Screening for Depression among Pregnant Women in Peripheral Care Units in Lomé: Knowledge and Practices of State Midwives and Auxiliary Midwives ()
1. Introduction
The gestation period and the postpartum period constitute a moment of great vulnerability for the women because, facing with emotions to physical and psychic reshuffles (Dayan et al., 2014; Bressoud & Nanzer, 2020) ; they sometimes develop psychiatric pathologies estimated between 15% and 30% by the World Health Organization (WHO) (OMS, 2010) . Among these pathologies, depression is recognized as a public health issue with a prevalence in the prenatal period of about 20% (De Noose et al., 2011) and 17% in the postnatal period (Shorey et al., 2018; Masmoudi et al., 2014) . It should therefore be identified and treated early. All the prenatal depressions and the two-thirds of the postnatal depressions are considered detectable in the antenatal period (OMS, 2010; Nadège et al., 2019) . Screening tools for depression exist but seem to be little known to perinatal professionals (Nadège et al., 2019) . That of the WHO Mental Health Gap Action Programme (mhGAP) is adapted to the providers of non-specialized peripheral structures (OMS, 2018) . It makes it possible to detect, among other things, the depression through the presence of one or more of these characteristic symptoms such as the intense sadness, a feeling of guilt or failure, a psychomotor slowdown, a decrease in self-esteem, an eating and sleep disorder, a decrease in libido, infanticidal or suicidal thoughts etc. But it is clear that this tool is less known to reproductive health providers and as a result, the mental health of pregnant women has remained less visible despite the fact that in Togo, as in many developing countries, commendable efforts have been made to improve the quality of the maternal and child health care. This is why it seemed important to us to conduct this study whose objective was to describe the knowledge and practices of the State Midwives (SMW) and State Auxiliary Midwives (SAM) in relation to the depression in pregnant women.
2. Framework and Method
2.1. Study Framework
The maternity wards of the public Peripheral Care Units (PCU) of the Health District No. 5 (HD5) of the Lomé-Commune Health Region (LCHR) served as a framework for our study. These PCUs are: Centre Médico-Social (CMS) Bè-Attikoumé, CMS Cacavéli, CMS Djidjolé, CMS Doumassesse, CMS Tokoin- Elavagnon. The HD5 of the LCHR with 22.33 km2 is one of the largest health districts (HD) of Togo. It had served an estimated population of 271,345 inhabitants in 2019. Like the structure of the Togolese population in general, the population of the HD5 area is very young with a relative female predominance. The population of women of reproductive age was 15,046 or about 6% of the population of HD5 which included 48 reproductive health providers namely 26 state midwives and 22 state auxiliary midwives (Ministère de la Santé du Togo, 2019) .
2.2. Study Method
2.2.1. Type and Period of Study
Our study was a cross-sectional descriptive study conducted from May 13, 2019 to July 16, 2019, i.e. a duration of 2 months.
2.2.2. Study Population and Sampling
Our study population consisted of:
Target population: the reproductive health providers in the Lomé-Commune Health Region (LCHR).
Source population: the reproductive health providers who worked in the maternity wards in the five public CMS of the HD5.
The sampling had been a reasoned choice of the Health District No. 5 on the basis of its large area and its population great size. All the 5 CMS in the district were selected for consideration. The midwives and the auxiliary midwives have been all chosen.
➢ Inclusion criteria
The State midwives and the state auxiliary midwives who were present at the maternity ward during the study period and who had agreed to participate in the survey were included in the study.
➢ Non-inclusion criteria
The state midwives and the auxiliary midwives who were enjoying their administrative leave during the survey period were not included in the study.
2.2.3. Data Collection
Data had been collected through a pre-established survey sheet with multiple- choice and closed-ended questions. These included socio-demographic data and data on knowledge and practices related to the depression in pregnant women. The administration of the questions was done in self-evaluation and took between 15 and 20 minutes for each respondent. The survey sheet had been tested and validated with reproductive health providers at the Lomé Health Centre. This centre had been chosen for the test because it had the same profiles as those we studied without belonging to the same health area.
2.2.4. Data Analysis
The data collected had been analyzed using Epi info 7 version 7.1.5 software. The table and the figure had been made by Microsoft Excel 2016.
2.3. Ethical Aspects
The authorization of the management of the HD5 as well as the free and informed consent of each respondent had been obtained before the administration of the questions. The anonymity and the confidentiality were respected.
3. Results
Of the 48 HD5 reproductive health providers, 44 (91.7%) had met the inclusion criteria. One SM and three SAMs were enjoying their administrative leave during the survey period.
3.1. Study Population Characteristics
The average age of respondents was 35 ± 11.3 years with extremes of 23 and 51 years. The 35 - 40 age group had accounted for 50.0%. Thirty respondents (68.2%) had already worked for at least 5 years or more. Six respondents (13.6%) had received an instruction on the depression in pregnant women during their initial training. Five respondents (11.4 percent) had received an instruction in the screening and the management of the depression in pregnant women as on-the-job training. Table 1 shows the age groups and the professional experience.
3.2. Knowledge and Practices Related to Depression in Pregnant Women
Forty-two of the respondents (95.5%) experienced less than 5 characteristic symptoms of the depression. Forty respondents (90.9%) were not aware of the existence of specific screening tools for the depression. The most well-known symptoms of the mhGAP-GI 2.0 list were (Figure 1) the intense fatigue (20.5% of respondents) and the loss of interest or pleasure in the usually enjoyable activities (18.2% of respondents). Outside of the mhGAP-GI 2.0 list, the most well-known symptoms were the negative feelings towards pregnancy (34.1%), the feeling of guilt (25.0%), the loss of self-esteem (25.0%) and the weight loss (15.9%). Thirty-three respondents (75.0%) had never screened the pregnant
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Table 1. Distribution of the respondents by the age group and the professional experience.
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Figure 1. Distribution of the respondents according to the most well-known symptoms in the mhGAP-GI 2.0 list.
women for symptoms of the depression. Of the 11 reproductive health providers who had screened the pregnant women for depression, 5 (45.5%) did so in the 1st trimester of pregnancy, one (9.1%) in the 2nd trimester, two (18.2%) in the 3rd trimester, and three (27.2%) in perinatal. The life events triggering the depression in the 11 cases were the undesirable nature of pregnancy (4 cases or 36.4%), the negative obstetric history (3 cases or 27.3%), the existence of a disease (2 cases or 18.2%) and the separation of the couple (2 cases or 18.2%). The therapeutic decisions taken by the 11 respondents were the reference (9 cases or 81.8%), the consultation (1 case or 9.1%), the antiasthenic treatment associated with an appetite stimulant and an anxiolytic (1 case or 9.1%).
4. Discussion
4.1. Study Population Characteristics, Knowledge, and Practices
The young adults under the age of 40 had predominated in our study with an average age of 35 ± 11.3 years. The young age of our sample was not only in harmony with the youth of the Togolese population (République Togolaise, 2010, 2015) , but also through the successive recruitment of health workers, Togo’s health care staff had become predominantly young (OMS, 2018; Ministère de la Santé du Togo, 2017, 2020) . The professional experience of 68.2% of our respondents was 5 years old; sufficient time to experience at least once most common pregnancy conditions including depression in pregnant women. This professional experience was also found among all the health care staff in Togo (Ministère de la Santé du Togo, 2017, 2019, 2020) . Six respondents (13.6%) had received an instruction on the depression during their initial training and five respondents (11.4%) had received an instruction on the depression detection and management as on-the-job training. The lack of specific and adequate training of reproductive health providers in relation to the mental health of pregnant women was also raised by Nadège et al. (Nadège et al., 2019) . In our country, the introduction of psychiatry education in the training curricula of SMW and SAM only dates back to 2013. In addition, the scarcity of psychiatrists (5 psychiatrists for about seven million inhabitants (Salifou et al., 2022) ) makes it difficult to teach in the schools and on the job. All this justified the fact that almost the entire sample (95.5%) knew less than five characteristic symptoms of the depression and 90.9% were not aware of the existence of specific screening tools for the depression. This resulted in the depression not being taken into account in their practice. Thus, 75.0% of the respondents had never detected symptoms of the depression among pregnant women. Of the 11 providers who had screened the pregnant women for the depression, 9 providers (81.8%) who were unable to initiate therapy had instead referred the pregnant women to a psychiatric service. Dayan et al. (Dayan et al., 2014; Dayan, 2016) had made the same observation according to which, non-specialized professionals referred depressed pregnant women to a specialized center. As a result, ongoing on-the-job training sessions were needed to address the mental health gaps of reproductive health providers.
4.2. Strengths and Weaknesses of the Study
Our study of the reproductive health providers’ knowledge and practices about the gestation depression was limited to LCHR HD5. This study, which is too small, cannot be generalized to the entire population of reproductive health providers in Togo. This is a weakness of this study. Large-scale, funded studies could fill this gap. Nevertheless, the choice of the LCHR HD5 for this study is a relevant choice because it is one of the largest HD in Togo. Thus, the reality at the LCHR HD5 level gives an idea of the reality of the other HDs and is a starting point for further mental health research among these providers.
5. Conclusion
We have conducted a descriptive cross-sectional study of the knowledge and practices of State Midwives (SMW) and State Auxiliary Midwives (SAM) on the depression in pregnant women in LCHR HD5. Our study found that reproductive health providers had a lack of knowledge and practices related to the depression and its management in the pregnant women. On-the-job ongoing mental health training sessions were needed to address the gaps for these claimants.