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Postpartum Depression
In 2004, the World Health Organisation estimated
that over 150 million people were living with
depressive disorders, with about 10% of these being
in Africa (1). Depression is the third leading cause of
the global burden of disease as measured using the
Disability-Adjusted Life Years (DALYs), contributing
to upto 4.3% of the DALYs. In the high and middle-
income countries, it is the leading cause of the burden
of disease while in low income countries it is the 8th
leading cause. It is estimated that in 2030, depressive
disorders will be the leading cause of the global burden
of disease (1).
Among women in the reproductive age-group,
depressive disorders are the leading cause of the
global burden of disease (1). This is due to the greater
prevalence of depression among women compared to
men in the general population, and the chronic nature
of the illness. For various reasons, including the
reproductive cycle, it is highly probable that women
suffer a greater burden of depression than men.
The Diagnostic and Statistical Manual for Mental
Disorders, DSM IV TR (2) does not dene postpartum
depression as a distinct category of illness. However,
under the classication for major depressive disorders,
a specier for ‘postpartum onset’ is included. Although
the postpartum period in this case covers the period
upto four weeks postpartum, in most research and
clinical settings a period of upto one year is considered
postpartum.
The clinical presentation of postpartum depression
is the same as that of depression outside of this period,
although additional symptoms such as mood lability
and over-concern with the infant are commonly
reported (2). This disorder should be distinguished
from postpartum blues, a syndrome characterised by
mood symptoms that are common in the rst seven
to ten days after delivery and that usually resolve
within a few days without any intervention. Symptoms
include mood lability, irritability, interpersonal
hypersensitivity, insomnia, anxiety, tearfulness, and
sometimes elation (3).
Although there is no difference between the
prevalence rate of postpartum depression and that of
depression among women in the general population,
the incidence of depression within one month of
delivery rises to three times the average monthly
incidence in non-childbearing women (4). Many
studies suggest that the postpartum period carries a
higher risk of developing depression than any other
period during the reproductive life of a woman (5, 6).
Depending on the criteria used to diagnose postpartum
depression, prevalence rates range from 7% to 20% (3,
4) but can go as high as 63% as was found in a review
of Asian studies (7).
In this issue of the journal, Onwere et al (8) reports
the ndings of a study using the Edinburgh Postnatal
Depression Scale to determine the prevalence and
possible risk factors for postpartum depression in
Nigeria. This study yielded a relatively high prevalence
of screen-positive postpartum depression of 23.5%.
Comparable studies from African settings are few,
but the results are comparable to those reported by
Onwere et al(8) in this issue of the journal.
A 2005 study in Nigeria reported a postpartum
depression prevalence rate of 14.6% (9), while in a
Zimbabwean random sample of postpartum women
33% of them met the DSM IV criteria for depression
(10). A South African study similarly found a high
prevalence rate of 34.7% among mothers in a peri-
urban settlement (11). Obviously, then, postpartum
depression is a serious problem among women in
Africa, and it is possible that further research will
yield the true burden of this disabling disorder.
Among the identied risk factors for the
development of postpartum depression are: history of
any psychopathology (including history of previous
postpartum depression), low social support, poor
marital relationship, recent life events and unwanted
pregnancy (4,7). Studies from African countries
have identied further risk factors including hospital
admissions during the pregnancy, female sex of
the baby, preterm delivery, instrumental delivery,
Caesarean section and being single (9).
The importance of onwere et al’s(8) study lies in
two areas. Firstly, it adds to the small but growing body
of knowledge originating from Africa and other low-
income regions on postpartum depression and mental
disorders in general. In this regard, more cross-
EDITORIAL
Journal of Obstetrics and Gynaecology of
Eastern and Central Africa
1
JOGECA 2011; 23(1):1-3
disciplinary research of this nature is to be encouraged
due to the potential saving in costs and the benet of
pooling expertise.
Secondly, the study highlights the magnitude
of the problem, raising the need for screening and
treatment of depression during the postnatal clinic
visits. Due to the limited amount of research in this
area, it has remained difcult for policy-makers to
design interventions targeting depression and other
mental disorders among women in this category, and
one hopes that studies such as these will provide the
necessary evidence base for action.
Questions may be raised concerning the need
to screen for depression, and whether management
of postpartum depression has any public health
importance beyond relieving the patient’s symptoms.
The evidence overwhelmingly supports an aggressive
approach to management of this disorder in order
to reduce the risk of multiple socio-economic and
psychological complications.
Many studies have demonstrated a link between
postpartum depression and problems with child-rearing
and family dynamics, resulting in multiple negative
effects including slow infant growth and malnutrition,
multiple infections, poor family dynamics and
increased risk of current and future behavioural and
psychological problems in the child (11-15). Evidently,
then, it follows that proper management of postpartum
depression has the potential to improve not only the
mother’s overall health, but also that of the infant and
the family as a whole.
Based on these observations, it is evident that
postpartum depression is a global public health priority
that needs more research and interventions than is
currently the case. As in the paper by onwere et al (8)
in the current issue of the journal, it is recommended
that routine screening for depression be carried out
during visits by pregnant and postnatal women in order
to identify the problem early and institute corrective
measures.
In conclusion, there is little doubt that depression
among women of reproductive age, including
syndromes such as postpartum depression, is a
major public health issue and interventions should
be integrated into the routine care of women in
reproductive health services. It is my conviction that
this integration is the only approach that will have
signicant impact towards improving both maternal
and child health in Africa.
Dr. Lukoye Atwoli -
Lecturer, Department of Mental
Health, Moi University School of Medicine PO Box
1493 Eldoret 30100, Kenya. Email: Lukoye@gmail.
com
References
1. WHO. The global burden of disease: 2004 update.
Geneva: WHO: 2008.
2. American Psychiatric Association. Diagnostic
and Statistical Manual of Mental Disorders.
Washington, DC: American Psychiatric
Association: 2000.
3. O’Hara M.W. Postpartum depression: what we
know. J. Clin. Psychol. 2009; 65:1258-1269.
4. Craig, M. and Howard, L. Postnatal depression.
Clin. Evid. (Online) 2009; 2009.
5. Eberhard-Gran, M., Eskild, A., Tambs, K.,
Samuelsen, S.O. and Opjordsmoen, S. Depression
in postpartum and non-postpartum women:
prevalence and risk factors. Acta Psychiatr. Scand.
2002; 106:426-433.
6. Vesga-Lopez, O., Blanco, C., Keyes, K., Olfson,
M., Grant, B.F. and Hasin, D.S. Psychiatric
disorders in pregnant and postpartum women
in the United States. Arch. Gen. Psych. 2008;
65:805-815.
7. Klainin, P. and Arthur, D.G. Postpartum depression
in Asian cultures: a literature review. Int. J. Nurs.
Stud. 2009; 46:1355-1373.
8. Onwere, S., Chigbu, B., Kamanu, C. I., Okoro, O.,
Aluka, C. and Onwere, A. Use of the Edinburgh
Postnatal Depression Scale to identify postpartum
depression and its risk factors in South-Eastern
Nigeria. JOGECA. 2011; 23(1): 4-8
9. Adewuya, A.O., Fatoye, F.O., Ola, B.A., Ijaodola,
O.R. and Ibigbami, S.M. Sociodemographic and
obstetric risk factors for postpartum depressive
symptoms in Nigerian women. J. Psych. Pract.
2005; 11:353-358.
10. Chibanda, D., Mangezi, W., Tshimanga, M. et al.
Validation of the Edinburgh Postnatal Depression
Scale among women in a high HIV prevalence
area in urban Zimbabwe. Arch. Womens Ment.
Health. 13:201-206.
11. Cooper, P.J., Tomlinson, M., Swartz, L., Woolgar,
M., Murray, L. and Molteno, C. Post-partum
depression and the mother-infant relationship in a
South African peri-urban settlement. Br. J. Psych.
1999; 175:554-558.
12. Adewuya, A.O., Ola, B.O., Aloba, O.O., Mapayi,
B.M. and Okeniyi, J.A. Impact of postnatal
depression on infants’ growth in Nigeria. J. Affect.
Disord. 2008; 108:191-193.
13. Burke, L. The impact of maternal depression
on familial relationships. Int. Rev. Psych. 2003;
15:243-255.
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Journal of Obstetrics and Gynaecology of
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Atwoli L
14. Ndokera, R. and MacArthur, C. The relationship
between maternal depression and adverse infant
health outcomes in Zambia: a cross-sectional
feasibility study. Child Care Health Dev. 2010;
37:74-81.
15. Parsons, C.E., Young, K.S., Rochat, T.J.,
Kringelbach, M.L. and Stein, A. Postnatal
depression and its effects on child development: a
review of evidence from low- and middle-income
countries. Br. Med. Bull. 2011; Epub (PMID
22130907).
Journal of Obstetrics and Gynaecology of
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JOGECA 2011; 23(1):1-3
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