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Prenatal Maternal Depression Symptoms and Dietary Intake – a Population Based Study in Rural Pakistan

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Prenatal Maternal Depression Symptoms and Dietary Intake – a Population Based Study in Rural Pakistan Prenatal Maternal Depression Symptoms and Dietary Intake – A Population Based Study in Rural Pakistan Thesis submitted in accordance with the requirements of the University of Liverpool for the of Doctor of Philosophy by Rukhsana Khan October 2017 Institute of Psychology Health and Society (IPHS) University of Liverpool ABSTRACT Background: High prevalence of depression among pregnant women has been observed in low and middle-income countries including Pakistan.Pregnancy is an important stressor for depression and depressed women tend to have poor dietary intake.The present study aimed to determine the prevalence of prenatal depression and its risk factors, and explored the relationship of prenatal depression with dietary intake in a representative sample of women living in a rural setting of Pakistan. Methods: This study was conducted at the baseline of a large cluster randomised controlled trial. Five hundred pregnant women in the second and third trimester of pregnancy, living a in a rural area of district Rawalpindi Pakistan, were recruited for the baseline of the trial. Depression was assessed using “Patient Health Questionnaire” (PHQ9), with a cut-off score of 10, and the dietary intake assessment was carried out by“Food Frequency Questionnaire” and “24 Hour Dietary Recall”.Data on stressful life-events and perceived social support were captured through “Life Events Checklist” and “Multidimensional Scale of Perceived Social Support”.All pregnant women who had PHQ-9 scores of 10 or more were invited to participate. Those women whose PHQ 9 was less than 10 were selected through simple random sampling and invited for baseline measurements after obtaining informed consent. Response rate was around 98%.Appropriate tests of significance were used for bivariate analysis. Final Generalized Linear Model with logit link function was obtained. Results: The prevalence of prenatal depression was found to be 27%.Depressed pregnant women belonged to 23-30 years age group, were less educated had,lived in joint family and had less perceived support from family and friends.Depressed women suffered from at least 3-4 stressful life events .Food variety scores were generated and dichotomized at median for dietary inadequacy. Mean intake of all the energy, macronutrients and micronutrients was significantly less among depressed (p<0.001).Prenatal depression was significantly associated with dietary inadequacy (P<0.05). In addition factors like life satisfaction, husband away from home in last six months (P<0.05), physical IPV (P<0.05) and stressful life events (P<0.01) were also independently associated with dietary inadequacy. Conclusion: The current study to the best of my knowledge is the first study to investigate in a large rural community based sample of women the link between i prenatal depression and dietary intake. Most of the depressed women did not eat sufficient items from various food groups to meet the recommended dietary allowance. Prenatal depression was independently associated with inadequate dietary intake. Risk factors for prenatal depression as well as dietary inadequacy were psychosocial in nature. There is a need to screen women at antenatal visit and provide nutritional counselling to improve dietary behaviors for better pregnancy outcomes. ii DECLARATION I certify that I have read and understood the rules and regulations of University of Liverpool regarding assessment procedures and offences. I confirm that the work presented in this thesis is my own apart from properly referenced quotations. Where information has been derived from other sources, I confirm that this has been indicated in the thesis. Where my work is indebted to others, I have made acknowledgements. I declare that the material contained in this thesis has not been accepted in substance wholly or partly for any other degree, nor is it currently being submitted in candidature for any other degree. iii ACKNOWLEDGEMENT I owe my gratitude to Almighty God in whom and through whom the all the work which went into this thesis was made possible. I want to acknowledge all those who in one way or another contributed in the completion of this thesis. Above all I am grateful to my supervisors, Dr Atif Rahman and Dr Mukesh Dherani, from whom I learnt a lot. Professor Atif”s wealth of experience in maternal mental health, global public health and health systems gave me an opportunity to broaden my vision. I am grateful for his generous and patient advice and guidance throughout my research and beyond. I would specially like to thank Dr Mukesh Dherani who co-supervised the work and provided his detailed feedback and advice especially in statistical analysis. I am grateful to Dr Siham Sikander and Dr Shamsa Rizwan for their valuable inputs into my research and continuous support and encouragement. My special thanks to my colleagues Dr. Zille Huma Mustehsan, Dr Arshia Bilal for their continuous support and Dr Katrina Ronis for her expert advice related to maternal nutrition. I would like to thank the health staff at the primary care centers and especially the Lady Health Workers and their supervisors for their support. Of course, none of this would have been possible without the field team. I am grateful to Human Development Research Foundation (HDRF) for operational assistance in completing the field work, activities. Importantly, I would like to thank my field team in Kallar Syedan - Mr Ikhlaq Ahmed project coordinator and,Miss Tayyaba Abbasi, Miss Amna Ijaz , Miss Quratul Ain, Nida Amin and Miss Rakhshanda who worked tirelessly. I am grateful to the people behind the numbers - all those women and their families who were part of this study. iv ABOUT THE AUTHOR Born and brought up in large cities of Pakistan, I did MBBS from Allama Iqbal Medical College Lahore and pursued my carrier as general physician. After a decade I got opportunity to get a MPH degree from Health Services Academy (HSA) Islamabad. I joined LHWs program as training consultant for a short time when I shifted to South Africa because of my husband’s appointment. I joined clinical epidemiology department as research officer voluntarily and also joined MSc clinical epidemiology degree program .I returned to Pakistan and joined Health Services Academy as Assistant Professor. Along with teaching epidemiology I got a chance to start an elective course in Public Health Nutrition which was my area of interest for Masters of Public Health students with a senior expert. Research sites of Human Development Research Foundation were used as field demonstration area for HSA students. As a coordinator I used to visit the sites with students and found the research in mental health interesting and wanted to take up a topic with focus on nutrition and mental health as a PhD thesis. While I was in the decision making process I came across a saying by the Founder of Pakistan Quaid- e -Azam Muhammad Ali Jinnah “Think one hundred times before you take a decision But once a decision is taken stand by it as a man” This was my motivation. Although it was not easy to take a decision to take up PhD studies given the work, finance and family considerations yet I took a decision and stood by it. v TABLE OF CONTENTS ABSTRACT .................................................................................................................. I DECLARATION....................................................................................................... III ACKNOWLEDGEMENT ........................................................................................ IV ABOUT THE AUTHOR ............................................................................................ V LIST OF TABLES ................................................................................................. XIII LIST OF FIGURES ............................................................................................... XVI LIST OF ABBREVIATIONS .............................................................................. XVII SECTION I (CHAPTER 1 – 6) ................................................................................... 1 ................................................................................................................. 2 INTRODUCTION TO THE PROBLEM AND STUDY .......................................... 2 1.1 INTRODUCTION ...................................................................................................... 2 1.2 PRENATAL DEPRESSION ........................................................................................ 2 1.3 RISK FACTORS FOR PRENATAL DEPRESSION ......................................................... 2 1.4 DEPRESSION AS A RISK FACTOR FOR DIETARY PRACTICES ................................... 3 1.5 PROBLEM STATEMENT ........................................................................................... 3 1.6 SIGNIFICANCE OF THE STUDY ................................................................................ 3 1.7 STRUCTURE OF THE THESIS ................................................................................... 4 ................................................................................................................. 7 LITERATURE REVIEW (PREVALENCE AND RISK FACTORS FOR PRENATAL DEPRESSION) ...................................................................................... 7 2.1 INTRODUCTION ...................................................................................................... 7 2.2 TYPES OF PERINATAL DEPRESSION .......................................................................
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