Prevalence of common mental disorder and associated factors among pregnant women in South-East Ethiopia, 2017: a community based cross-sectional study

Background Mothers suffering from common mental disorder (CMD), such as anxiety and depression may not be able to function properly, which could adversely affect the mother-infant bond and even result in increased infant morbidity and mortality. The purpose of this study was to assess the prevalence of CMD and its determinants among pregnant women in Southeast Ethiopia. Methods Data was collected from 743 pregnant women via interview-administered, standardised questionnaires during Dec–Jan 2017. The WHO Self-Reported Questionnaire (SRQ) was used to screen CMD. Multivariate logistic regression was conducted and ORs and 95% confidence intervals were calculated. Results The prevalence of CMD during pregnancy was 35.8% (95% CI: 34–38%) and the main determinants of CMD were: illiteracy, presence of health risk, financial instability, physical or emotional abuse, having sexual intercourse without her willingness, family history of psychiatric illness and history of chronic medical illness. Conclusion CMD prevalence during pregnancy was high, indicating a need to regularly screen pregnant women for CMD and its determinants as part of routine obstetric care.


Background
Globally, around 450 million people are living with mental illness [1]. In low and lower middle income countries the non-psychotic perinatal common mental disorder (CMD) is common primarily among poorer women with gender-based risks or a psychiatric history [2]. From 2005 to 2009, out of 10, one pregnant women experienced at least one major depressive episode in one year [3]. In developing countries perinatal depression is common and one in three women had significant mental health disorder but is under-estimated public health concern in low and middle income countries making substantial contribution to maternal and infant morbidity and mortality [4]. In high-income countries perinatal mental illness is the leading cause of maternal morbidity and mortality and causes unfavorable impacts on short and long term physical and mental health of off springs [5,6]. In low, middle and high income countries, the prevalence of CMD during pregnancy varies from 12 to 43% [7].
The main determinants of antenatal CMD are women's marital status, unplanned pregnancy, gestational age and bleeding [4], Furthermore, the presence of poor health status before conception like headache, diabetic mellitus, hypertension, absence of support from partner, history of intimate partner violence and being from low socioeconomic status also leads to antenatal CMD [5,6].
A number of independent studies have identified the association between antenatal depression and adverse neurobehavioral outcomes including reduced social, emotional and cognitive functioning during childhood development [8]. Besides depression, anxiety disorders, eating disorders and psychosis are the antenatal mental disorders which are associated with pre-term delivery, low birth weight of newborn, increased infant mortality and postnatal psychosis causing subsequent emotional problems in the child and adolescent [9].
Ethiopia is one of the low income countries with high rates of mental health problems in pregnant women ranging from 9.2-33% in different areas of the Ethiopia [4]. Even though some studies have been carried out in Ethiopia to recognize the impact of this issue, but none of them has focused on South Eastern region [10][11][12]. So the current study was carried out in the Bale zone of South-East Ethiopia. This zone is considered to be the developed and representative area with much better antenatal facility available in this region. So this study was intended to assess the prevalence of CMD and its associated factors during pregnancy in South-East Ethiopia.

Material and methods
Study design, population and sampling procedures A community based cross-sectional study was conducted in three administrative towns (Robe, Goba and Ginnir) of Bale zone South-East Ethiopia from December-January 2017. The three administrative towns encompass a total of seven Kebeles (Kebele is the smallest administrative unit in Ethiopia similar to that of ward); out of which Robe has three, Goba and Ginnir each has two Kebeles. Using a simple random sampling technique, one Kebele from Goba (East Goba), one from Ginnir (01 Kebele) and two from Robe town (Café Donsa and Baha Biftu) were selected. In the selected 3 towns the number of pregnant women registered by health extension workers was 2376. Out of this, 1086 were found in Robe town, 840 and 450 in Goba and Ginnir towns respectively. The prevalence of CMD during pregnancy ranged from 9.2-33% in different areas of the Ethiopia [4,[10][11][12]. Hence, a single population proportion formula was used to obtain maximum sample size of 748. Multistage sampling technique was used to select study subjects. The calculated sample size was proportionally allocated based on the estimated number of pregnant women in selected Kebeles. Therefore, 341 from Robe, 265 from Goba and 142 pregnant women from Ginnir town were selected for the study. Then, the study participant was selected using systematic random sampling technique at every K th interval; where K th is the ratio of estimated number of pregnant women in each Kebele to the proportionally allocated sample size for specific Kebele. Therefore, we accessed the pregnant women at every 3rd interval. From the first three women, the third one was selected by lottery method. With the help of antenatal registration book maintained by the health extension workers the selected participants were located and interviewed in their homes. All registered pregnant women at any trimester living in the study area for at least six months were included in the study except those taking antidepressants and who had known mental health problems.

Data collection tools and procedures
The data was collected by face to face interview using structured questionnaire addressing socio-demographic and obstetric characteristics of study participants which was developed after reviewing the literature. The List of threatening experience questionnaire (LTE-Q) [13] was adopted and modified in present context to assess the stressful life events. The Oslo-3 Social Support Scale (OSS) [14], the Abuse Assessment Screen (AAS) questions [15] and WHO's alcohol, smoking and substance involvement screening test (WHO-ASSIST V3.0) [16] were used to assess social support, presence of victimization and substance or alcohol abuse, respectively. To screen CMD during pregnancy, the standardized WHO's Self-Reporting Questionnaire (SRQ-20) was used and those who answered "Yes" to six or more of the twenty questions were categorized as CMD caseness (Yes, No). This criterion was validated by the study conducted in Butajira, Ethiopia [17]. Twelve trained data collectors and four supervisors were involved in the process.

Data quality control
The questionnaires were translated from English into the local languages (Amharic and Afan Oromo) using language experts. To confirm that meaning was not altered in the translation process the translated questionnaires were tested for reliability and validity on 5% of the final sample size with pregnant women in Delomena, a town in Bale Zone that was not included in the study. The results obtained were found to be consistent with Amharic version, so there was no need to translate it back. Data collectors and supervisors received two days of training on proper instrument administration and study protocol. Throughout the data collection period, the supervisor monitored the data collectors and 10% of the collected daily data were checked by the field supervisors and principal investigator. Incomplete questionnaires were excluded from the study and counted as non-respondents.

Data processing and analysis
Double data entry was performed for all data and then Epi Info 7.1.2's validation program was used to check the completeness, accuracy and consistency of data and exported to statistical package for social sciences (SPSS) 21 for the analysis [18,19]. Descriptive statistics were calculated to obtain percentages, frequencies and means for all variables. Those variables with significance level (p-value) < 0.05 in bivariate analysis were entered into multivariate logistic regression model for further analysis in order to adjust the confounding factor on the dependent variables.

Results
The response rate of current study was 99.3%.

Socio-demographic factors
The mean ± SD age of participants was 27.3 ± 5.2 with the majority being 20-34 years of age (83.6%). As shown in Tables 1, 68.5% were of the Oromo ethnic group and 43.7% were Muslims. The majority of participants worked as housewives (61.1%) and had either a primary or secondary school education (55.8%). Most participants were married (96.4%) and of these, over half of them had been married for more than 4 years (59.8%) ( Table 1).

Obstetric care factors
More than half of the participants (54.6%) were in the second trimester of their pregnancy and had been pregnant 2-4 times before (58.8%). In this sample, 21.4% had an unplanned pregnancy, 12.5% had history of abortion, and 4% had a prior history of a neonatal death. The participants who had at least one antenatal care (ANC) follow up for the current pregnancy accounted up to 90.8% (Table 2).

Psychosocial factors
Amongst the participants, 14.4% had financial instability, 10.9% had legal problems, 8.1% had relationship issues, 7.9% had health risks, and 5.5% had lost a loved one. Seventy-seven (10.4%) reported that they had been emotionally or physically abused during their lifetime and 6.2% reported abuse during the current pregnancy. Thirty-four (4.6%) participants reported being forced to have sexual intercourse within the last year and of these, the majority (88.2%) reported that it was their husband who forced them for intercourse (Table 3).

Substance abuse
Most participants reported no substance abuse, 25.2% of the participants reported ever drinking alcoholic beverages and 10.4% reported ever chewing khat. Of those who drink alcohol, 46.5% reported having alcohol on a monthly basis (Table 4).

Clinical factors
Participants were asked about various clinical conditions and forty-five (6.1%) reported to have a history of chronic medical illness and 10 (1.3%) had a history of psychiatric illness. Additionally, 58 (7.8%) had a family history of psychiatric illness.

Common mental disorders
The SRQ-20 was used to assess the prevalence of common mental disorder amongst the participants.  1.64-6.48) showed statistically significant association (p < 0.05) with CMD (Table 5).

Discussion
The overall prevalence of CMD during pregnancy from our study finding was 35.8% (95% CI: 34-38%), which is higher than the studies conducted in Maringa Parana (12.9%) [20], Brazil (20.2%) [21], Pakistan (18%) [22], Peru (30%), Vietnam (21%), India (30%) [23], Nigeria (7%) [24] and Kilimanjaro (28.8%) [25], and slightly lower than reported in Tanzania (39.5%) [26] and in the   two Cape Town's peri-urban settlements (39%) [27]. These differences in CMD prevalence might be attributed to differences in measurement tools used, level of knowledge and understanding of the participants, sample size and socio-cultural and economic variations. Similarly, within Ethiopia, there were also variations in CMD prevalence rates, all of which were lower than the current study; for example: Butajira (33%) [10], Maichew (31.1%) [11], Gondar University Hospital (23%) [28], Debre Tabor town (11.8%) [29] and Addis Ababa health facility (24.94%) [30]. These variations may be due to differences in sample size, the time of study, the age, location, and educational status of participants and/or the tools used to diagnose CMD. In the present study the women who were not able to read and write were 2.08 times more likely to have CMD than the literate women. Our findings were in agreement with a population-based cohort study in Southern Brazil where lower educational levels were significantly associated with antenatal depressive manifestations [31]. However a study conducted in rural Bangladesh, India and Pakistan reported that being literate [32] and spending more than 10 years in formal education were predisposing factors for CMD during pregnancy [33]. In addition to socio-economic and cultural differences this discrepancy may be due to the personal circumstances like the relationship quality with the intimate partner, empowerment at home and society and the workload in the populations studied.
Furthermore, in our study, women having a history of previous pregnancy-related complications had 1.59 times chance of development of CMD during pregnancy. While in two different studies conducted in Sao Paulo [34] and Debre Tabor Town [29], women with current pregnancy-related complications were at risk of developing CMD. This is obvious, since during pregnancy a  Note: *p value is significant at p < 0.05 **p value is significant at p < 0.01 1.00 = Reference for category women feels depressive state of mind and any kind of complication during this period may make it worse. The socio-economic factors like financial instability and history of physical and/or emotional abuse showed the likelihood of CMD 1.88 and 2.47 times respectively. Our results were consistent with previous researches carried out in Ethiopia and other countries where financial instability was found to predict the development of CMD during pregnancy [11,33,35,36] as did a history of physical and/or emotional abuse [24,27,32,33,[37][38][39]. and forced sexual activities over the past year [32,33]. In addition to the basic needs of life, moral, social and financial support is important for the wellbeing of a person and lack of any of them may lead to mental instability. Similar to our current findings, the absence of husband's support during pregnancy in two peri-urban settlements in Cape Town [27] were the main predictors of CMD. Also a family history of psychiatric illness was significantly associated with CMD during pregnancy in the present study.
Lastly, in this study, pregnant women with a history of chronic medical illness were vulnerable for CMD, which are similar with the findings of a study conducted in Brazil, Maringa and Parana [20]. Women with chronic illnesses are more worried about their sickness and also remain detached from the social life, hence causing a disturbed mental state. A major limitation of current study is the use of a standardized screening tool to measure CMDs but not locally validated. Further it is a cross-sectional study, hence a temporal relationship could not be determined; only an association between the variables, and not causation, could be inferred. In our study we addressed that there is a strong knowledge gap in the pregnant women about CMD. Further our study is a community based study it can be generalized to the population at large.

Conclusion
The prevalence of self-reported CMD during pregnancy in Bale Zone south east Ethiopia is high. Being unable to read and write, a history of previous pregnancyrelated complications, financial instability, a history of physical or emotional abuse, being forced to engage in sexual intercourse activities over the past one year, poor husband support, a family history of psychiatric illness and a history of chronic medical illness are the main predictors for CMD during pregnancy. The Bale Zone health office in collaboration with key stakeholders should organize the seminars, conferences and create the awareness programs in communities regarding CMD. Further the women education should be encouraged and for this they should be morally and socially supported.