The effect of maternal common mental disorders on infant undernutrition in Butajira, Ethiopia: The P-MaMiE study

BackgroundAlthough maternal common mental disorder (CMD) appears to be a risk factor for infant undernutrition in South Asian countries, the position in sub-Saharan Africa (SSA) is unclearMethodsA population-based cohort of 1065 women, in the third trimester of pregnancy, was identified from the demographic surveillance site (DSS) in Butajira, to investigate the effect of maternal CMD on infant undernutrition in a predominantly rural Ethiopian population. Participants were interviewed at recruitment and at two months post-partum. Maternal CMD was measured using the locally validated Self-Reported Questionnaire (score of ≥ six indicating high levels of CMD). Infant anthropometry was recorded at six and twelve months of age.ResultThe prevalence of CMD was 12% during pregnancy and 5% at the two month postnatal time-point. In bivariate analysis antenatal CMD which had resolved after delivery predicted underweight at twelve months (OR = 1.71; 95% CI: 1.05, 2.50). There were no other statistically significant differences in the prevalence of underweight or stunted infants in mothers with high levels of CMD compared to those with low levels. The associations between CMD and infant nutritional status were not significant after adjusting for pre-specified potential confounders.ConclusionOur negative finding adds to the inconsistent picture emerging from SSA. The association between CMD and infant undernutrition might be modified by study methodology as well as degree of shared parenting among family members, making it difficult to extrapolate across low- and middle-income countries.

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title: Effect of maternal mental health on infant growth in low income countries: new evidence from South Asia
abstract: Impaired infant growth, a major problem in South Asia, may require interventions to improve maternal mental health in addition to current interventions targeting infant nutrition 

Unicef estimates that over 220 million children aged less than 5 years in the developing world have significantly impaired growth.1 The South Asian region is perhaps worst affected, being home to more than half of all the underweight children in the world.2 This article considers the relevance of new evidence on the epidemiology and impact of postnatal depression in South Asia on poor infant growth in low income countries. This evidence shows, for the first time, that a common and potentially treatable mental health problem in mothers is one of the causes of infant failure to thrive. We use this evidence to present a case that child focused interventions, largely aiming to provide supplementary nutrition, may need to be combined with mother focused interventions that target maternal mental health.

Postnatal depression is depressive disorder occurring in the postnatal period and is typically diagnosed about 4-12 weeks after childbirth (see box).

Several recent studies from South Asia have documented substantial rates of postnatal depression.3–6 Patel et al's cohort study of women attending a district hospital antenatal clinic in Goa, India, reported a prevalence of 23%.4 Chandran et al's community cohort study from Tamil Nadu, India, documented prevalence and incidence of 19.8% and 11%,  Rahman et al's community cohort study from Pakistan reported a prevalence of 28%.6 These studies also showed that depressed mothers had significantly higher levels of disability, and that more than half remained ill for at least six months.

Consistent risk factors for postnatal depression were antenatal psychiatric morbidity, economic deprivation, low education, and marital disharmony. Education, support from extended family members, and employment were …

title: Association between antenatal depression and low birthweight in a developing country
abstract: There is a high prevalence of depression in south Asian women. We aimed to examine the association between antenatal depression and low birthweight (LBW) in infants in a rural community in Rawalpindi, Pakistan.

title: Maternal psychological morbidity and low birth weight in India
abstract: Depression following childbirth is associated with poor child growth in developing countries. We describe the association between psychological morbidity during pregnancy and low birth weight (<2.5 kg). A cohort of 270 mothers was recruited from a district hospital in Goa, India; all mothers were interviewed with a screening questionnaire for psychological morbidity. Babies of 250 mothers were reviewed at birth to measure their weight. Excluding 5 premature babies, we found that maternal psychological morbidity was independently associated with low birth weight (odds ratio 1.44, 95% CI 1.00–2.07). We conclude that maternal psychological morbidity has an adverse impact on foetal growth.

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abstract: BackgroundBoth violence and depression during pregnancy have been linked to adverse neonatal outcomes, particularly low birth weight. The aim of this study was to investigate the independent and interactive effects of these maternal exposures upon neonatal outcomes among pregnant adolescents in a disadvantaged population from Sao Paulo, Brazil.Methods930 consecutive pregnant teenagers, admitted for delivery were recruited. Violence was assessed using the Californian Perinatal Assessment. Mental illness was measured using the Composite International Diagnostic Interview (CIDI). Apgar scores of newborns were estimated and their weight measured.Results21.9% of mothers reported lifetime violence (2% during pregnancy) and 24.3% had a common mental disorder in the past 12 months. The exposures were correlated and each was associated with low education. Lifetime violence was strongly associated with Common Mental Disorders. Violence during pregnancy (PR = 2.59(1.05–6.40) and threat of physical violence (PR = 1.86(1.03–3.35) and any common mental disorders (PR = 2.09 (1.21–3.63) (as well as depression, anxiety and PTSD separately) were independently associated with low birth weight.ConclusionEfforts to improve neonatal outcomes in low income countries may be neglecting two important independent, but correlated risk factors: maternal experience of violence and common mental disorder.

title: Maternal depression increases infant risk of diarrhoeal illness: a cohort study
abstract: Maternal depression increases infant risk of diarrhoeal illness: a cohort study . Rahman A., Bunn J., Lovel H. & Creed F. ( 2007 ) Archives of Disease in Childhood , 92 , 24 – 28 . 
 
 
 
To examine the associations between post-natal depression in mothers and diarrhoeal illness in their infants in the first year of life in a low-income country. 
 
 
 
Using a prospective cohort design, 265 infants (n = 130 of mothers having a depressive episode according to the International Classification of Diseases, 10th revision, at 3 months post-natal and n = 135 of psychologically well mothers), living in rural Rawalpindi, Pakistan, were followed up for 1 year. Frequency of diarrhoeal episodes was measured fortnightly by health workers using a standard questionnaire. 
 
 
 
Results  Infants of depressed mothers had significantly more diarrhoeal episodes per year than those of controls (mean 5.5 vs. 4.0; 95% CI 0.9–2.0). The relative risk of having ≥5 diarrhoeal episodes per year in infants of depressed mothers was 2.3 (95% CI 1.6–3.1). The association remained significant after adjustment for other risk factors by multivariate analysis. 
 
 
 
Conclusions  Maternal depression is associated with infant diarrhoeal morbidity in a low-income community setting. It is independent of the effects of known factors such as under-nutrition, socio-economic status and parental education. Preventive child health programmes targeting mothers must consider their mental health.

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abstract: To compare mothers of undernourished children with mothers of adequately nourished children on maternal depression, parenting self-esteem, social support and exposure to stressors and to determine if these variables are independently related to undernutrition and stimulation provided in the home after controlling for socio-economic status. A case control study. Children and their mothers were recruited from 18 government health centres in the Kingston, St Andrew and St Catherine parishes of Jamaica. One hundred and thirty-nine mothers of undernourished children (WAZ≤−1.5z scores) aged 9 – 30 months and 71 mothers of adequately nourished children (WAZ > −1z scores) matched for sex and age group were enrolled into the study. Mothers of undernourished children came from poorer homes but had similar social support to mothers of adequately nourished children. They were more depressed, had lower levels of parenting self-esteem (both P<0.01), reported higher levels of economic stress (P<0.001) and provided a less stimulating home environment (P<0.05). However, after controlling for social background variables there was no independent relationship between either psychosocial function or home stimulation and nutritional status. Undernutrition was found to be mainly explained by economic factors. The mothers' self-esteem was independently associated with the level of stimulation provided to the child. When caring for undernourished children attention should be paid to the psychosocial status of the mother as well as the physical condition of the child. Campus Research and Publication Fund, UWI, Jamaica

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Semantic, content, technical, criterion and construct validity of the Edinburgh Postnatal Depression Scale (EPDS) and Self-Reporting Questionnaire (SRQ) were evaluated in perinatal women in rural Ethiopia. Gold-standard measure of CMD was psychiatric assessment using the Comprehensive Psychopathological Rating Scale (CPRS). Community-based, convenience sampling was used. An initial validation study (n=101) evaluated both EPDS and SRQ. Subsequent validation was of SRQ alone (n=119).



EPDS exhibited poor validity; area under the receiver operating characteristic (AUROC) curve of 0.62 (95%CI 0.49 to 0.76). SRQ-20 showed better validity as a dimensional scale, with AUROC of 0.82 (95%CI 0.68 to 0.96) and 0.70 (95%CI 0.57 to 0.83) in the two studies. The utility of SRQ in detecting 'cases' of CMD was not established, with differing estimates of optimal cut-off score: three and above in Study 1 (sensitivity 85.7%, specificity 75.6%); seven and above in Study 2 (sensitivity 68.4%, specificity 62%). High convergent validity of SRQ as a dimensional measure was demonstrated in a community survey of 1065 pregnant women.



Estimation of optimal cut-off scores and validity coefficients for detecting CMD was limited by sample size.



EPDS demonstrated limited clinical utility as a screen for perinatal CMD in this rural, low-income setting. The SRQ-20 was superior to EPDS across all domains for evaluating cultural equivalence and showed validity as a dimensional measure of perinatal CMD.

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