|Year : 2022 | Volume
| Issue : 3 | Page : 264-269
Prevalence and determinants of antepartum psychiatric disorders: A cross-sectional study in 25 villages of sarjapur PHC area, Bangalore Urban district
Meera George1, Avita Rose Johnson2, Sulekha Thimmaiah2
1 Community Health Centre, Idukki, Kerala, India
2 Department of Community Health, St. John's Medical College, Bengaluru, Karnataka, India
|Date of Submission||10-Mar-2020|
|Date of Decision||28-Oct-2020|
|Date of Acceptance||12-Nov-2020|
|Date of Web Publication||25-Mar-2022|
Dr. Avita Rose Johnson
Department of Community Health, St. John's Medical College, Sarjapur Road, John Nagar, Bengaluru - 560 034, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Antenatal psychiatric disorders are linked to adverse perinatal outcomes and postpartum depression, yet there is a paucity of rural community-based data in India. Objectives: The is to estimate the prevalence and identify determinants of antepartum psychiatric disorders among rural women. Methods: Pregnant women in the third trimester residing in 25 villages under Sarjapur Primary Health Centre, near Bangalore were included. The sample size was calculated as 150 and simple random sampling is done with probability proportional to the size of the village. Screening for antepartum psychiatric disorders and psychiatric symptoms was done using revised Clinical Interview Schedule. Chi-square test and Fischer's exact test was done for associating antepartum psychiatric disorders and independent co-variates. Adjusted odds ratios (AOR) were calculated with 95% confidence intervals, using multiple logistic regression. Results: The prevalence of antepartum psychiatric disorder was 15.3%. The most common psychiatric symptoms were somatic symptoms (43/3%), fatigue (37.3%), sleep problems (28%), and anxiety (22.7%). Poor relationship with in-laws (OR = 5.9 [1.48–50.71] P = 0.017), lower education (OR = 2.3 [1.04–7.80] P = 0.036), low socioeconomic status (P = 0.01) and recent adverse events (P = 0.01) were risk factors for antepartum psychiatric disorder. None of the women sought consultation or treatment for psychiatric symptoms and none were screened for antepartum psychiatric disorders during antenatal visits. Conclusion: A high burden of antepartum psychiatric disorders exists among rural women in our study. There is a need for screening, referral, and management of antepartum psychiatric disorders to be included as a part of routine antenatal care along with capacity building at the primary care level and utilization of existing platforms such as community women's groups for health education, sensitization, and de-stigmatization of antepartum psychiatric disorders.
Keywords: Antepartum psychiatric disorders, clinical interview schedule-revised, maternal mental health, pregnant women, rural
|How to cite this article:|
George M, Johnson AR, Thimmaiah S. Prevalence and determinants of antepartum psychiatric disorders: A cross-sectional study in 25 villages of sarjapur PHC area, Bangalore Urban district. Indian J Soc Psychiatry 2022;38:264-9
|How to cite this URL:|
George M, Johnson AR, Thimmaiah S. Prevalence and determinants of antepartum psychiatric disorders: A cross-sectional study in 25 villages of sarjapur PHC area, Bangalore Urban district. Indian J Soc Psychiatry [serial online] 2022 [cited 2022 Nov 30];38:264-9. Available from: https://www.indjsp.org/text.asp?2022/38/3/264/340953
| Introduction|| |
Over the past two decades, maternal and child health has received much focus and thrust through government-driven programs such as Reproductive and Child Health, National Health Mission , and reproductive, maternal, newborn, child, and adolescent health. Maternal mental health, however, has not been addressed in these programs. Postpartum depression is a common phenomenon, a meta-analysis of 38 studies in India, revealing a high prevalence of 22%. The strongest predictor of postpartum depression is the presence of antepartum psychiatric disorders, the screening and management of which has been ignored in the package of essential antenatal care services that all pregnant women receive. Depression is the most common psychiatric disorder in pregnancy, followed by anxiety, eating disorders, psychosis, and insomnia.
Determinants of antepartum psychiatric disorders range from stressful life events during pregnancy, lack of social support, poor relationship with the partner, low socioeconomic status, previous history of depression, and discontinuation of psychotropic medication during pregnancy. Antenatal psychiatric disorders are known to be associated with poor attendance at antenatal clinics, hypertension, difficult labor/delivery, low birth weight, preterm delivery, as well as breastfeeding difficulties, cognitive delay, and future behavioral problems for the child. Thus, interventions to improve maternal mental health during pregnancy are important preventive strategies against adverse maternal and perinatal outcomes as well as health and developmental outcomes in children.
Considering the fact that two-thirds of the Indian population resides in rural areas, there is a paucity of community-based data regarding antepartum psychiatric disorders among this population, who is challenged in terms of awareness, availability, and accessibility of mental health services. Therefore, this study was conducted with the objective to estimate the prevalence and identify determinants of antepartum psychiatric disorders among rural women. The findings from this study would help in developing targeted interventions during the antenatal period to focus on mitigating risk factors, to prevent perinatal complications and adverse childhood outcomes.
| Methods|| |
A cross-sectional study in 25 villages under Sarjapur Primary Health Centre, Anekal Taluk, Bangalore Urban District, covering a population of around 30,000, was conducted in 2017.
Pregnant women in the third trimester residing in the study area were included under the study population. Gestational age ≥28 weeks was selected, as the earlier gestational period is characterized by physiological changes that might mask psychiatric disorders.
Based on a previous study in Bangalore city where the prevalence of antepartum depression was found to be 8.7%, with 5% margin of error, 95% confidence level and a 10% nonresponse rate, the sample size was calculated to be 135 and rounded off to 150.
Anganwadi worker in each village was contacted for the list of antenatal women currently in the third trimester, and a sampling frame was prepared. Using probability proportional to size, the study subjects were selected from each village using simple random sampling from within this sampling frame.
Pregnant women who completed 28 weeks of gestation were included.
Women who were seriously ill and not able to comprehend the questions were excluded. Women who were not available at home at two consecutive visits were excluded. Any woman who was excluded from the study was replaced by another subject, randomly selected from the sampling frame, from the same village.
The study was approved by the Institutional Ethics Committee, and written informed consent was obtained from each study participant.
Data collection and study tools
Written informed consent was obtained, sociodemographic and obstetric data of the study participants were collected using a pretested, structured, face-validated interview schedule administered in the local language, along with a Kannada-translated version of clinical interview schedule-revised (CIS-R) to screen for psychiatric disorders and psychiatric symptoms. The CIS-R has 14 sub-sections assessing common mental disorders: Somatic symptoms, fatigue, concentration, sleep problems, irritability, worry about physical health, depression, depressive ideas, worry, anxiety, phobia, panic, obsessions, and compulsions, with scores for each sub-section ranging from 0 to 4. The CIS-R screens for antenatal psychiatric disorder with a sensitivity of 88% and specificity of 96% at a total score of ≥12. CIS-R total score of <12, but scoring on one or more sub-sections was used to detect the presence of psychiatric symptoms. Study participants with a suspected psychiatric disorder were referred to a psychiatrist for further evaluation and management at the weekly mental health clinic of the Medical College Rural Health Training Centre located in one of the study villages. Socioeconomic status was determined using the Standard of Living Index.
The data collected was entered in Microsoft Excel and analyzed using IBM Statistical Package for Social Sciences (SPSS) version 20 (IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp. 2011). The study variables were described using frequencies, proportions, mean, standard deviation, median, and interquartile range. Chi-square test and Fischer's exact test as applicable were used to test for association between antenatal psychiatric disorder and various independent co-variates. Significantly associated variables were entered into a multiple logistic regression model, and adjusted odds ratios (OR) were calculated with 95% confidence intervals. Value of P < 0.05 was considered significant for all statistical analyses.
| Results|| |
A total of 150 pregnant women were included in the study. The mean age was 23.31 ± 3.03 years (Range = 18–36 years). Majority were educated up to high school (60.7%), were homemakers (94%), of the middle class (48%) and belonged to joint families (62%). Most (58.7%) had at least one living child and were of 28 to <32 weeks gestational age (71.3%).
Based on the CIS-R cut-off score of ≥12, 15.3% of the participants were found to have antepartum psychiatric disorder. The most common antepartum psychiatric symptom found were somatic symptoms (aches, pains, headache, and general discomfort), which was seen among 43.3% of women, followed by symptoms of fatigue (37.3%), sleep problems (28%), anxiety (22.7%), and irritability (21.3%). None of the study participants were found to have symptoms of depression, depressive ideas, worry, phobias, panic, compulsions, or obsessions [Table 1]. None of the women in our study had sought any consultation or treatment for their psychiatric symptoms. None of them had been screened for antepartum psychiatric disorders during their routine antenatal visits.
|Table 1: Presence of psychiatric symptoms among the study subjects (n=150)|
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The presence of antepartum psychiatric disorder was significantly associated with higher education (P < 0.001) and lower socioeconomic status (P = 0.01), but not associated with age or occupation of the subject [Table 2]. The proportion of antepartum psychiatric disorder was higher among those with <4 Antenatal care (ANC) visits and those with unplanned pregnancy, but this was not statistically significant [Table 3]. Antepartum psychiatric disorder was not associated with the number of living children and the gestational age of current pregnancy. Women who reported an adverse event in the past 1 year (death or major illness in close family, financial crisis, or loss of livelihood) had a higher prevalence of the antepartum psychiatric disorder, and this was found to be statistically significant (P = 0.02). Antepartum psychiatric disorder was also significantly more among women with a poor relationship with their in-laws (P < 0.001), but not associated with the type of family, pressure for a male child, or relationship with spouse [Table 4].
|Table 2: Association of antepartum psychiatric disorders with various socio-demographic variables (n=150)|
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|Table 3: Association of antepartum psychiatric disorders with obstetric factors (n=150)|
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|Table 4: Association of Antepartum psychiatric disorders with family factors (n=150)|
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After regression analysis, participants who reported a poor relationship with in-laws had six times higher risk of antepartum psychiatric disorders as compared to those who reported a good or satisfactory relationship (OR = 5.9 [1.48–50.71], P = 0.017). Participants with lower education (up to high school education) had more than double the chance of antepartum psychiatric disorders as compared to those educated to preuniversity level or above (OR = 2.3 [1.04–7.80], P = 0.036) [Table 5].
|Table 5: Multiple logistic regression of factors associated with antenatal psychiatric disorder (n=150)|
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| Discussion|| |
A variety of tools are available for screening for antepartum psychiatric disorders; Perinatal Anxiety Screening Scale, Kessler Psychological Distress Scale (K-10), Patient Health Questionnaire-9, Generalised Anxiety Disorder-7 scale, and state anxiety inventory to name a few. However, these tools are specifically designed to screen for just one or two psychiatric disorders, namely anxiety, and depression. By far, the most comprehensive screening tool for antepartum psychiatric disorders is the CIS-R, which screens for 14 different psychiatric disorders. This tool has been used in previous hospital-based studies in south India, in Vellore, Tamil Nadu, and in Bangalore city. Our study among pregnant women in villages under the Sarjapur PHC area, using CIS-R, estimated the prevalence of antepartum psychiatric disorder as 15.3%, which means one in every seven pregnant women. This is comparable to the result of a similar study done in the United Kingdom, where 11.9% of pregnant women screened positive for common mental disorders. A study done among 1795 pregnant women in Northern Sweden estimated that psychiatric disorders were present in 14.1% of the women, which was also similar to our study. However, the prevalence of antepartum psychiatric disorders in our study was much lower compared to an Iranian study where the prevalence was 21.4% and in Tanzania, where it was 39.5%. This may have been because of the higher level of education in our study as compared to the Iranian and Tanzanian studies. More than a third of the subjects in the present study were educated beyond preuniversity. This reasoning is supported by the fact that women who were of lower education in our study also had a significantly higher prevalence of antepartum psychiatric disorders. Participants with lower education had more than double the chance of antepartum psychiatric disorders as compared to those educated to preuniversity level or above. Higher education is lined to improved awareness and health-seeking, as well as de-stigmatization of mental health problems. Higher education levels of women in the community are also linked to the improved status of women, better employment opportunities, and empowerment, all of which play a role in women's mental health.
Some amount of anxiety in pregnancy and childbirth is natural, as it is a normal reaction to a physically and emotionally stressful, life-altering event. However, in our study, over one in five women screened positive for anxiety symptoms, similar to an urban community in Pakistan, a rural area of Bangladesh and in a hospital-based study among pregnant women attending outpatient department in rural Karnataka. Our findings have public health implications, as antepartum anxiety has been shown to be associated with a greater chance of adverse perinatal outcomes like preterm and low birth weight; therefore, such a high proportion of anxiety indicates an urgent need to identify and manage antepartum anxiety.
We found that the pregnant women in our study suffered commonly from somatic symptoms, that is aches, pains, headache and general discomfort, as well as symptoms of fatigue, sleep problems, and irritability. This could be explained by the fact that the majority of women in our study lived in joint or extended family and already had one or more living children; therefore, they had to take care of their children and the rest of the family along with regular household chores. We also found that subjects who reported a poor relationship with in-laws had six times higher risk of antepartum psychiatric disorders as compared to those who reported a good or satisfactory relationship. This was similarly demonstrated in a hospital-based study in Bengaluru city, as well as in the Netherlands, where it was found that antepartum psychiatric disorders were associated with daily stressors and low satisfaction with social support. In the Indian sociocultural context, the joint or extended family system is fairly common, and while inter-personal issues and increased work-load are often experiences, joint families can also be a potential source of social support to the mother. This indicates a need for counseling of family members of pregnant women who are diagnosed with antepartum psychiatric disorders. Family members may encourage or actively intervene for women to use maternal mental health services or may facilitate care by paying for health-care costs, accompanying women to health facilities, and communicating about health-related information.
In this study, none of the pregnant women were found to have depression or depressive symptoms. This finding is in contrast to other studies in India, Pakistan, UK, and Sweden, which have shown depression to be a common antepartum psychiatric disorder.,,,, While there is no concrete evidence in our study to support this, we question whether social support mechanisms may have played a role in the lack of depression in our study, considering that majority belonged to joint or extended families. Furthermore, being from a rural area, did the women have the benefit of social cohesiveness and participation in community women's groups which acted as a protective factor to antepartum depression? This needs to be explored further and shows us direction for future research in this area.
The presence of antepartum psychiatric disorder was significantly associated with lower socioeconomic status in our study. This has been also stated in a study by Witt et al. in the USA, analyzing nation-wide data from 3552 women, which showed that women from low-income groups face challenges with regards to accessing essential antenatal care services, while maternal mental health often goes ignored in the quest for basic health care. Lack of awareness, poor attitude to mental health, and distrust of the health system may play a role in poor-health seeking among those from the low socio-economic group.
Women who reported a recent adverse event (death or major illness in a close family, financial crisis, or loss of livelihood) were more likely to have an antepartum psychiatric disorder. A systematic review to identify risks of antenatal anxiety and depression has cited such adverse events as possible triggers. This indicates that adverse events like these could set pregnant women on a trajectory of poor mental health, with an inability to cope or deal not only with the event itself but also with the ensuing psychiatric disorder. The occurrence of adverse events should raise the index of suspicion of antepartum psychiatric disorders, especially among village-level workers who are familiar with pregnant women and their families.
Our study has shown the need for a greater focus on antepartum mental health screening, especially since none of the women in our study had sought any consultation or treatment for their psychiatric symptoms and none of them had been screened for antepartum psychiatric disorders during their routine antenatal visits. Policymakers need to take note of the high prevalence of antepartum psychiatric disorders and introduce strategies to address the same. Screening for antepartum psychiatric disorders should be a part of the routine and essential antenatal care. The World Health Organization, in its revised guidelines for antenatal care has recommended eight antenatal visits during pregnancy. Diagnosis, treatment, and counseling during these antenatal visits will not only mitigate antepartum psychiatric disorders but will also help to reduce adverse perinatal outcomes and incidence of postpartum psychiatric disorders since there is ample evidence to show that antepartum psychiatric disorders are determinants of adverse perinatal outcomes and postpartum psychiatric disorders., Rural areas in India have unique platforms through which maternal mental health programs can be scaled-up: Capacity building of village-level workers like Accredited Social Health Activist, Auxiliary Nurse Midwife and Anganwadi worker in screening and referral of antepartum psychiatric disorders, as well as health education, sensitization, and de-stigmatization through organized community women's groups like self-help groups and Mahila Mandals, and local events like Village Health and Nutrition Days.
The findings of this study are applicable to rural areas in Karnataka and may not be generalizable to all rural areas of India owing to the socio-cultural differences between states and regions.
| Conclusion|| |
Our study has revealed that a high burden of antepartum psychiatric disorders exists among rural women in the Sarjapur PHC area. Low socioeconomic status, lower education, poor relationship with in-laws, and recent adverse events were found to be the risk factors significantly associated with antepartum psychiatric disorders. There is a need for public health focus on antepartum psychiatric disorders, especially since none of the women in our study sought any consultation or treatment for their psychiatric symptoms and none had been screened for antepartum psychiatric disorders during their routine antenatal visits. Screening, referral, and management of antepartum psychiatric disorders should be included as a part of the routine and essential antenatal care along with the utilization of existing platforms like community women's groups for health education, sensitization, and de-stigmatization of antepartum psychiatric disorders.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]