1. 30/9/2007 WHO study on PPD for urban and rural population1 Assessing prevalence and determinants of PPD Pakistani population Presenter: Dr. Rozina Farhad Mistry Aga Khan Health Service Pakistan

2. 30/9/2007 WHO study on PPD for urban and rural population2 PAKISTAN-SHARE OF THE WORLD 2005 POPULATION:153 MILLION ( 2.37%) WOMEN IN RH GROUP: >33 million CHILDREN IN 22 million

3. 30/9/2007 WHO study on PPD for urban and rural population3 Countries HDICountriesHDI Canada4China94 United States8Kyrgystan110 Cyprus30Sao Tome123 Poland37India127 Mexico53Ghana131 Brazil72Cameroon141 Georgia97Pakistan142 Peru85Bangladesh138 Turkey88Sierra Leon177 Ecuador100 COUNTRIES ACCORDING TO THE HUMAN DEVELOPMENT INDEX 2004

4. 30/9/2007 WHO study on PPD for urban and rural population4 2005 - OTHER HARD FACTS - MILLIONS POPULATION LIVING BELOW POVERTY LINE = 35.5 POPULATION WITH NO ACCESS TO SAFE WATER FOR DRINKING = 56.9 POPULATION WITH ONE ROOM HOUSE = 57.9 POPULATION WITH NO SANITATION = 78.2 ADULT LITERATCY RATE = 57.4%.

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7. 30/9/2007 WHO study on PPD for urban and rural population7 Primary To assess prevalence of postpartum depression (PPD) among postpartum mothers in urban area (Karachi) and in the rural (Northern Areas) of Pakistan using the screening tool of Edinburgh Postpartum Depression Scale (EPDS). Secondary To assess any differences in health and growth outcomes of children of the mothers diagnosed as having PPD versus the mothers without it. Primary To assess prevalence of postpartum depression (PPD) among postpartum mothers in urban area (Karachi) and in the rural (Northern Areas) of Pakistan using the screening tool of Edinburgh Postpartum Depression Scale (EPDS). Secondary To assess any differences in health and growth outcomes of children of the mothers diagnosed as having PPD versus the mothers without it. Research Questions

8. 30/9/2007 WHO study on PPD for urban and rural population8 Definition of Post Partum Depression DSM IV defines Postpartum depression as a form of severe depression after delivery that requires treatment. Studies state that postnatal depression is a psychological disorder which occurs within six weeks after childbirth

9. 30/9/2007 WHO study on PPD for urban and rural population9 After delivery: 50%-75% of the new mothers experience "baby blues" 10% of these women develop a longer- lasting depression one in 1,000 women develop the more serious condition called postpartum psychosis

10. 30/9/2007 WHO study on PPD for urban and rural population10 ICD 10 diagnostic criteria for PPD i) At least two of the following features must be present for at least two weeks: A depressed mood for most of the day Loss of interest or pleasure in activities that are normally pleasurable, such as playing with the baby Tiredness, decreased energy, and fatigue

11. 30/9/2007 WHO study on PPD for urban and rural population11 ii) Any four of the following should be present: Loss of confidence and self esteem Feelings of guilt and blaming oneself Recurrent thoughts of suicide or death, including that of the child Difficulty in concentration Agitation or lethargy Sleep disturbance Appetite disturbance

12. 30/9/2007 WHO study on PPD for urban and rural population12 PPD-WHY SHOULD WE BE CONCERNED WHY? ?? Mother suffering from PPD is unable to do things she needs to do every day Only 20% seek Rx. The remaining individuals remain either undiagnosed, misdiagnosed, or seek no medical assistance. In the absence of Rx, PPD can get worse and last for as long as a year. PPD is a serious condition, it can be effectively treated with antidepressant medications and counseling PPD has consequences for the physical and psycho- social development of children. Infants show growth retardation at several time points in the first year of life

13. 30/9/2007 WHO study on PPD for urban and rural population13 Rationale for the study Widely different PPD rates have been documented for developing countries Scarce country specific data Advocacy for incorporating early diagnosis and management of PPD mother and her baby To develop culturally appropriate interventions to create awareness about impact of PPD on mothers and children

14. 30/9/2007 WHO study on PPD for urban and rural population14 Biological factors Socio environmental factors Obstetric related factors Post Partum Depression Impact On maternal Health Impact on Growth outcome of Children CONCEPTUAL FRAMEWORK Child related factors

15. 30/9/2007 WHO study on PPD for urban and rural population15 Cross sectional study with simple random sampling Study Sites: a) Karachi (urban setting) Three women and children hospital of Aga Khan Health Service, Pakistan b) Gilgit and Ghizer district in the Northern Areas (rural setting). STUDY DETAILS

16. 30/9/2007 WHO study on PPD for urban and rural population16  Actual sample surveyedTotal: 1256 Urban: 720 Rural : 536  Response rate Urban: 97.5% Rural : 95.7%

17. 30/9/2007 WHO study on PPD for urban and rural population17 Data collection instrument The instrument used in the study had two sections: General information section Developed on the basis of log of factors identified from various studies Edinburgh post partum depression scale

18. RESULTS

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21. 30/9/2007 WHO study on PPD for urban and rural population21 Method of assessing nutritional status % Malnourished Urban Area n=720* Rural Area n=536* Overall n=1256 * Weight for Age Z-scores  % < -2 o 95% CI 3.3% (2.2, 5.0) 1.3% (0.6, 2.8) 2.5% (1.7, 3.5) Weight for Length (height) Z- scores  % < -2 o 95% CI 4.5% (3.1, 6.3) 2.2% (1.1, 4.3) 3.7% (2.7, 5.0)

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24. 30/9/2007 WHO study on PPD for urban and rural population24 ANALYTICAL FINDINGS

25. 30/9/2007 WHO study on PPD for urban and rural population25 Statistical analysis SA was done using SPSS-10.0 Frequencies and percentages of the variables was calculated Logistic regression analysis was performed to assess the significance of the variables by taking PPD either present or absent as a binary variable P value of <0.05 was considered significant

26. 30/9/2007 WHO study on PPD for urban and rural population26 Prevalence of depressive symptoms

27. 30/9/2007 WHO study on PPD for urban and rural population27 OR=2.66 P<0.001

28. 30/9/2007 WHO study on PPD for urban and rural population28 Variables TotalPositive (%)ORP-value Any health problem during ANC Yes No 157 (12.5) 1099 (87.5) 15.3 9.7 1.670.033* Delivery assisted by Unskilled Skilled 128 (10.2) 1128 (89.8) 16.4 9.8 1.820.029 Place of delivery Home Hospital/ Clinic 141 (11.2) 1115 (88.8) 15.6 9.8 1.710.033* Complications during delivery Yes No 237 (18.9) 1019 (81.1) 19.4 8.3 2.64< 0.001* Type of delivery Caesarean section Vaginal delivery 216 (17.2) 1040 (82.8) 14.4 9.6 1.580.038* OBSTETRIC RELATED CONTRIBUTORY FACTORS OF PPD

29. 30/9/2007 WHO study on PPD for urban and rural population29 SOCIO-ENVIRONMENTAL CONTRIBUTORY FACTORS OF PPD Variables TotalPositive (%)ORP-value Husband/ family feelings about pregnancy Upset Happy 14 (1.1) 1242 (98.9) 28.6 10.2 3.510.049 Personal feeling after delivery Stressful Relaxed 28 (2.2) 1228 (97.8) 08 28.6 10.0 3.590.006* Performing daily working Stressfully Calmly 619 (49.3) 637 (50.7) 24.3 6.1 1.33< 0.001* Support from Husband /Others in daily work Husband Others 466 (37.1) 790 (62.9) 38 (8.2) 93 (11.8) 1.500.042 Breast feed After 24 hours Within 24 hours 119 (9.5) 1137 (90.5) 16.8 9.8 1.870.017* Gender of baby Girl Boy 615 (49.0) 641 (51.0) 12.2 8.7 1.450.045*

30. 30/9/2007 WHO study on PPD for urban and rural population30 Child related contributory factors of PPD Variable Mother with PPD Mothers without PPD p-value (n=131)(n=1124 ) Mean Birth Weight of babies (kg.) 2.913.020.01* Mean Current Weight (kg.) 4.224.370.03* % of mothers reported illness of their baby during preceding 2 weeks 47 % 26 % < 0.001

31. 30/9/2007 WHO study on PPD for urban and rural population31 0.746 0.891 0.560

32. 30/9/2007 WHO study on PPD for urban and rural population32 Factors that were not found to be contributory in the urban and the rural population Age of the mother (less than 20 years) Parity History of child death Family structure: nuclear/extended Education of parents Planned or unplanned delivery Married more than once

33. 30/9/2007 WHO study on PPD for urban and rural population33 0.891 0.50 0.39 0.32 0.33 0.74 0.326

34. 30/9/2007 WHO study on PPD for urban and rural population34 % of PPD <0.195 <0.301 <0.281 <0.757 <0.621

35. 30/9/2007 WHO study on PPD for urban and rural population35 CONCLUSION Our study has highlighted that the prevalence of PPD is: almost similar (10.4%) to that found in the developed and many developing country setting PPD is more prevalent in rural then in urban population While there are many common determinants of PPD, there are also determinants which vary in urban and rural setting of Pakistan

36. 30/9/2007 WHO study on PPD for urban and rural population36 A very strong association of PPD exists with the biological factor (family history of mental illness), obstetric and child growth related parameters Our study confirms that babies born to mothers vulnerable to PPD exhibit signs of lagging on the growth parameters as early as in 4-6 weeks of baby’s age. CONCLUSION

37. 30/9/2007 WHO study on PPD for urban and rural population37 RECOMMENDATION

38. 30/9/2007 WHO study on PPD for urban and rural population38 CREATE SUPPORTIVE ENVIRONMENT More awareness programs are needed to reduce stigma attached to diagnosis of mental illness The roles of father and mother need to be redefined from their traditional boundaries into creating a more supportive environment. More awareness need to be created amongst the family member for extending additional social support to the new mothers.

39. 30/9/2007 WHO study on PPD for urban and rural population39 DEVELOP PERSONAL SKILLS Women and young girls need to learn to prepare themselves for different stages of life, to diagnose the condition and seek help at the right time. Birth preparedness should be an integral component of the reproductive health strategy

40. 30/9/2007 WHO study on PPD for urban and rural population40 REORIENT HEALTH SERVICES Midwifery, Nursing, and medical education should develop capacity in skilled birth providers about diagnoses, management and counseling skills on PPD Health care providers need to be trained to act as an enabler, mediator and advocate for implementation of policies and strategies that will support a mother suffering from PPD

41. 30/9/2007 WHO study on PPD for urban and rural population41 REORIENT HEALTH SERVICES Screening of mother for PPD should be instituted at 4-6 weeks of post natal period Unskilled birth attendants (TBAs) should be trained in early diagnosis and referral at the right time for PPD.

42. 30/9/2007 WHO study on PPD for urban and rural population42 STRENGTHEN COMMUNITY ACTION Support groups and networks need to be established for PPD mothers from where she and her husband should be able to get the support required to deal with this condition.

43. 30/9/2007 WHO study on PPD for urban and rural population43 HEALTH PUBLIC POLICY Promote Multisectoral interventions for destigmatizing mental illness in Pakistani society Media should be encouraged to bring about social change through challenging the traditional role of husbands in child rearing

44. 30/9/2007 WHO study on PPD for urban and rural population44 FUTURE STUDIES Assessment of prevalence of Ante-natal depression Prospective study of babies born to PPD mother upto two years of age Qualitative studies to understand the underlying norms of the societies related to gender preferences Further analysis of differential impact of socio-economic status on the occurrence of PPD

45. 30/9/2007 WHO study on PPD for urban and rural population45 STRENGTHS OF THE STUDY Estimated PPD prevalence both in rural and urban areas. Also assessed the impact of PPD on child growth parameters as early as 4 - 6 weeks of age; Wide representation of the population from various socio-economic class

46. 30/9/2007 WHO study on PPD for urban and rural population46 Limitation of our study The cases identified at risk of PPD with >12 score or equal to 12 score were not clinically evaluated to confirm the diagnosis. It was not possible to undertake advanced statistical analysis such as multivariate analysis Findings cannot be generalized to the entire rural population of Pakistan because of the ethnically different population living in different rural areas of Pakistan.

47. 30/9/2007 WHO study on PPD for urban and rural population47 Ms. Laila Khalfan Dr. Abid Hoosein Mr. Rasool Bux Mr. Intisar Siddiqui Mr. Shamsu Rehman Field teams and staff of AKHS, P Board of AKHS, P Acknowledgment

48. 30/9/2007 WHO study on PPD for urban and rural population48 Thanks and Questions Please !