Psychological Medicine, 2003, 33, 1161–1167. f 2003 Cambridge University Press DOI: 10.1017/S0033291703008286 Printed in the United Kingdom Life events, social support and depression in childbirth: perspectives from a rural community in the developing world A. RAHMAN,1 Z. IQBAL AND R. HARRINGTON From the School of Psychiatry and Behavioural Sciences, University of Manchester; and Human Development Research Foundation, Islamabad, Pakistan ABSTRACT Background. High rates of depression associated with childbirth have been reported in many parts of the developing world. However, the prevalence and associations of antenatal and post-natal depression in the rural population remain unknown. Disability associated with depression and its impact on infant health and development could have important public health implications for many developing countries where large proportions of the population are rural. Method. All women living in southern Kahuta, Pakistan, in their third trimester of pregnancy were interviewed at 6 weeks before delivery (N=632) and again at 10–12 weeks after delivery (N=541), using WHO Schedule for Clinical Assessment in Neuropsychiatry (SCAN), Personal Information Questionnaire (PIQ) and Brief Disability Questionnaire (BDQ). Results. The point prevalence of ICD-10 depressive disorder was 25% in the antenatal period and 28% in the post-natal period. Depressed mothers were significantly more disabled, had more threatening life events, and poorer social and family support than non-depressed mothers. Vul- nerable mothers were more likely to be depressed during pregnancy, rather than have an onset in the post-natal period. Conclusion. Over one-quarter of mothers in a rural sub-district of Pakistan suffer from depression shortly before and after childbirth. Rapidly changing traditional family structures and practices may be increasing the risk of depression in many women. Recognizing and treating depression should be initiated during the antenatal, rather than post-natal period. INTRODUCTION 15.8% in Dubai, United Arab Emirites (Ghu- bash & Abou-Saleh, 1997). Risk factors ident- Epidemiological studies have reported increas- ified include previous psychiatric problems, life ingly high rates of post-natal depression in di- events in the previous year, poor marital re- verse cultures across the developing world. An lationship, lack of social support and economic early pioneering study by Cox (1979) in a semi- deprivation. Female infant gender was found rural Ugandan tribe found rates of 10% based to be an important determinant of post-natal on the ICD-8 criteria. More recently, a com- depression in India, but not in South Africa. munity study by Cooper et al. (1999) found rates of 34.7% in a peri-urban settlement in South Importantly, post-natal depression was found to be associated with high degrees of chronicity, Africa, while hospital-based studies found rates disability and disturbances of mother–infant of 23% in Goa, India (Patel et al. 2002) and relationship. Numerous studies carried out in developed 1 Address for correspondence: Dr Atif Rahman, Department of Child and Adolescent Psychiatry, Royal Manchester Children’s countries provide compelling evidence that post- Hospital, Hospital Road, Pendlebury, Manchester M27 4HA. natal depression is associated with long-term 1161 1162 A. Rahman and others emotional, cognitive and intellectual problems adult male members serving in the armed forces in children (Cooper & Murray, 1998). There is or working as government employees, semi- some evidence that in developing countries, skilled, or un-skilled labourers in the cities. poor maternal mental health may also be as- Kahuta typifies the state of under-development sociated with malnutrition and poor physical in most of South Asia’s rural areas. Unemploy- health in infants (Rahman et al. 2002). Possible ment rates are estimated to be 36%, mainly higher prevalence of post-natal depression in due to the high population growth rate (2.7%), mothers of female children could mean that a modernization in agriculture, and lack of non- cycle of poor psychological and physical health agricultural jobs. Male and female literacy rates in many females is perpetuated from birth, are 80% and 50% respectively. The infant contributing to poor health of future gener- mortality rate is 84 per 1000 live births. There ations. Post-natal depression is therefore likely are 20 basic health units and two rural health to have important public health consequences centres, consisting of 28 doctors, 12 midwives in the developing world. (female health visitors, providing obstetrical More than 60% of the population in de- care), 15 vaccinators (providing immunization), veloping countries lives in rural areas but the and 120 female primary health workers (Lady prevalence and associations of post-natal de- Health Workers (LHWs), providing mainly pression in this population remain unknown. basic mother and child health care). There are The sample for such a study would need to be a number of private medical practitioners. community-based because many women in rural areas do not attend health facilities for antenatal care, and would be missed if hospital-based Subjects and sampling samples were recruited. Furthermore, while The current study was carried out in two ad- post-natal depression is considered common joining administrative circles in southern and its recognition and treatment emphasized, Kahuta (Kallar Syedan QH and Choha Khalsa depression during pregnancy has been rela- QH), comprising of 10 union councils (the tively neglected. Studies in developed countries smallest rural administrative unit, each consist- suggest that depressed mood during pregnancy ing of 5–12 villages). The sample comprised of may be associated with poor attendance at ante- all physically healthy women aged 17–40 years natal clinics, low birth weight and preterm de- in their third trimester of pregnancy, recruited livery (Pagel et al. 1990; Hedegaard et al. 1993). from all 10 union councils over a 4-month In developing countries such as Pakistan where period (September to December 2001). This was infant mortality rates are high, this association achieved using a number of strategies. First, may assume added significance. This study LHWs were approached to provide lists of all aimed to investigate a large rural community- women in the third trimester of pregnancy in based sample for the prevalence of antenatal their respective areas (it is an official task of and post-natal depression and its association LHWs to record all pregnancies). Secondly, in with life events, family relationships and social some areas where there were no LHWs, Vacci- support, and other psychosocial and economic nators were asked to provide lists of women factors. who had been given tetanus toxoid in the fifth month of pregnancy. Thirdly, traditional birth METHOD attendants and private practitioners were paid a small amount to identify such women under Study area their care. Finally, to ensure that no women had The study was done in Tehsil Kahuta, a rural been missed, a local person from each village sub-district, 60 km south-east of Rawalpindi. was employed to enquire about any pregnancies Kahuta has an area of 1096 km2, a population in the last trimester. of 313 200 and consists of four Administrative The Research Ethics Committees of Univer- Circles (Government of Pakistan, 1999). The sity of Manchester and Rawalpindi Medical average household consists of 6.2 members. College approved our study. It was conducted Most families depend on subsistence farming, according to good clinical practice and the dec- supported by earnings of one or more of the laration of Helsinki. Childbirth and depression in the developing world 1163 Data ascertainment Disability in mothers was assessed using the Assessment of post-natal depression Brief Disability Questionnaire (BDQ). This is an 8-item questionnaire that rates current prob- The mothers were interviewed on recruitment lems in carrying out daily activities on a scale of (average 6 weeks before expected date of deliv- 0 (not at all) to 2 (definitely), with a maximum ery) and 10–12 weeks after delivery, by one of score of 16. This instrument has been validated two clinically experienced and trained mental in a 15-centre cross-national, multi-lingual health professionals (A.R. and Z.I.). The same study (Von Korff et al. 1996). Socio-economic interviewer interviewed each mother on both status was assessed by two methods: objective occasions. Women with a psychotic disorder, assessment was done by enquiring about hus- learning disability or chronic physical illness band’s average monthly income; subjective as- were excluded. Maternal depression was as- sessment was carried out by the LHWs. They sessed using the Schedule for Clinical Assess- rated each family’s socio-economic situation, ment in Neuropsychiatry (SCAN) (World relative to overall prosperity in the sub-district, Health Organization, 1992), a semi-structured on a five-point Likert scale ranging from 1 interview for the diagnosis of psychiatric dis- (richest) to 5 (poorest). All instruments were order. The interview schedule was translated translated and culturally adapted using the and culturally adapted after key-informant in- procedure described above. terviews with the target population, structured The data were coded, inputted and analysed focus group discussions with mothers to obtain using the STATA 7 statistical package (Stata- better cultural understanding of difficult con- Corp, 2001). Following a descriptive