problems (Handini & Puspitasari, 2021). Because age has an impact on uterine health, University of Ghana http://ugspace.ug.edu.gh 29 postpartum blues are correlated with age. Postpartum blues left untreated may develop into PPD. While mothers under the age of 20 are more likely to experience complications during childbirth and hospital treatments and may require the assistance of medical professionals, mothers over the age of 35 also run the risk of PPD because of exhaustion and inadequate anatomical preparation for childbirth and pregnancy (Handini & Puspitasari, 2021). According to Handini & Puspitasari (2021), low-educated mothers tend to have more children and are more likely to have postpartum depression because they cannot give enough care. Conversely, mothers with higher education will face social pressure and conflicting expectations regarding their roles as housewives and workers. It is impossible to overstate the significance of socioeconomic status in the development of mental health disorders and depression. Socioeconomic factors include low family income, unstable jobs, financial difficulties, financial dependence on partner, high monthly expenditure, recent home relocation, recently divorced/separated, the recent death of a loved one, and loss of job. Handini & Puspitasari (2021) assert that hormonal changes brought on by the family economy and a lack of confidence might cause anxiety in new mothers, and that poor family financial circumstances can give a mother the impression that killing her child is preferable to enduring suffering. Poverty, no support from husband, joblessness, being a first-time, and unplanned pregnancy are factors found to be associated with PPD (Alam et al., 2021; Coast et al., 2012). The quality of a marriage may influence the husband's involvement and support during the pregnancy, delivery, and postpartum period, ultimately influencing mothers' postpartum University of Ghana http://ugspace.ug.edu.gh 30 depressive symptoms and improving their health behavior. Couples with greater family incomes and fewer children were more likely to have a positive marital relationship (Handini & Puspitasari, 2021). The mother's and the rest of the family's preparation to welcome a new member is influenced by family support. Husbands are particularly crucial since they play a supportive role from the time of conception till the baby is born. Clinical factors include a previous history of depression, family history of mental disorder, and health professional counselling/education on PPD. Previous studies show that women with a history of mental illness are more likely to experience postpartum depression, with prior depression being the biggest risk factor (Suri & Altshuler, 2012; Wisner et al., 2013). Problems with breastfeeding are also considered to be a strong risk factor for developing PPD (Fiala et al., 2017). In summary, the conceptual framework illustrates elements that could cause postpartum depression. Early detection of postpartum depression and the subsequent promotion of early treatment are goals that awareness, communication, and support may help achieve. 2.10 Chapter summary and outstanding gaps in literature The postpartum period is well-known as a time of difficulty for new mothers, especially first- time mothers who have no prior experience in how to care for a child and have little knowledge of what to expect. This makes them more vulnerable to developing PPD. Even though there is substantial literature on the prevalence and correlates of PPD in mothers globally and locally, little is known about the prevalence and factors associated with PPD in University of Ghana http://ugspace.ug.edu.gh 31 first-time mothers generally, especially in LMIC and for that matter, Africa and Ghana. The few studies which have been conducted on first-time mothers were in Asia and Europe. This calls for more research to be done among first-time mothers in these settings to be able to better understand the factors that contribute to developing PPD in these areas. University of Ghana http://ugspace.ug.edu.gh 32 CHAPTER THREE METHODOLOGY 3.0 Introduction This chapter covers in detail the methods and procedures that were used to carry out the study. The study’s setting and ethical issues were also discussed. 3.1 Study design This study was a facility-based cross-sectional study involving first-time mothers within 6 months of childbirth attending the postnatal or child welfare clinic at the Korle Bu Teaching Hospital (KBTH). The study was conducted between November 2022 and December 2022. 3.2 Study Area The Korle-Bu Teaching Hospital is the leading tertiary healthcare facility in Ghana. It was established on October 9th, 1923 as a General Hospital to serve the healthcare needs of the population under the administration of Sir Frederick Gordon Guggisberg, then Governor of the Gold Coast (KBTH, 2022). The hospital is situated in the Ablekuma South constituency in Korle-Gonno, a suburb of Accra. Being the largest of the three (3) Sub Metropolitan District Councils of the Accra Metropolitan Assembly (AMA), the Ablekuma South Sub Metropolitan District Council covers an area of 15.1 sqkm and shares its boundaries with Ablekuma Central, Ablekuma North Municipal Assembly, and Ashiedu Keteke Sub Metropolitan District Council. It is estimated to have a population of 257,543 people, 22,751 homes, and 69,401 households as per the 2010 housing University of Ghana http://ugspace.ug.edu.gh 33 census. Ablekuma South's population is anticipated to reach 315,051 in 2018, based on the Greater Accra Growth Rate of 3.1% (Accra Metropolitan Assembly, 2022). Since most of the communities are located near the coast, fishing and fishmongering are the primary economic activities of the locals, and as a result, the Sub Metro area has made significant contributions to Accra's economic growth. Other commercial establishments like educational institutions, banks, supermarkets, gas stations, and hotels are also housed there. The Tuesday Market in Korle Gonno and the Dansoman Market are its two primary markets. (Wikipedia, 2022). The boundary from the current office location travels through the Kpakpo Oti Road intersection to Ring Road West (Mortuary Road), then travels east on Ring Road West to Laterbiokorshie Road (Zoti), turning left from Laterbiokorshie Road to Link Road Intersection to Chemu Road (Summer Hut Junction). Following that, takes Mampong Stream to Oblogo Road via Sempe Traffic Light Street (I.B.E), and then turns left at the intersection of Mars Road. to the Dansoman roundabout from the intersection of Mars Road. From the Dansoman Main Road, Poultry Farm Avenue, the Dansoman High Street, the SSNIT apartments, and then back to the Otorjor, Opetekwei, Gbegbeyise, and Shaibu Communities. There are 5 electoral areas in the Sub-Metro: Korle Gonno, Korle-Bu, Chorkor, Mamprobi, and New Mamprobi.(Accra Metropolitan Assembly, 2022; Wikipedia, 2022) Population growth and the effectiveness of hospital-based therapy led to an increase in hospital attendance shortly after the Korle Bu Teaching Hospital was founded. This development resulted in severe congestion when utilizing the hospital's services, necessitating an expansion in 1953. University of Ghana http://ugspace.ug.edu.gh 34 With 2,000 beds, 17 clinical and diagnostic Departments/Units, and a total staff strength of over 5000, the hospital is currently the third-largest hospital in Africa and the main national referral center in Ghana. There are around 250 in-patient admissions each day and 1,500 patients on average daily attendance. In addition to serving as a reference hospital for other facilities in the nation, it also serves as one for other nations in the West African Subregion. The hospital's clinical and diagnostic divisions include Accident & Emergency, Family Medicine/Polyclinic, Psychiatry, Reconstructive Plastic Surgery and Burns Center, Child Health, Surgery, Obstetrics and Gynecology, Anaesthesia, and Internal Medicine and Therapeutics. Other fields include pharmacy, pathology, laboratory, and radiology, which includes subspecialties in neurosurgery, pediatric surgery, dental/oral maxillofacial surgery, ophthalmology, ear, nose, and throat (ENT), renal, orthopedic, oncology, dermatology, reconstructive plastic surgery, cardiothoracic surgery, and radiotherapy & nuclear medicine. The hospital has three centers of excellence: The National Cardiothoracic Centre, the National Reconstructive Plastic Surgery and Burns Centre, and the National Centre for Radiotherapy and Nuclear Medicine. These centers draw a sizable number of patrons from both within the nation and from neighboring nations, including Burkina Faso, Nigeria, Togo, and Benin, among others (KBTH, 2022). The hospital acquired its status as a teaching hospital for the training of physicians in 1962, with the founding of the University of Ghana Medical School (UGMS) (Ministry Of Health, 2022). University of Ghana http://ugspace.ug.edu.gh 35 3.3 Study population First-time mothers within 6 months of childbirth attending the postnatal or child welfare clinic within the period of November and December 2022 at the Korle Bu Teaching Hospital (KBTH). Study sites Postnatal clinic The postnatal clinic is located within the obstetric OPD of the Obstetrics & Gynaecolgy department of the Korle Bu Teaching Hospital. The clinic operates from Mondays to Fridays. It serves all postnatal women who delivered in the facility two weeks after delivery and then six weeks post-delivery. Those with special problems are seen more frequently. The unit sees an average of 80 mothers per day. The clinic recorded 18,088 postnatal cases in 2013 compared to 16,088 in 2012 and 15,795 in 2011 (Korle Bu Teaching Hospital, 2013). Child Welfare Clinic (CWC) The child welfare clinic is one of the support clinics under the Department of Child Health of the Korle Bu Teaching Hospital. The Department was established in 1964 under the leadership of its first Head Dr. Susan De-Graft Johnson. It is a tertiary referral center for children under 13 years with medical and surgical problems (Korle-Bu Teaching Hospital, 2022). In 2016, the OPD attendance was 28,152 (Korle Bu Teaching Hospital, 2016). The OPD General Clinic recorded 18,572 cases in 2013 while the Sub-Specialty Clinics, which include the Child Welfare Clinic recorded 10,776 cases (Korle Bu Teaching Hospital, 2013). The Child Welfare Clinic serves children from 6 weeks old to 5 years through continual growth monitoring and immunization. On average, 60 babies are seen per day. University of Ghana http://ugspace.ug.edu.gh 36 3.3.1 Inclusion criteria The study included first-time mothers who fully met these criteria: 1. Within six months of delivery 2. Between 15-45 years 2. Had a full or pre-term delivery 3. Discharged with baby/babies 4. Had spontaneous vaginal delivery, delivery by CS, or assisted delivery (e.g. vacuum delivery, forceps delivery). 3.3.2 Exclusion criteria The following categories of first-time mothers were excluded from the study: 1. Those whose babies had died 2. Those with known mental disorders 3.4 Sample size determination 194 first-time mothers made up the total sample size for this study. The Cochran formula was used to determine this: 𝑛 = !∝ "# %('(%) " "" Where, 𝑍∝ $% − 𝑠𝑐𝑜𝑟𝑒 𝑎𝑡 5% 𝑠𝑖𝑔𝑛𝑖𝑓𝑖𝑐𝑎𝑛𝑐𝑒 𝑙𝑒𝑣𝑒𝑙 = 1.96 𝑒 – 0.05, 𝑡h𝑒 𝑚𝑎𝑟𝑔𝑖𝑛 𝑜𝑓 𝑒𝑟𝑟𝑜𝑟, 𝑠𝑒𝑡 𝑎𝑡 5% α = significance level = 5% P = Prevalence of PPD in first-time mothers = 13.2% (Leahy-Warren, McCarthy, & Corcoran, 2011) 𝑛 = &.()"× ,.&-$ (&/,.&-$) ,.,1" = 176.06 University of Ghana http://ugspace.ug.edu.gh 37 ⇒ n = Minimum required sample size = 176.06, approximately 176. A nonresponsive rate of 10% was added to allow room for no responsiveness and dropout of respondents. Adjusting for a non-response rate of 10% = 176 + 0.10 (176) = 193.6 ∴ Total sample size = 194 A total sample size of 194 was calculated for the study. However, due to the difficulty in finding first-time mothers at both clinics within the short period of the study and in order to meet the university deadline for submission of the final work, only 150 first-time mothers were able to be recruited for the study, forming about 80% of the total sample size. 3.5 Sampling procedure Consecutive sampling technique was used given the constraint of time and difficulty in finding first-time mothers within six months postpartum. Every first-time mother who came to the postnatal or child welfare clinic and met the inclusion criteria was recruited until the required sample size was attained. 3.6 Data collection methods A quantitative survey was conducted using structured interviews. The principal investigator was available at the child welfare clinic on clinic days (Mondays and Fridays) and at the postnatal clinic from Tuesdays to Thursdays every week from November 16th to December 30th for the recruitment of participants for the study. Mothers who met the selection criteria were identified and approached. The study was explained to them and after consent was obtained, data was collected from participants. University of Ghana http://ugspace.ug.edu.gh 38 Data was collected using a structured questionnaire and the Edinburgh Postnatal Depression Scale (EPDS). The structured questionnaire and EPDS were administered to each mother by the principal investigator. This took approximately 15 minutes to complete. The questionnaires were read aloud to mothers verbatim in their preferred language (whether local or English). Mothers at the postnatal clinic were interviewed while they waited their turn to be examined by the midwife-in-charge. This was after their vital signs had been taken and their babies weighed. Mothers at the Child Welfare Clinic were interviewed while they waited their turn to weigh their babies, or while they waited their turn for their babies to be vaccinated. This was to prevent unduly delaying mothers at the clinics. 3.7 Instrument for data collection Information on participants’ characteristics and other independent (explanatory) variables was gathered using a structured questionnaire, while the EPDS was used for assessing symptoms of postpartum depression. The EPDS is a valuable, self-rated screening tool used for the early identification of postpartum depressive symptoms. It is the most widely used and most validated screening tool for depression during the perinatal period (Cox, Holden, & Sagovsky, 1987). The 10-item self-reported tool comprises two positive and eight negative items designed to assess postpartum depression symptomatology in new mothers from their experiences in the previous week that is well known for its validity and reliability and has become a globally accepted tool in PPD research (Affonso, De, Horowitz, & Mayberry, 2000; Maimburg & Væth, 2015; Weobong et al., 2009). It includes questions like “I have been able to laugh and see the University of Ghana http://ugspace.ug.edu.gh 39 funny side of things”, “I have blamed myself unnecessarily when things went wrong” and “I have been anxious or worried for no good reason”, among others. There are four possible responses for each item; from 0 to 3, with 0 as the minimum score and 30 representing the maximum score (Paddy et al., 2021). It is made up of four-point response options, i.e. (0,1,2,3) which gives a total maximum score of 30 (Weobong et al., 2009). The scale is effective as it shows sensitivity and specificity (Atuhaire, Brennaman, Cumber, Rukundo, & Nambozi, 2020). Questions related to somatic complaints such as changes in appetite and fatigue are not included in the scale as such complaints would not help distinguish women who are depressed from those who are not (Murray & Carothers, 1990). The cutoff value used to identify women as high risk for postpartum depression varies. However, a cutoff score of ≥10 or ≥12 is typically used in research to identify women who are at high risk for postpartum depression. A cut-off of ≥10 is diagnosed as severe PPD as recommended in the original publication by Murray & Carothers (1990), with a sensitivity of 85% and specificity of 77%. The combined sensitivity and specificity to detect major depression in postpartum women were higher for a cut-off value of 12 or higher (sensitivity 0.86, specificity 0.87, 15 studies) than for a cut-off value of 10 or higher (sensitivity 0.92, specificity 0.77, 14 studies), or for a cut-off value of 13 or higher (sensitivity 0.79, specificity 0.89, 18 studies), among a total of 18 studies, according to a previous meta-analysis that looked at the accuracy of the EPDS (Hewitt et al., 2009). University of Ghana http://ugspace.ug.edu.gh 40 According to WebMD (2022), a score of 12 or greater indicates the likelihood of depression but not severity. Although scores cannot be interpreted as diagnostic, they can indicate the need for further evaluation. A cutoff score of ≥12 was used to identify PPD in this study. 3.8 Pre-test The Greater Accra Regional Hospital was used as a pre-test site for the study tools (questionnaires) since it shares similarities with Korle Bu Teaching Hospital. This pre-test mostly assessed the questions' applicability, predicted how long the study would take, and finalized the tools for the main investigation. 3.9 Data processing and analysis The collected data were verified, coded, input into Excel, and then exported to STATA version 17 for cleaning and analysis. Important respondent characteristics were described using descriptive statistics, and the prevalence of postpartum depression was estimated. The association between independent (explanatory) variables and postpartum depression was investigated using bivariate analyses (binary logistic regression). A multivariable logistic regression model was fitted to evaluate the independent determinants of postpartum depression, and the statistical significance of the bivariate logistic regression models was determined using a p-value of 0.05. Odds ratios with 95% confidence intervals were used to determine the strength of the association. University of Ghana http://ugspace.ug.edu.gh 41 3.10 Variables 3.10.1 Outcome variable Postpartum depression symptom(s) is the outcome variable. The EPDS was used to measure this. There are 10 questions on the EPDS. Responses are given a score of 0, 1, 2, or 3 depending on whether the symptom is absent, present, or has become more severe. The sum of the scores for each of the 10 elements was used to calculate the overall score. Mothers with scores of 12 points and higher were categorized as having postpartum depression symptoms, whereas those with lower total EPDS scores (0-11 points) weren't. 3.10.2 Independent (Explanatory) Variables The structured questionnaire was used to define and measure a variety of independent (explanatory) variables. These variables were broadly divided into six main factors: socio- demographic, socioeconomic, obstetric (pregnancy and antenatal-related factors and delivery history), maternal and infant-related, spousal & social support, and clinical & psychological factors. Socio-demographic factors The socio-demographic factors comprised maternal age, occupation/employment, educational level, place/ type of residence, marital status, and religion. Socio-economic factors The socioeconomic factors included monthly family income, working conditions, financial difficulties, economic dependence on partner or financial independence, monthly expenditure, recent home relocation, recently divorced/separated, the recent death of a loved one, loss of job, and cultural practices and beliefs e.g., some customs dictate that new mothers should not University of Ghana http://ugspace.ug.edu.gh 42 be seen outside for some time; hence, women are forced to remain indoors several days after delivery. Another cultural practice is sitting on hot water after delivery, which might cause more pain and discomfort to a new mother. Obstetric factors comprised pregnancy and antenatal-related factors and delivery history of respondents. Pregnancy and antenatal-related factors consisted of gravidity, whether the pregnancy was planned, bed rest during pregnancy, previous miscarriages, antenatal care (ANC) attendance and numbers of visits, bed rest during pregnancy, and past infertility treatment, health professional counselling on PPD during ANC, gestational age ANC was started and previous knowledge about PPD. Delivery history was made of gestational age at birth, type of delivery, number of babies delivered, time breastfeeding was initiated after delivery and length of hospital stay. Maternal and infant-related factors Included previous knowledge of postpartum depression, gestational age at birth, complications intra or postpartum, length of hospital stay after delivery, baby’s age, baby’s sex, whether baby’s sex was expected, baby’s weight at birth, maternal health condition, baby ever ill, inability of the child to suckle properly, baby’s current health condition, temperament of baby, difficulty feeding baby and whether baby has special needs. University of Ghana http://ugspace.ug.edu.gh 43 Spousal, social support, and psychological factors These included whether the mother can rely on her partner for help, whether she can share all her problems with her partner, marital relationship satisfaction, relationship with parents and parents-in-law, family support in taking care of the baby. Clinical factors Clinical factors comprised past depression history, family history of mental disorder, and health professional counselling/education on PPD. Psychological factors Included intimate partner violence (IPV), childcare stress, and pressure related to childcare 3.10 Quality assurance A pilot study was done to correct all feasibility concerns and issues with the data collection instrument before the survey or data collection itself began. Daily data collection was carried out. The researcher cross-examined the completed questionnaires at the end of the day to look for any missing data, completeness, and consistency. Microsoft Excel was used to enter and clean the data simultaneously. 3.11 Ethical issues Ethical clearance was obtained from the Korle Bu Institutional Review Board with approval number KBTH-IRB 000169/2022 before the study was carried out. The consent of participants was also sought before interviews were done. The Researcher did not anticipate any direct risks to be associated with this study although participants were urged not to provide any private or sensitive information that made them University of Ghana http://ugspace.ug.edu.gh 44 uncomfortable. In the unlikely event that there was some risk, the Researcher believes such will be lower than Minimal Risk. Minimal Risk to subjects per NIH guidelines “means that the probability and magnitude of harm or discomfort anticipated in the research are not greater than those ordinarily encountered in daily life or during the performance of routine physical and psychological examinations or tests and that confidentiality is adequately protected” (NIMH » NIMH Guidance on Risk-Based Monitoring, n.d.). There were no direct benefits for the participants of this study. However, the respondents were informed that the information they provide may advance a general understanding of postpartum depression. Also, participants were made to understand that participation in the study is voluntary and that withdrawal from the study was allowed without any penalty. Data collected for the study were kept confidential and used solely for the purpose indicated for the study. Interviews were conducted in a separate room set aside specifically for the project to ensure privacy. Electronic data files were password protected while hard copy data were stored securely in locked file cabinets without the study participants' names, and access was limited to the study's Principal Investigator. Parental consent was obtained before minors were recruited into the study. Some challenges encountered with enrolling minors into the study were difficulty in accessing parents for consent. This is because some minors who visited the postnatal/child welfare clinics were not accompanied by a parent, making it difficult to get consent. Minors who were accompanied by a guardian could not speak freely or respond truthfully to some questions in the presence of their parent/guardian. Another problem experienced with the presence of a parent was an increase in interview time as two people had to be interviewed instead of one. Also, for minors University of Ghana http://ugspace.ug.edu.gh 45 who attended the clinics alone, the phone number of their parent was taken. Phone calls had to be made to the parents to obtain consent to interview their wards which had its own challenges. For instance, sometimes the parent was not in the same location as the child to give them the phone, so would then either give another phone number to reach the child, or give a time that they thought they would be with the child. Also, the already high expense of telephone surveys with teenagers was made even higher by the fact that interviews over the phone frequently needed more time and effort and necessitated follow-up calls to try to contact them. 3.12 Chapter Summary In summary, this chapter elaborated on the descriptive cross-sectional quantitative study design used in the study. Also, the procedures and tools for gathering data, as well as quality control and ethical concerns, were covered in detail. Results are presented in the following chapter. University of Ghana http://ugspace.ug.edu.gh 46 CHAPTER FOUR RESULTS 4.1 Introduction This chapter focuses on the presentation of the study’s findings and their interpretations. These findings are presented according to the objectives of the study which include a report on the obstetric, maternal and infant-related, clinical, and psychological characteristics of respondents, as well as the prevalence and factors associated with postpartum depression in first-time mothers at KBTH, but are preceded by the background and socio-demographic characteristics. For clarity purposes, the chapter is organized into subheadings. 4.2 Background and Sociodemographic characteristics of first-time mothers The study recruited 150 first-time mothers who met the inclusion criteria. Majority (41.3%) of the respondents were between the ages 26 and 30 years, with only about 7.3% above 35 years. A greater percentage (63.3%) of the mothers were married. Most (60.7%) of them lived in rented apartments. About 43.3% of them had attained tertiary education with most (38%) having had diploma and undergraduate education. A little above half (52%) of the mothers had partners who had attained tertiary education. Only a few of them (2.7%) had partners who were unemployed. Most of the respondents (66%) had a family income below average (i.e., 35 11 7.3 Employment Civil servant 22 14.7 Health professional 34 22.7 Unemployed 23 15.3 Trader/Business 19 12.7 Housewife 1 0.7 Student 5 3.3 Other 46 30.7 Educational level None 1 0.7 Basic school 5 3.3 Junior high school/MLSC 36 24 Senior high school 43 28.7 Diploma/Undergraduate 57 38 Postgraduate 8 5.3 Residence type Private 39 26 Parent’s house 20 13.3 Rented 91 60.7 Marital status Married 95 63.3 Unmarried 31 20.7 Cohabiting 23 15.3 Separated 1 0.7 Religion None 2 1.3 Christian 131 87.3 Muslim 17 11.3 University of Ghana http://ugspace.ug.edu.gh 49 Partner’s educational status No formal education 1 0.7 Primary 3 2 JSS/JHS/MLSC 22 14.7 Secondary/SHS 46 30.7 Tertiary 78 52 Partner’s occupation Trading/Businessman 24 16 Civil servant 28 18.7 Student 5 3.3 Health worker 14 9.3 White color job 13 8.7 Unemployed 4 2.7 Other 62 41.3 Family income (combined) Below average (GH¢5000) 25 16.7 Had stable working conditions 94 62.7 Had financial difficulty 60 40 Economically dependent on partner 89 59.3 Forced to stay indoors after delivery 87 58.0 Forced to sit on hot water after delivery 31 20.7 Received some form of family support in taking care of baby 131 87.3 Lost a loved one recently 19 12.7 Gone through a divorce/separation recently 13 8.7 Relocated to a new home recently 39 26 Amount spent in a month < GH¢200 3 2 GH¢200 - 499 27 18 GH¢500 – 999 76 50.7 GH¢1000 & above 44 29.3 University of Ghana http://ugspace.ug.edu.gh 50 4.3 Prevalence of Postpartum Depression Out of 150 first-time mothers who were screened, 19.3% (29/150) were identified to have PPD using the EPDS cut-off of ≥12. Figure 2 shows the prevalence of postpartum depression in first-time mothers within 6 months of childbirth at the KBTH. Figure 2: Prevalence of Postpartum Depression (PPD) 4.3.1 Classification of PPD in respondents by severity The study further attempted to classify depressed first-time mothers by adopting the classification of PPD according to the severity ranges established for the Edinburgh Postpartum Depression Scale by McCabe-Beane, Segre, Perkhounkova, Stuart, & O'Hara (2016). This suggests a score of 0–6 as No depression, 7–13 as Mild depression, 14–19 (Moderate depression), and 19–30 as Severe depression. The results show that out of the 19.3% of first-time mothers who were depressed, 48.3% had mild depression; same for moderate depression, while the remaining 3.5% were severely 19.3% 80.7% 0 20 40 60 80 pe rc en t Not depressed Depressed DEPRESSION STATUS University of Ghana http://ugspace.ug.edu.gh 51 depressed. Even for the rest of the study population who were found to have no PPD, it is observed that 15.7% had mild depression. Figure 3 provides a summary of the classifications of PPD by severity. Figure 3: Classification of PPD by severity 4.3.2 Classification of PPD in respondents by possibility/probability The study also adopted the classification of PPD according to the probability ranges established for the Edinburgh Postpartum Depression Scale by (Edinburgh Postnatal Depression Scale (EPDS), n.d.) which suggests the interpretation for PPD probability below. EPDS Score Interpretation Action <8 Depression not likely Continue support 9–11 Depression possible Support, re-screen in 2 – 4 weeks. Consider referral to primary care provider (PCP). 12–13 Fairly high possibility of depression Monitor, support and offer education. Refer to PCP. 14 and higher (positive screen) Probable depression Diagnostic assessment and treatment by PCP and/or specialist. 84.3% 15.7% 48.3% 48.3% 3.5% Not depressed Depressed no depression mild depression moderate depression severe depression LEVELS OF POSTPARTUM DEPRESSION University of Ghana http://ugspace.ug.edu.gh 52 The results show that one in ten (10%) first-time mothers was probably depressed. 9.3% of them had a fairly high possibility of depression. 7.3% of the mothers were possibly depressed, and majority (73.3%) of the respondents were not likely to have depression. Figure 4 provides a summary of the classification of PPD in the respondents by possibility/probability. This goes to suggest that by using different scales of classification, the rates of depression may vary. Figure 4: Classification of PPD by possibility/probability 4.3.3 Postpartum depression status by some selected characteristics of respondents The study also explored postpartum depression status by some selected characteristics of respondents that are consistent in literature. It revealed that first-time mothers between the ages of 20 and 25 years formed the majority (31.0%) of respondents with PPD. 73.3% 7.3% 9.3% 10% 0 20 40 60 80 pe rc en t Not likely Possible Fairly high possibility Probable DEPRESSION STATUS BY POSSIBILITY University of Ghana http://ugspace.ug.edu.gh 53 Mothers with below-average family income (35 Mari tal st atu s Marr ied Unmarr ied Fa mily in co me ( co mbined) Below av era ge (< GH¢ 5 000) Ave rag e (G H¢ 5 000) Above av erag e ( >GH¢ 5 000) Was las t p reg nan cy plan ned? Plan ned Unplan ned Ty pe of d eli ve ry SV D Assi ste d deliv ery/ CS Sp ousal su pport Had su pport No su pport Depression status by some selected characteristics of respondents Depressed (Frequency) Depressed (Percent(%) University of Ghana http://ugspace.ug.edu.gh 54 4.4 Obstetric, maternal and infant, clinical and psychological characteristics of respondents 4.4.1 Obstetric characteristics of respondents A number of obstetric factors were examined. These were grouped under two main factors; Pregnancy & antenatal-related characteristics and Delivery history of respondents. 4.4.1.1 Pregnancy and Antenatal-related characteristics of respondents For majority (78.7%) of the respondents, the last pregnancy was their first time being pregnant. A little more than half (51.3%) of the mothers planned their pregnancy. Nearly all (99.3%) attended antenatal clinic during pregnancy, of which a greater percentage (90.7%) attended more than four times. Most (66%) of the mothers had no previous knowledge about postpartum depression, and only 16% received health professional counselling on PPD during antenatal. 15