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ORIGINAL ARTICLE
Year : 2021  |  Volume : 65  |  Issue : 1  |  Page : 16-21  

Maternal mental health and its determinants – A community-based cross-sectional study in Aligarh, Uttar Pradesh


1 Ex Junior Resident, Department of Community Medicine, Jawaharlal Nehru Medial College, AMU, Aligarh, Uttar Pradesh, India
2 Associate Professor, Department of Community Medicine, Jawaharlal Nehru Medial College, AMU, Aligarh, Uttar Pradesh, India
3 Professor, Department of Community Medicine, Jawaharlal Nehru Medial College, AMU, Aligarh, Uttar Pradesh, India

Date of Submission18-Mar-2020
Date of Decision20-Apr-2020
Date of Acceptance30-Jun-2020
Date of Web Publication20-Mar-2021

Correspondence Address:
Nikhat Naaz
A-21, Alhamd Apartments, Shamshad Market, Badar Bagh, Aligarh, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_193_20

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   Abstract 


Background: Maternal mental health problems are one of the major public health challenges. Globally, depression and anxiety cause immense suffering and disability among mothers who later contribute to compromise parenting practices and increased unmet needs of their newborn and young children. Objectives: The aim of this study is to determine the prevalence and determinants of maternal common mental disorders (CMDs) among the study population. Methods: A community-based cross-sectional study was conducted in Aligarh, Uttar Pradesh, India, from July 2016 to June 2017, among 415 women of child-bearing age who had one or more children in the age group of 0–23 months. A World Health Organization prequalified questionnaire Self-Reporting Questionnaire 20 was used to assess the CMD of mothers. Binary logistic regression was used for finding out predictors of mental disorders. Results: Overall prevalence of maternal CMDs was 38.8%. The prevalence of maternal CMD was significantly higher among mothers in a higher age group, belonging to low socioeconomic class, nuclear type of family, living in the urban locality, having lower or no education, being single mothers, housewives, and having higher parity. Conclusion: Substantially, high prevalence of CMD among mothers suggests for further research to explore the factors affecting the mental health of mothers. Measures for the early identification, treatment, and prevention of maternal mental disorders should be taken.

Keywords: Common mental disorders, health, maternal, mental


How to cite this article:
Naaz N, Mehnaz S, Ansari M A, Amir A. Maternal mental health and its determinants – A community-based cross-sectional study in Aligarh, Uttar Pradesh. Indian J Public Health 2021;65:16-21

How to cite this URL:
Naaz N, Mehnaz S, Ansari M A, Amir A. Maternal mental health and its determinants – A community-based cross-sectional study in Aligarh, Uttar Pradesh. Indian J Public Health [serial online] 2021 [cited 2021 Jun 21];65:16-21. Available from: https://www.ijph.in/text.asp?2021/65/1/16/311518




   Introduction Top


The World Health Organization (WHO) proposition that there can be “no health without mental health” has also been endorsed by the Pan American Health Organization, the EU Council of Ministers, the World Federation of Mental Health, and the UK Royal College of Psychiatrists. Mental disorders make a substantial independent contribution to the burden of disease worldwide.[1] Certain population subgroups are at higher risk of mental disorders because of greater exposure and vulnerability to unfavorable social, economic, and environmental circumstances, interrelated with gender. Disadvantage starts before birth and accumulates throughout the life.[2].Common mental disorders (CMDs) mainly include depression and anxiety disorders. They are distinguished from psychotic disorders since there is no loss of contact with reality, as seen in psychotic disorders.

The WHO has defined maternal mental health as “a state of well-being, in which a mother realizes her own abilities, can cope with the normal stresses of life, can work productively and fruitfully and can make a contribution to her community.”[3] Maternal mental health problems are one of the major public health challenges. Worldwide 10% of pregnant women and 13% of postpartum women experience some form of mental disorder, primarily depression and anxiety. In developing countries, the situation is even worse, with the prevalence of mental disorder as 15.6% and 19.8% during pregnancy and postpartum period, respectively.[4] Globally, depression is the largest contributor of mental or neurological disorders in women of child-bearing years.[5] Suicide owing to severe depression is an important cause of death among pregnant and postpartum women. Community- and facility-based prevalence of perinatal depression ranged from 3% to 50% in a situation analysis conducted in five districts across five different countries Ethiopia, India, Nepal, South Africa, and Uganda. Moreover, no dedicated maternal mental health services were found in any of these regions under study.[6]

Data related to maternal CMDs from India, particularly Uttar Pradesh, is deficient. In a study in Goa (India), the prevalence of CMD in adults attending primary care clinics was found to be 46.5%.[7] In a multinational study, the prevalence of maternal CMD was found to be 30% in India.[8] However, in another study in India, the prevalence of CMD among women of child-bearing age group was 6.6%.[9] Some studies related to postpartum depression in India have been conducted in the past, but these are also predominantly from south India. In a systematic review and meta-analysis of studies from India, it was found that the pooled prevalence of postpartum depression was 22%.[10] In a cohort study among pregnant females in Goa (India), 23% of mothers were found to be depressed at 6–8 weeks after childbirth.[11]

Depression and anxiety cause immense suffering and disability among the mothers who later contributes to compromised parenting practices and increased unmet needs of the newborn and young children like suboptimal breastfeeding and complimentary feeding practices, reduced mother-to-child interaction and increased prevalence of medical disorders among their children.[1],[4] Therefore, addressing maternal mental problems could play a crucial role in achieving the Millennium Development Goals set by the United Nations in which three out six goals deal with the well-being of women and children.[12]

In this context, the present community-based study was conducted in Aligarh, Uttar Pradesh, with the following objectives-to determine the prevalence and determinants of maternal CMDs among the study population.


   Materials and Methods Top


Study design and study population

It was a community-based cross-sectional study conducted from July 2016–June 2017. The study population was women of child-bearing age (15–45 years) who had one or more children in the age group of 0–23 months and residing in the study area. Mothers who were critically ill, who did not give consent were excluded.

Study area/setting

The study was conducted in the registered field practice areas of urban and rural health training centers of the Department of Community Medicine, J. N. Medical College and Hospital, Aligarh Muslim University (AMU), Aligarh, Uttar Pradesh (UP), India. The Urban Health Training Centre, which caters to a population of 12,288 comprise Firdaus Nagar, Nagla Qila, Patwari ka Nagla and Shehenshabad of Aligarh city. The Rural Health Training Centre, which caters to a population of 17,434 comprises Tejpur, Chhota Jawan, Ghariya Bhojpur, and Jawan Sikanderpur in UP.

Sampling size and sampling technique

Due to the lack of sufficient studies on maternal CMD in our region, the sample size was calculated using prevalence as 50%, allowable error as 5%, and nonresponse rate of 3%. The final required sample size was 415. The sample size to be drawn from each area was calculated by probability proportion to size. Of 415 sample size, 243 children were drawn from rural areas, whereas 172 from urban areas. The desired samples were drawn through systematic random sampling from each area.

A list of children in the age group of 0–23 months (<2 years) was prepared using data in the study area by the door-to-door survey. Mothers of these children were taken for an interview. Informed consent was obtained before the interview.

Variables, tools and technique – Data collection

Data were collected at the household level by interviewing the subjects with a predesigned schedule for sociodemographic variables and applying the Self-Reporting Questionnaire (SRQ)-20 for CMDs.

Maternal CMD was evaluated through the application of a pre-validated screening questionnaire (SRQ-20).

SRQ 20 is a screening tool for psychiatric disorders developed by the WHO, which has a sensitivity of 83% and specificity of 80%.[13] It consists of 20 closed questions with two alternatives for the answers (yes/no). A “yes” is given a score of 1 and “no” is given a score 0. The maximum score is 20 and the minimum score is 0. A cutoff score of ≥8 positive responses was used to identify probable cases of CMDs or “CMD positive,” while a score of <8 positive responses was taken as “CMD negative”.[14]

CMDs refer to two main diagnostic categories, namely, “depression and anxiety disorders.” The reason they are called “common” is because they are highly prevalent in the population. Their impact on the mood of persons depends on the duration and severity of symptoms. These disorders are diagnosable and are distinct from feelings of sadness, stress, or fear that anyone can experience from time to time in their lives.[15]

Variables: Selected ten variables were dichotomized for analysis purposes as follows: (i) Mothers' ages were divided into ≤25 years and >25 years. This cutoff was chosen arbitrarily from the hypothesis that there is a change of social role for women in the social group from this age onward. (ii) Maternal educational level was defined as “low” when mothers had education up to primary and “high” when they had education above primary (5th standard). (iii) The number of children per mother (i.e., parity) was divided into low parity, defined as up to children up to three, and high parity as >3 children. This cutoff was chosen because we believed that low-income families with >3 children would have additional difficulties, such as more financial constraints and less time to spend with each child. (iv) Social class was defined according to the five classes proposed by the modified B. G. Prasad Classification[16] and then dichotomized by bringing together Classes I and II as the higher Classes and III, IV, and V as the lower classes. (v) Regarding employment status, mothers were categorized as homemakers/housewives and working mothers. (vi) Regarding marital status mothers were categorized as living with partner and living without partner (widowed/divorced/separated).

Statistical analysis

Data entry and analysis were performed using SPSS software version 22 (IBM Corp., Armonk, NY). A value of P ≤ 0.05 was taken as significant. Bivariate binary logistic regression analysis was used to calculate odd's ratio (OR) to determine the possible relationship and its strength between maternal CMDs with sociodemographic factors.

Ethical considerations

The study was approved by the Institutional Ethics Committee, Jawaharlal Nehru Medical College, AMU, Aligarh.


   Results Top


Out of 415 total subjects, 243 (58.5%) were from rural locality; majority (75%) belonged to low socioeconomic class (B. G. Prasad Class III, IV, V); 229 (55.2%) were Muslims and rest 186 (44.8%) were Hindus. The mean age of the mothers was 26 ± 4.7 years (range, 18–42); majority belonging to the age group of 20–30 years (328, 79%). Majority of them (64.6%) were either illiterate or had education up to primary levels only; and almost all (96.6%) were homemakers/housewives. Most of the women (408, 98.3%) were currently married and living with their husbands, and rest 7 (1.7%) were either separated, divorced, or widowed. Out of total of 415 women in the study population, 320 (77.1%) had low parity with ≤3 children [Table 1].
Table 1: Association between sociodemographic variables and maternal common mental disorders (n=415)

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Out of 415 subjects, 161 (38.8%) had a score of 8 or more in the SRQ 20 questionnaire and were taken as CMD positive. Thus, the overall prevalence of maternal CMD was 38.8% in our study population [Figure 1]. The mean score of SRQ 20 in our study was 6.61 ± 3.92. The median score of SRQ 20 was 6.0.
Figure 1: Prevalence of maternal common mental disorders.

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Table 1 shows the association between sociodemographic factors and maternal CMD. Significantly higher odds of maternal CMD were observed in single mothers (OR = 9.79; 95% CI = 1.17–82.12); Hindus (OR = 2.01; 1.34–2.98); mothers having age > 25 years (OR = 1.76; 1.18–2.63); mothers with high parity (OR = 2.34; 1.47–3.73); belonging to low socioeconomic status (OR = 9.63; 1.32–3.35); having low or no education (OR = 1.58; 1.03–2.4); and those who were housewives (OR = 8.6; 1.11–67.0). However, no significant association was found between maternal CMD and living in crowded dwellings.

Lesser odds of maternal CMD was observed in mothers living in urban areas (OR = 0.63; 0.42–0.95) compared to rural areas. Similarly, women living in joint families were at a lesser risk for maternal CMD (OR = 0.636; 0.43–0.95) compared to mothers who were living in nuclear families.


   Discussion Top


The prevalence of CMDs in our study was high as 38.8%. Studies in the past, particularly in developing countries, have concluded similar findings. In a study in Goa (India), the prevalence of CMD in adults attending primary care clinics was found to be 46.5%.[7] In a multinational study, Harpham et al. found that the prevalence of maternal CMD was 30% in India, 33% in Ethiopia, 30% in Peru, and 21% in Vietnam.[8] In a study among mothers of children 0–5 years, Nguyen et al. found that maternal CMD (using SRQ 20) was high and ranged from 31% in Vietnam to 49% in Bangladesh.[17] Similarly, Khan and Flora reported a prevalence of maternal CMD as 46.2% among mothers in Bangladesh,[18] and Hartley et al. found the prevalence of CMD as 39% in women during pregnancy in South Africa.[19] Studies in other regions have also reported a high prevalence of maternal CMD and depression. In a cohort study among 132 mother-infant pairs in the Hispanic population, the prevalence of depressive symptoms among mothers ranged from 33% to 38%.[20]

Data in relation to CMDs among mothers in India still remains deficient and inconclusive. Among the few studies conducted, the majority are from south India, and the prevalence of CMD was found to be variable across different studies. In a cross-sectional survey among adults (16–65 years) who attended primary care clinics in Goa (India), the prevalence of CMD was 46.5%. In a multinational study including India, mothers who had children in the age group of 6–18 months were interviewed using SRQ20, and the prevalence of maternal CMD was found to be 30% in India.[8] In a population-based survey among women of age 18–49 years in India, the prevalence of CMD was 8.2%. In a systematic review of studies on postpartum depression from India, the pooled prevalence of postpartum depression was 22%. Due to the lack of proper mental health screening programs and adequate research, the exact situation of maternal mental health in our country still remains unclear.

The high prevalence of maternal CMD in our study may be multifactorial. Since our study included women who had children in the age group of 0–2 years, the prevalence of CMD in our study might be higher than the general population as these women who are already struggling with child care responsibilities and domestic duties are at a much higher risk for mental health problems. However, more studies and research related to maternal mental health needs to be conducted for a better understanding.

In our study, it was found that mothers living in rural areas had higher odds of being CMD positive. This finding is consistent with similar associations found in the past studies. Maternal CMD was found to be higher among women living in rural areas as compared to urban areas in studies conducted in Vietnam,[21] Zimbabwe,[22] and Brazil.[23] The higher prevalence in rural areas could be a result of poor quality of life, poor health-care facilities, and lower awareness toward mental well-being.

Our study shows a significant association between maternal CMD and low socioeconomic status. Low socioeconomic status and low family income have been found to be a strong predictor of mental health issues among mothers in many studies in the past. In a systemic review of studies in 17 different low- and middle-income countries, Fisher et al. concluded that low socioeconomic status was significantly associated with depression in mothers.[21] Similarly, depressive symptoms among mothers belonging to low socioeconomic status were significantly higher in studies conducted in Pennsylvania (US),[24] Brazil,[23] and Australia.[25] Food insecurity was also found to be a strong predictor of depression and anxiety among mothers.[26],[27] Low family incomes puts families at huge risk for food shortage, insufficient daily domestic supplies, and inadequate child care. These financial difficulties become more pronounced at the level of mothers who are already struggling with household and child care duties.

In this study, it was found that mothers who were illiterate or had low education levels were at significantly higher risk of having CMD compared to their more educated counterparts. Past studies have shown that education level plays a significant role in maintaining a good maternal mental health. In a systemic review in low- and middle-income countries, risk of common perinatal disorders was significantly higher in women with lower education (relative risk: 0.5; P = 0.03).[21] Poor education of mothers was found to be a strong predictor of maternal depression and common maternal mental disorders in studies conducted in Pakistan,[28] Brazil[23] and Ethiopia.[29] Education plays an important role in the quality of life and may contribute toward a better understanding of both physical and mental health. This association is significant since improving on literacy and education of mothers can go a long way in improving their physical as well as mental health.

Our study reported that maternal CMD was higher in women of higher age group (>25 years). Studies in the past have concluded that postpartum depression is significantly higher with every 5 years increase in age.[30],[31] Similarly, in a cohort study Abbasi et al. concluded that postpartum depression was higher among mothers in a higher age group.[24] This is an important association and should be explored in future. As the age of mothers increases, the family size increases and so does the domestic duties. With increasing workload, mothers may have less time for themselves and this may take a toll on their physical and mental health.

In our study, single mothers were more likely to have maternal CMD compared to mothers living with their partners. In the past, many community-based studies have found a higher association of maternal CMD in single mothers than those who were living with their partners.[19],[23] In a systemic review, Fisher et al. found that unmarried mothers were more likely to suffer from CMDs.[21] Other studies also reported that unmarried mothers[24] or single mothers[32] (divorced, separated, or unmarried) had higher odds of having mood disorders or any mental illness. A good and supportive family is very important for the emotional well-being of every individual. Therefore, single mothers who are already struggling with daily domestic life issues have an additional responsibility of taking care of their children making them more susceptible to emotional disturbances.

The study concluded that mothers with higher parity (>3 children) had higher rates of maternal CMD compared to mothers with lower parity (≤3 children). This finding is consistent with findings in the past studies. In a study in Turkey, Senturk et al. found a significant association between maternal distress and high parity.[29] Similarly, in a cohort study in Zimbabwe, it was found that women who had 3 or more children were at higher risk for depression.[22] High number of children leads to more responsibility, which not only comprises the efficiency of mothers but also may lead to poor consequences on their mental health. This problem may further aggravate if the interpregnancy interval is less. Addressing this issue through regular counseling of mothers on family planning and maintaining adequate interpregnancy intervals may prove to be beneficial for the well-being of mothers as well as their children.

The study shows that working mothers were less likely to be positive for CMD compared to mothers who were homemakers/housewives. A study in Cape Town found that unemployed mothers had a significantly higher risk of being depressed compared to those who were employed.[21] Similarly, in another study in Pakistan, Saeed et al. found that depression among mothers was significantly associated with maternal unemployment.[28] Being employed gives a sense of financial security and thus may contribute significantly toward the mental health of mothers.

In our study, maternal CMD was higher in mothers who were living in households where overcrowding was present; however, this finding was not significant. In a cross-sectional study in Brazil, overcrowding was found to be significantly associated with the presence of CMD among pregnant females.[33] Overcrowding may hamper the privacy and development of a healthy environment at home. A healthy environment at home is very important for the mental well-being of every individual.


   Conclusions Top


Substantially high prevalence of CMDs among mothers and some of the significant correlates in the area highlights the need for further research to explore factors affecting the mental health of mothers. Measures for the early identification, prevention, and treatment of common maternal mental disorders should be strengthened.

Acknowledgment

The authors would like to thank Faculty and staff of J. N, Medical College.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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