Prevalence and Factors Associated with Anxiety and Depression in Expectant Mothers at Parakou in 2018 ()
1. Introduction
Pregnancy and childbirth allow women to access the status of mother. But, the physiological and psychosomatic modifications induced during that period weaken the woman and expose her to many psychiatric disorders including anxiety and depression. Their onset during pregnancy constitutes a risk for both the mother and the child. About 10% of pregnant women are affected [1] [2] . At least, one expectant mother out of ten coming at the regular appointments for pregnancy follow-up is or will be depressed. However, very few of them are diagnosed. They refrain from revealing their feelings or consulting a health care professional due to the symptoms minimization or the stigma attached to mental health issues. During pregnancy, the pre-existing psychotic disorders can resurface, like a substance abuse or a suicide attempt when they are combined with an undesired pregnancy. According to Gourine et al. [3] , more than 15 years as duration of diabetes is predictive of developing a depression during pregnancy. Depression rates are also high at the end of the pregnancy and during postpartum. Postpartum depression affects more than 15% of new mothers [4] .
In Benin and particularly at Parakou, no study was submitted on psychiatric disorders during pregnancy and puerperium. That is the reason for this study.
2. Population and Methods
2.1. Type and Period of the Study
It was a cross-sectional study with analytical aim and prospective data collection of all the expectant mothers followed from June 14th to September 14th, 2018 in Parakou maternity wards.
2.2. Population and Inclusion Criteria
The sample size was the sum of the encountered expectant mothers who have given their prior consent during data collection. Non available expectant mothers were excluded. A total number of 835 expectant mothers was retained.
2.3. Study Variables
The dependent variables were related to anxiety and depression.
The independent variables were related to sociodemographic and gynaeco-obstetrical factors; a previous psychological vulnerability such as personal and family history of psychiatric disorders, abuse or rape in childhood; psychosocial factors during pregnancy and personal history such as the desire of pregnancy, existence of marital conflicts, a child or a close relative death, a stressful life event during pregnancy, the absence of social support, Difficulties or pathologies about the current pregnancy, the lesser follow-up of the pregnancy; risky maternal behaviour; alcohol, tobacco and others psychoactive substances consumption.
2.4. Data Collection Tools and Technique
Data collection was realized through individual semi-structured interviews basing on a questionnaire in which were integrated the scales: Edinburgh Postnatal Depression Scale-3 (EPDS-3), EPDS [5] and modular Integrated Household Living Conditions Survey (IHLCS-2015) [6] to assess respectively anxiety, depression (the threshold value used to assess depression was 11 and 4 for anxiety) and expectant mothers’ socio-economic level 5 (SEL: high SEL = total score ≥ 85%, average SEL = 50% ≤ total score ≤ 85%, low SEL = total score ≤ 50%). The scales used in the study were translated and validated for local population.
2.5. Ethical Considerations and Data Processing
The study follows a medical thesis. It has been conducted after the approval from the local research ethics board and biomedical research of Parakou University. The data collection was carried out through a semi-structured individual interview using a pre-tested questionnaire, in accordance with the ethical principles set out in the Helsinki Declaration of the Medical World [7] ; the informed consent of the respondents was required, as well as the preservation of their anonymity. Data have been collected on a sheet survey by the personnel who usually perform the childbirth at the survey location and recycled for the circumstance.
For the study of association’s stability between anxiety, depression and the different factors, a univariate analysis (p < 0.05) was simultaneously included in a logistic regression model using a downward and step by step successive iterations. The comparison of factors percentages between dependent variables and the factors associated was made basing on a “chi-2” test. The association strength, meaning and stability were estimated using Odd ratios and 95% as their confidence intervals. The significance level was set at 5%.
3. Results
3.1. Prevalence of Anxiety and Depression in Encountered Expectant Mothers
According to the scales EPDS 3A and EPDS, the number of the survey respondents having an anxiety or a depression was respectively 375 (44.91%) and 295 (35.33%).
3.2. Factors Associated with Anxiety
The mean age of the interviewed expectant mothers was 25 ± 5.1 years with the extremes 15 and 45 years. The age group 15 to 24 years was the most represented (47.12%). The socioeconomic level and the previous onset of a spontaneous miscarriage is associated with anxiety in the interviewed expectant mothers. Table 1 and Table 2 present the factors associated with anxiety in encountered expectant mothers.
3.3. Factors Associated with Depression
The educational level and difficulties during pregnancy were associated with depression in expectants mothers. Table 3 and Table 4 show the factors associated with depression in the encountered expectant mothers.
3.4. Determinants of Anxiety in Encountered Expectant Mothers
In the multivariate logistic regression, low socioeconomic level, third trimester of pregnancy respectively increase 6.70 times and 2.47 times the risk of developing anxiety. Table 5 shows the determinants of anxiety during pregnancy in expectant mothers.
3.5. Determinants of Depression in the Encountered Expectant Mothers
In this multivariate logistic regression, low socioeconomic level increases 8.64 times the risk of developing depression. Table 6 presents psychosocial determinants of depression during pregnancy in expectant mothers.
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Table 1. Distribution of patients by profession, marital status, socioeconomic level and previous onset of spontaneous miscarriage, according to anxiety. (Parakou, 2018; N = 835).
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Table 2. Distribution of encountered expectant mothers by previous onset of an induced abortion, absence of social support, gestational age, dear parent or perinatal death, abuse or rape in childhood, according to anxiety. (Parakou, 2018; N = 835).
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Table 3. Distribution of expectant mothers according to the educational level, socio-economic level and a previous spontaneous miscarriage, according to depression. (Parakou, 2018; N = 835).
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Table 4. Distribution of expectant mothers by onset of previous induced abortion, gestational age, difficulties during the current pregnancy, alcohol consumption, according to depression (Parakou, 2018; N = 835).
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Table 5. Determinants of anxiety in encountered expectant mothers (Parakou, 2018; N = 835).
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Table 6. Determinants of depression inexpectant mothers (Parakou, 2018; N = 835).
4. Discussion
4.1. Limitations of the Study
A depression screening strategy in expectant mothers should take into account the potential chronicity of depression symptoms through repeated assessment in order to provide an intervention to the vulnerable women.
4.2. Prevalence of Anxiety and Depression
4.2.1. Prevalence of Anxiety
The prevalence of anxiety disorders in expectant mothers was 44.91%. Unemployed pregnant women were more affected (see Table 1). Studies on maternal anxiety prevalence reported rate from 12% to 59% during pregnancy [8] [9] . Basing on Hospital Anxiety and Depression Scale, Lee et al. [10] found a prevalence of anxiety close to 54% in a Chinese population. However, a lower prevalence of anxiety at 23% has been reported by Heyningen et al. [11] , in South Africa basing on the Mini International Neuropsychiatric Interview scale. The variability of those prevalences confirm the extent of anxiety during pregnancy. All the authors agree with adverse effects of anxiety on the pregnancy outcome, mother-child interaction and the infant development. According to Capponi et al. [12] , mothering approaches are modified by a high level of anxiety “even non pathological”, and reflect in mother-child relationships quality. In general, the anxiety specific to pregnancy has numerous consequences on both mother and foetus [1] .
4.2.2. Prevalence of Depression
Depressive syndrome prevalence in expectant mothers of Parakou was 35.33%. The third trimester of pregnancy was more depressogenic (see Table 2). And marriage did not protect against depression (see Table 3). In a meta-analysis, Ayano et al. [13] , reported a higher antenatal depression (32.10%) during the third trimester of pregnancy. Although close to the prevalence found in Parakou, that number rather assesses depression particularly at the third trimester (see Table 4). By contrast, Duko et al. [14] , reported 21.5% as prevalence after a similar study in Ethiopia. Basing on Life Event Scale for Pregnancy Women (LESPW) to assess stress at 12 - 16 weeks of pregnancy and at 32 - 36 weeks of pregnancy, 11.1% and 10.3% of expectant mothers developed respectively anxiety and depressive mood in Shanghai MCPC District [15] . The fluctuation of depression prevalences reported in expectant mothers is related to the different tools and the threshold values used.
4.3. Social Determinants of Anxiety and Depression in Expectant Mothers at Parakou
4.3.1. Deficit in Education and Economic Resources
Lack of education (OR 1.85; IC95% [1.06 - 3.23]; p = 0.028) and low socioeconomic level (OR 8.643; IC95% [09 - 17.18]; p = 0.00), have been identified as risk factors for depression in expectant mothers at Parakou (see Table 1 and Table 5). Unemployed expectant mothers are mostly dependent on their partner/spouse and could suffer from deprivation. Van Heyningen et al. [11] , observed that a high social support seemed to reduce the risk for prenatal anxiety in South African expectant mothers who had a low income (OR 0.95; IC95% [0.91 - 0.99]). Therefore, a good socioeconomic level protects from anxiety and depression during pregnancy [16] . Kinser et al. [17] , reported the income and stressful events as the most important predictors of depression during pregnancy.
Educational levels in the sample varied. The majority had a secondary level (47%). Chan et al. [18] found similar results in China in 2013 (52.4%). Silva et al. [19] , also got the same results (41.1%) in Brazil, in 2017. Whereas Giardinelli et al. [16] reported almost the same frequencies of both secondary (47%) and high level (46.4%) in Italy in 2012. That difference with the observations made at Parakou is due to the fact that this study has been conducted only in public maternities which are not frequented by intellectual expectant mothers.
4.3.2. Celibacy as Risk of Developing Anxiety and Depression in Pregnancy
In the multivariate logistic regression, celibacy was a risk factor (celibacy: OR = 2.18; IC95% [1.07 - 4.40]; p = 0.026) for depression in expectant mothers (see Table 6). Räisänen et al., [20] in Finland (2014), achieved the same conclusions; (celibacy: OR = 2.86; IC95% [2.62 - 3.11]). Besides Weobong et al. in Ghana [21] and Duko et al., [14] , reported the lack of social support as a factor significantly associated with depression in pregnancy. So, single expectant mothers can be considered as vulnerable because of their poor support.
4.3.3. Gynaecological and Obstetrical Factors
The risk of developing anxiety during the third trimester of pregnancy is 2.47 times higher (OR = 2.47; IC95% [1.68 - 3.64]; p = 0.000) than the one at the 1st trimester (see Table 5). The third trimester is for sure very critical for the management of risky pregnancies. Moreover, the third trimester is the period in which the expectant mother intensively lives the problem of “imaginary/real child” before the childbirth.
A previous spontaneous miscarriage potentiates 3.70 times (OR = 3.70; IC95% [2.46 - 5.56]; p = 0.001) the risk of developing depression during pregnancy in expectant mothers at Parakou. Zhu et al. [22] , in Singapore (2018) found a similar result (OR = 2.70; IC95% [1.55 - 4.71]; p < 0.001). A previous induced abortion had the same potential risk for the onset of depression in pregnancy (OR = 3.11; IC95% [1.81 - 5.32]; p = 0.000). Pregnancy in women is a particular moment for the recurrence of past traumas and bereavements. Here, the underlying psychological constructions for the bereavement are the same [23] . In retrospective and observational study using a large sample including 38,000 pregnancies, Wallwiener et al. [24] , reported 9.3% of depression and 16.9% of anxiety disorders.
4.3.4. Stressful Life Event and Alcoholism during Pregnancy
A close one or a perinatal death during pregnancy was a risk factor for anxiety (see Table 5). It increases 2.10 times (0R = 2.10; IC95% [1.26 - 3.50]; p = 0.003) the risk of developing anxiety during pregnancy. Van Heyningen et al. [11] , in South Africa (2017), made the same observation. All those losses assimilated to stressful events had been identified by Bayrampour et al. [25] as predictive factors of anxiety and depression during pregnancy. Alcohol consumption (see Table 6) during pregnancy, was associated with a higher risk of depressive mood (OR = 1.99; IC95% [1.15 - 3.44]; p = 0.012). This study doesn’t provide information on the impact of maternal addiction to alcohol on the foetus. Easey et al. [26] , reported through a meta-analysis, a positive association between prenatal exposure to alcohol and children with mental health problems proved by more than half of analysis.
5. Conclusion
The risk factors found during pregnancy such as: single status, low educational level, low socioeconomic level are to be considered as true social determinants of anxiety and depression during pregnancy. They have harmful consequences on the mother and her child. Past history of spontaneous miscarriage or induced abortion, stressful life events; all those difficulties during pregnancy lead expectant mothers to alcohol consumption without regard for its damage for the unborn child. The implementation of social support seems necessary in order to help and accompany women suffering from anxiety and depression during the perinatal period.