An Exploration of Postnatal Depression in Central Vietnam

Linda Murray, PhD Candidate, QUT

Supervisors:Professor Michael Dunne, QUT School of Public HealthProfessor Cao Ngoc Thanh, Hue University of Medicine and PharmacyDr Nigar Khawaja, QUT School of Psychology and Counselling

Definition of Postnatal Depression• A depressive episode that occurs between two weeks

and one year postpartum• Clinical presentation similar to major depression• 1/3 of women who develop PND will experience

symptoms in the first 4 weeks, 2/3 between 10 and 14 weeks

• Women who experience symptoms after 14 weeks may be misdiagnosed or missed altogether

• 1/3 of women who suffer PND will have it develop into chronic clinical depression

(Cox et al, 1987; Brockington, 1996; Beck & Driscoll, 2006; Hanley, 2009)

Causes of PND

• Complex mix of biological, psychological and social factors

• No strong evidence of a consistent link between PND and hormonal adjustment (Miller, 2002; Dennis & Creedy, 2004)

• Globally, women’s own explanations of the causes of their episode of PND are predominantly social (Affonso, et al, 2000)

EpidemiologyPrevalence of 10 – 20 % Worldwide (Halbreich & Karkun,

2006; O’Hara, 1994)

< 10% of low and middle income countries have data available (UNFPA & WHO, 2008)

Australia - 16% in 2008 (www.beyondblue.org)

Vietnam - 33% in Ho Chi Minh City in 2004 (Fisher et al, 2004)

Hanoi and Ha Nam - 29.9% had a perinatal mental health disorder in 2010 (Fisher et al, 2010)

Why research PND in Public Health?

• Long term impact on a child cognitive development and mental health (Murray & Cooper, 1997; Hay and Kumar, 2005)

• Evidence of a link between PND, and infant growth, nutrition and infectious disease in low and middle income countries

• In India and Africa, infant weight and length were significantly lower at 3, 6, and 9 months if their mothers are depressed (Patel, et al, 2002; Fisher et al, 2010; Anoop, Saravan et al, 2004)

Social Determinants of PNDInternationally Recognised

– Support from partner– Support from other relatives– Unwanted pregnancy– Socioeconomic status– History of mental illness

East Asian Literature- Confinement practices- Infant Gender- Relationships with extended families

Research Questions1.) What knowledge and attitudes are held about PND amongst women

and health workers in Thua Thien Hue Province?

2.) What is the prevalence of postnatal depression (PND) in Thua Thien Hue Province?

3.) What social and cultural factors influence PND in Thua Thien Hue Province?

4.) What formal, informal and informational support mechanisms exist for women with PND in Thua Thien Hue Province?

Study DesignSystematic

Literature Review

Systematic

Literature Review

Qualitative Research

Participatory qualitative research with 23 health system stakeholders

-In-depth interviews (n = 11)

- focus group activities (n = 12 x 2 sessions)

Qualitative Research

Participatory qualitative research with 23 health system stakeholders

-In-depth interviews (n = 11)

- focus group activities (n = 12 x 2 sessions)

Quantitative Research-Pilot of quantitative questionnaire

-Cross-sectional survey of 500 women 4 weeks – 6 months postpartum

Quantitative Research-Pilot of quantitative questionnaire

-Cross-sectional survey of 500 women 4 weeks – 6 months postpartum

Dissemination of FindingsDissemination of Findings

Qualitative Research

In-depth interviews and analysis with 20 (10 rural, 10 urban) postpartum women

Qualitative Research

In-depth interviews and analysis with 20 (10 rural, 10 urban) postpartum women

Preliminary Exploratory Qualitative Research

Focus groups with 12 health professionals

Health Service Participants

Hue University Hospital 6 Midwives with 2-14 years experience

3 Commune Health Centres from Thua

Thien Hue Province

3 Midwives with 24 - 32 years experience

3 Doctors/CHC Directors with 15-18 years

experience

In-depth interviews were also conducted with 12 experts in Women’s Health and Mental Health from

Hue and Hanoi

Concept Mapping Process

1. Brainstorm a list of statements 2. Sort the statements into meaningful groups3. Rate the statements on a 5 point likert scale

- Most likely to cause PND- Most likely to protect against PND- Most important to study

4. Analyse using Concept Systems™5. Present and discuss the analysis as a group

Statements in Clusters

Cluster Statements1. Economics 2 Worry about losing employment (applies to professionals)

11 Lost opportunities for promotion (e.g after third child)1 Economic difficulty9 Loss of income post delivery10 Sufficient financial resources4 Less time for social activities

2. Family Aspects 25 Informational support from relatives and family44 Happy/harmonious family21 Supportive husband22 Gender of the baby is the one they desired

3. Society and Friendship

26 Support from the reproductive health program40 Good atmosphere43 Help of the neighbourhood46 Support from mother’s friends

4. Mother’s Emotions and Worry

34 Single mother31 Husband very concerned about the gender of the baby5 Gender of the baby the parents don’t want33 Gender of the baby the mother didn’t want39 Disappointment because the gender is different to the ultrasound10 Lack of confidence about their place in the community (e.g after third child)3 Worry about physical appearance after delivery

Statements in Clusters Cont…

5. Negative Stressors

14 Husband isn’t loyal38 Grandparents don’t accept the baby and send it to an orphanage30 Husband is rude, drinks, and goes out a lot13 Lack of care, concern and help from relatives35 A family member has recently died45 The family observes traditional customs the mother doesn’t want to follow

6. Baby’s Health 6 Stillbirth15 The baby has a congenital disability18 Poor health of the baby32 Baby difficult to nurse17 Worry about enough milk for the baby42 Healthy baby24 The baby is feeding well

7. Mother’s Health 19 The mother has a history of mental illness8 Obstetric complications (e.g postpartum haemorrhage)37 Caesarean wound infection12 Other physical disease during pregnancy and delivery36 Pain and fatigue after delivery7 Pain during delivery

8. Protective Factors

16 Sleeplessness due to the baby28 Regular diet29 Sufficient relaxation, wakes up late27 Physical activity for avoiding stress41 Mother doesn’t smoke or drink coffee or alcohol23 The mother has enough time to take care of the baby

Concept Map

1. Economics 2. Family Aspects

3. Society and Friendship

4. Mother's Emotions and Worry

5. Negative Stressors

6. Baby's Health 7. Mother's Health

8. Protective Factors

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Most Likely to Cause PND

1. Economics

2. Family Aspects

3. Society and Friendship

4. Mother's Emotions and Worry

5. Negative Stressors

6. Baby's Health 7. Mother's Health

8. Protective Factors Cluster Legend

Layer Value

1 1.73 to 2.23

2 2.23 to 2.73

3 2.73 to 3.23

4 3.23 to 3.73

5 3.73 to 4.24

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Quantitative SurveyDependent VariableDepression: Edinburgh Postnatal Depression Scale (validated in Vietnamese) CES-D, Checklist of Somatic ComplaintsIndependent Variables- Socio Economic Status- Obstetric Factors (including infant gender)- Traditional Practices- Social Support- Maternal Competence and Self Esteem- Infant Health

Study Sites

ReferencesAffonso, D. D., Anindya, K. D., Horowitz, J. A., & Mayberry, L. J. (2000). An international study exploring levels of postpartum

depressive symptomatology. Journal of Psychosomatic Research, 49(3), 207-216. Anoop, S., Saravanan, B., Joseph, A., Cherian, A., & Jacob, K. S. (2004). Maternal depression and low maternal intelligence as risk

factors for malnutrition in children: a community based case-control study from South India. Arch Dis Child , 89(4), 325-329. Beck, C. T., & Driscoll, J. W. (2006). Postpartum Mood and Anxiety Disorders: A Clinician's Guide. Massachusetts: Jones and Bartlett

Publishers.Beyondblue. (2009). Beyond Blue Australia. Retrieved January 21, 2009, from http://www.beyondblue.org.au/.Brockington, I. F. (1996). Motherhood and Mental Health. Oxford: Oxford University Press.Cox, J. L., Holden, J.M., Sagovsky, R. (1987). Detection of Postnatal Depression: Development of the 10 item Edinburgh Postnatal

Depression Scale. British Journal of Psychiatry, 150, 782-786. Dennis, C. L., & Creedy, D. K. (2004). Psychosocial and psychological interventions for preventing postpartum depression. Fisher, J. R. W., Tran, T., Buoi, L. T., Rosenthal, D., Kriitmaa, K., & Tuan, T. (2010). Common perinatal mental disorders in women in the

north of Vietnam: Community prevalence and interaction with health care use. Bulletin of the World Health Orgaisation, In Press.

Fisher, J. R. W., Morrow, M. M., Ngoc, N. T. N., & Anh, L. T. H. (2004). Prevalence, nature, severity and correlates of postpartum depressive symptoms in Vietnam. BJOG: An International Journal of Obstetrics & Gynaecology, 111(12), 1353-1360.

Halbreich, U., Karkun, S. (2006). Cross-cultural and social diversity of prevalence of postpartum depression and depressive symptoms. Journal of Affective Disorders, 91, 97-111.

Hanley, J. (2009). Perinatal Mental Health. Singapore: Wiley-Blackwell.Hay, F., Pawlby, S., Sharp, D., Asten, P., Mills, A., & Kumar, K. (2001). Intellectual problems shown by 11 year old children whose

mothers had postnatal depression. Journal of Child Psychology and Psychiatry, 42(7), 871-889. Miller, L. J. (2002). Postpartum depression JAMA, 287, 762-765Murray, L., & Cooper, P. J. (1997). Postpartum depression and child development. Psychological Medicine, 27, 253-260. O'Hara, M. W. (1994). Postpartum Depression: Causes and Consequences. New York: Springer-Verlag Inc.Patel, V., Rodrigues, M., & DeSouza, N. (2002). Gender, poverty, and postnatal depression: a study of mothers in Goa, India. The

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