Abstract
Purpose
We examined stillbirth and neonatal death as predictors of depressive symptoms in women experiencing these events during the first six months postpartum.
Methods
We performed secondary analyses using data from 41,348 married women ages 13–44, originally collected for the JiVitA-1 study (2001 to 2007) in northwest Bangladesh. Adjusted relative risk ratios were estimated to determine the associations between stillbirth and early infant death and women’s risk of reported depressive symptoms (trichotomized 0, 1–2, 3–5) up to six months after the death. Adjusted risk ratios, comparing 0–2 versus 3–5 depressive symptoms, were used in stratified analyses.
Results
Women having fetal/infant deaths had elevated risk of experiencing 1–2 postpartum depressive symptoms (Adj. RRRs between 1.2 and 1.7) and of experiencing 3–5 postpartum depressive symptoms (Adj.RRRs between 1.9 to 3.3), relative to women without a fetal/infant death. Notably, those whose infants died in the early post-neonatal period had over a three-fold risk of 3–5 depressive symptoms (Adj RRR=3.3, 95% CI 2.6–4.3) compared to a two-fold risk for women experiencing a stillbirth (Adj RRR=1.9, 95% CI 1.7–2.1). Following early postneonatal deaths, women with higher levels of education were more likely to suffer 3–5 depressive symptoms (Adj RR=10.6, 95% CI 5.2–21.7, ≥10 years of education) compared to women with lower levels of education (Adj RR=2.0, 95% CI 1.6–2.4, no education; Adj RR=2.2, 95% CI 1.6–2.9, 1–9 years of education).
Conclusions
Women’s mental health needs should be prioritized in low-resource settings, where these outcomes are relatively common and few mental health services are available.
Keywords: stillbirth, neonatal death, Bangladesh, depressive symptoms, mental health
Introduction
According to the WHO, major depression is the leading cause of years lived with a disability and the second leading cause of disability-adjusted life years among women of reproductive age in low- and middle-income (LAMI) countries [1]. Given the high burden of depressive symptoms in women in resource-scarce contexts [2, 3], it is important to identify risk factors for depressive symptoms in LAMI countries, where risk factors are not well identified.
Possible risk factors for depression may include stillbirth and neonatal death, both highly traumatic events that can result in profound distress [4]. In Bangladesh, stillbirth and neonatal death are estimated to be 28 and 37 per 1,000 births, respectively [5]. Little is known about depressive symptoms following such adverse experiences in Bangladesh, despite the fact that these rates are over five times higher than in high income countries [6, 7]. Reporting problems, small sample size, hospital-based samples, and limited adjustment for confounders constrain research on pregnancy loss and maternal depression in LAMI countries [8–12]. Composite variables are often used to address lack of power, such that stillbirths are combined with neonatal loss, limiting our understanding of the mental health impact of loss of a live born infant relative to a stillbirth. If identified as important risk factors, care for women experiencing stillbirth and neonatal death could be addressed by government policies (e.g. extending maternity rights to mothers of unborn children, or options to delay women’s return to work if formally employed) in order to help mothers cope with such experiences [13]. Knowing the relative impact of different loss experiences may help policymakers or public health interventionists to better focus initiatives on the most affected women.
Some anthropologists posit that in settings of extreme hardship, mothers may be fatalistic and accepting of infant death [14]. On the other hand, in Bangladesh, special care is given to a woman during the forty day lay-in period after delivery of a live baby [15]. Women may experience distress if this support is not provided after a perinatal death or if they believe the loss means they have not fulfilled their childbearing role. Multiple stressors such as poverty, loss of a son or the birth of a girl in South Asian cultures may also precipitate more severe depression if women are blamed for the death or for the birth of a girl [16].
Our study objective was to examine stillbirth and neonatal death as predictors of depressive symptoms in women experiencing these events at six months postpartum. We hypothesized that neonatal deaths result in higher levels of depressive symptoms than stillbirth. Given strong son preference in Bangladesh [17], we also hypothesized that mothers with neonatal death of a boy are more likely to experience depressive symptoms than mothers losing a girl. Finally, because lower education is a risk factor for depression generally [18], is associated with anxiety following early pregnancy loss [19], and is related to higher fertility and greater likelihood of infant mortality [20–22], we hypothesized that low education would be associated with depressive symptoms for mothers experiencing stillbirth and infant death.
Material and Methods
Participants and Setting
We performed a secondary analysis using data from 41,348 married women ages 13–44, originally collected for the JiVitA-1 study. JiVitA-1 was a cluster randomized, double-masked, placebo-controlled, community trial. It was originally designed to examine the effect of maternal vitamin A and beta-carotene supplementation (given to pregnant women in the first 12 weeks of pregnancy) on maternal mortality in northwest Bangladesh [23].
JiViTA-1 took place in two rural districts of Bangladesh, Gaibandha and Rangpur. These two contiguous districts, covering 435 sq km, contain 596 villages or small groupings called ‘sectors’. About 85% of households in the study area lack electricity and most houses are made of dirt covered with tin roofs. Most men engage in subsistence agriculture, wage labor, or own small businesses. About 60% of the women do not work outside the home. At the start of the study, 40% of women were illiterate and 93% had <10 years of education [23]. In the study area, 93.75% deliveries occur at home, 5.74% in a facility and 0.51% en-route to a facility or in an unspecified location (unpublished data).
Procedure
The JiViTA-1 study took place between August 2001 and October 2007. Prior to enrollment, a census of married women of reproductive age residing in the study areas was conducted and enlisted for five-weekly pregnancy surveillance, based on being 13–44 years of age, married and residing with husband, and not menopausal or sterilized. Newly married women were enlisted for surveillance over the course of the trial, based on being registered with the trial within four months of marriage. To identify pregnant women, all eligible women were visited at home every five weeks and asked about their menstrual history. A urine test was used to identify new pregnancies for women reporting amenorrhea in the past 30 days. Women providing oral consent were randomized into three weekly supplement groups: vitamin A, beta-carotene and placebo.
At enrollment, trained interviewers conducted face-to-face interviews with participants to obtain information on demographic variables and maternal health status. Information on birth outcomes, including stillbirths and early infant deaths were collected at three months postpartum. Postpartum depressive symptoms were assessed six months after the event (median 24.7 weeks, mean-29.3 weeks, SD=11.4) and asked about the ‘past six months’ using a five-item scale developed in the study population.
The Johns Hopkins Bloomberg School of Public Health Institutional Review Board and the Bangladesh Medical Research Council granted ethical approval for the study.
Measures
Maternal postpartum depressive symptoms were assessed referring to the prior six months based on questions modified from the Patient Health Questionnaire (PHQ-9) and the Center for Epidemiologic Studies Depression Scale (CES-D); there were no validated scales for depression in Bangladesh at the time. Items were pilot tested in focus group discussions to identify symptoms from the two scales that were well-understood locally. A professional translator first translated the items from English into Bangla and another independently back translated the items into English. A standard question about suicidal ideation was added. The final, five-item scale included: feeling sad all the time; becoming more forgetful; crying all the time; having thoughts of hurting oneself; and not wanting to bathe or eat for several days (Cronbach alpha= 0.72). Women were asked if they experienced any of these symptoms in the last six months. The five depressive symptoms items were summed and categorized into three groups: zero, 1–2, and 3–5 symptoms. While the cutoffs we used served only as a descriptive indicators, our classification for high depressive symptoms was three or more symptoms, which 14% of the sample experienced. This makes it a more stringent cutoff compared to other reported prevalence estimates evaluated on the Edinburgh Scale for Postpartum Depression in rural Bangladesh [24, 25].
Pregnancy outcomes were categorized into four groups: live birth, stillbirth (fetal loss from 28 weeks gestation to delivery), early neonatal death (0–7 days), late neonatal death (8–28 days) and an “early” post-neonatal death (between 29 to 180 days postpartum). Newborn sex was included as a covariate as were demographic variables: maternal age (≤19, 20–29, ≥30), parity (zero vs. ≥1), maternal education (0, 1–9yrs vs. ≥10yrs), living standard index in quartiles (1st=low, 2nd, 3rd, vs. 4th=high), religion (non-Muslim vs. Muslim) and number of children ages ≤12 in the household (0, 1, ≥ 2). A living standard index was constructed based on Principal Component Analysis and included household assets (e.g. toilet facilities, beds, radios) [26].
Maternal nutritional status was evaluated with mid-upper arm circumference (<21.5 vs. ≥21.5) and possible anemia in the first trimester (yes, no) defined as symptoms of breathlessness at rest resulting in an inability to work, and based on the World Health Organization’s definition. Infection in the first trimester (none versus urinary tract infection, gastroenteritis or both) was used as a proxy for maternal morbidity during pregnancy.
Statistical Methods
The analytic sample included women with singleton live births and excluded women with miscarriages and multiple births. Multiparous women were excluded because we did not have data on sex for previous stillbirths. We first calculated the proportion of women with zero, 1–2 and 3–5 depressive symptoms by fetal/infant outcome, socio-demographic characteristics and maternal illness during pregnancy, using chi-square tests to examine bivariate associations. Analyses were performed with stillbirth and infant death as predictors of depressive symptoms with livebirths that survived past 180 days as the reference category. Crude and adjusted relative risk ratios and 95% confidence intervals (CI) were then computed using multinomial logistic regression models, comparing women with 1–2 and 3–5 depressive symptoms after fetal/infant death to those with no symptoms as the reference category.
In adjusted models, covariates were based on statistically significant results from crude risk ratios (p≤0.05); they were maternal age, education, parity, household living standard index, religion, number of children ≤ age 12 years in the household, maternal mid- upper arm circumference in third trimester, symptoms of anemia and infection in the first trimester. All models were adjusted for geographical cluster and micronutrient supplementation group.
Because of very few early post neonatal deaths, we were unable to use multinomial logistic regression to compute relative risk ratios between timing of death and depressive symptoms in stratified models. Therefore, in models stratified (separately) by sex, education, micronutrient status and maternal religion, we treated depressive symptoms as a dichotomous outcome variable (low: 0–2 symptoms versus high: 3–5 symptoms). We performed Wald’s t-test to determine if there was a significant interaction (p<0.05) between timing of neonatal death and each of these four variables. We computed adjusted risk ratios using generalized linear models (GLM) with a log-link and Poisson distribution, which approximates the relative risk from a binomial distribution. Because the binomial error structure for GLM failed to converge, we assumed a Poisson distribution and adjusted the standard errors and 95% Cis using the Huber-White robust estimator [27].
Results
In all 60,294 women were identified as pregnant through the study’s pregnancy surveillance, out of which 628 (1.04%) did not consent or were lost to follow-up. Of the 59,666 women who were enrolled in the study, 2,566 had missing data on depressive symptoms at 6 months postpartum corresponding to 4.3% loss to follow-up (of which 0.6% were refusals). Finally, after exclusion of an additional 15,762 women having multiple births, miscarriages and incomplete birth outcome information, our final analytic sample of was 41,348 women. (See Figure 1).
Figure 1.
The respective percentages of women experiencing a stillbirth, early neonatal, late neonatal and early post-neonatal death (29–180 days) were 5% (N=1914), 4% (N=1550), 1% (N=413), and 1 percent (N=391). The proportions of women reporting zero, 1–2 and 3–5 depressive symptoms were 49.0% (N=20,262), 37.2% (N=15,394) and 13.8% (5,692), respectively. There was a noticeably higher prevalence of women with depressive symptoms who experienced a stillbirth or early infant death (0–180 days) than among women with livebirths (Table 1). Newborn sex and trial status were not related to depressive symptoms.
Table 1.
Descriptive characteristics: Pregnancy outcome, socio-demographic characteristics, maternal postpartum illness and postpartum depression at six months
| Number of Depressive Symptoms | |||||
|---|---|---|---|---|---|
| Variable | Zero | 1 to 2 | 3 to 5 | ||
|
| |||||
| Total, n (%) | n (%) | n (%) | n (%) | p-value | |
| Pregnancy outcome variables | |||||
| Live birth | 37,080 (89.68) | 18,6 32 (50.25) | 13,679 (36.89) | 4,769 (12.86) | <0.001 |
| Stillbirth (28 weeks gestation to delivery) | 1,914 (4.63) | 812 (42.42) | 715 (37.36) | 387 (20.22) | |
| Early neonatal death (0–7 days) | 1,550 (3.75) | 543 (35.03) | 664 (42.84) | 343 (22.13) | |
| Late neonatal death (8–28 days) | 413 (1.00) | 150 (36.32) | 181(43.83 ) | 82 (19.85) | |
| Early post neonatal death (29–180 days) | 391 (0.95) | 125 (31.97) | 55 (39.64) | 111 (28.39) | |
| Maternal age (yrs) | |||||
| ≤ 19 | 21,294 (51.53) | 11,064 (51.96) | 7,709 (36.20) | 2,521 (11.84 ) | <0.001 |
| 20–29 | 16,580 (40.12) | 7,817 (47.15) | 6,306 (38.03 ) | 2,457 (14.82 ) | |
| ≥ 30 | 3,451 (8.35) | 1,371 (39.73) | 1,369 (39.67) | 711 (20.60) | |
| Parity | |||||
| Zero | 16,477 (39.88) | 8,808 (53.46) | 5,776 (35.05) | 1,893 (11.49) | <0.001 |
| ≥ 1 | 24,835 (60.12) | 11,436 (46.05) | 9,605 (38.68 ) | 3,794 (15.28 ) | |
| Maternal education (yrs) | |||||
| No education | 19,919 (48.21) | 9,218 (46.28 ) | 7,547 (37.89) | 3,154 (15.83 ) | <0.001 |
| 1–9 | 18,359 (44.44) | 9,316 (50.74) | 6,784 (36.95) | 2,259 (12.30) | |
| ≥10 | 3,038 (7.35) | 1,712 (56.35) | 1,052 (34.63) | 274 (9.02) | |
| Living standard index | |||||
| 1st quartile (poor) | 10,595 (25.64) | 4,918 (46.42) | 3,933 (37.12 ) | 1,744 (16.46) | <0.001 |
| 2nd | 10,500 (25.41) | 4,959 (47.23) | 4,023 (38.31) | 1,518 (14.46 ) | |
| 3rd | 10,088 (24.42) | 4,980 (49.37) | 3,812 (37.79) | 1,296 (12.85) | |
| 4th quartile (rich) | 10,134 (24.53) | 5,390 (53.19) | 3,615 (35.67) | 1,129 (11.14) | |
| Religion | |||||
| Non-Muslim | 3,347 (8.10) | 1,791 (53.51) | 1,155 (34.51) | 401 (11.98) | 0.002 |
| Muslim | 37,970 (91.90) | 18,456 (48.61) | 14,228 (37.47) | 5,286 (13.92) | |
| Number of children (0–12yrs) in household | |||||
| Zero | 13,084 (31.72) | 6,877 (52.56) | 4,607 (35.21) | 1,600 (12.23) | <0.001 |
| One | 15,227 (36.83) | 7,605 (49.94) | 5,653 (37.12) | 1,969 (12.93 ) | |
| Two or more | 13,006 (31.45) | 5,765 (44.33) | 5,123 (39.39) | 2,118 (16.28) | |
| Mid-upper arm circumference (cm)† | |||||
| < 21.5 | 11,817 (28.74) | 5,648 (47.80) | 4,408 (37.30) | 1,761 (14.90) | <0.001 |
| ≥ 21.5 | 29,302 (71.26) | 14,516 (49.54) | 10,890 (37.16 ) | 3,896 (13.30) | |
| Anemia† | |||||
| No | 26,739 (64.96) | 13,879 (51.91) | 9,732 (36.40) | 3,128 (11.70|) | <0.001 |
| Yes | 14,426 (35.04) | 6,301 (43.68) | 5,590 (38.75 ) | 2,535 (17.57) | |
| Infections† (urinary tract infection and gastroenteritis) | |||||
| None | 36,669 (88.68) | 18,299 (49.90) | 13,591 (37.06) | 4,779 (13.03) | <0.001 |
| At least one or both | 4,679 (11.32) | 1,963 (41.95) | 1,803 (38.53 ) | 913 (19.51) | |
| Sex of the child | |||||
| Male | 20,061 (50.87) | 9,852 (49.11) | 7,495 (37.36 ) | 2,714 ( 13.53) | 0.65 |
| Female | 19,373 (49.13) | 9,598 (49.54) | 7,184 (37.08 ) | 2,591 (13.37) | |
| Vitamin Supplementation Group | |||||
| Beta Carotene | 13,863 (33.53) | 6,766 (48.81) | 5,229 (37.72 ) | 1,868 (13.47) | 0.42 |
| Vitamin A | 13,704 (33.33) | 6,798 (49.33) | 5,054 (36.67 ) | 1,929 (14.00) | | |
| Placebo | 13,781 (33.33) | 6,698 (48.88) | 5,111 (37.30 ) | 1,895 (13.83) | |
Measured in the first trimester of pregnancy
Although the total sample size varied due to some missing observations on some of the variables, the total sample size with no missing information was N=41,348, i.e. 20,262 reported no symptoms; 15,394 1–2 symptoms; and 5,692 reported 3–5 depressive symptoms.
Women who experienced fetal/infant deaths compared to those who did not experience these losses, had between 1.2 and 1.7 higher risks of 1 to 2 postpartum depressive symptoms and between 1.9 and 3.3 higher risks of 3 to 5 postpartum depressive symptoms, relative to women without fetal/infant deaths (Table 2). Mothers of infants who died in the early post-neonatal period (Adj RRR=3.33, 95% CI 2.55–4.32) compared to women experiencing stillbirths (Adj RRR=1.88, 95% CI 1.66–2.13) had somewhat higher risk of experiencing 3 to 5 depressive symptoms, relative to women with livebirths that survived until 180 days postpartum (Table 2).
Table 2.
Crude and adjusted relative risk of postpartum depression at six months after birth: Pregnancy outcome, socio-demographic and infant risk factors
| Crude Relative Risk Ratioa (95% CI) | Adjusted Relative Risk Ratioa,b (95% CI) | |||
|---|---|---|---|---|
|
| ||||
| Pregnancy outcome variables | 1–2 symptoms | 3–5 symptoms | 1–2 symptoms | 3–5 symptoms |
| Live birth | 1.00 | 1.00 | 1.00 | 1.00 |
| Stillbirth (28 weeks gestation to delivery) | 1.19 (1.08–1.33) | 1.86 (1.64–2.11) | 1.22 (1.09–1.35) | 1.88 (1.66–2.13) |
| Early neonatal death (0–7 days) | 1.66 (1.48–1.86) | 2.47 (2.15–2.84) | 1.73 (1.52–1.95) | 2.64 (2.29–3.04) |
| Late neonatal death (8–28 days) | 1.64 (1.32–2.04) | 2.14 (1.63–2.80) | 1.66 (1.33–2.07) | 2.14 (1.63–2.83) |
| Early post neonatal death (29–180 days) | 1.69 (1.33–2.14) | 3.47 (2.68–4.49) | 1.67 (1.32–2.12) | 3.33 (2.55–4.32) |
| Maternal age (yrs) | ||||
| ≤ 19 | 1.00 | 1.00 | ||
| 20–29 | 1.16 (1.11–1.21) | 1.38 (1.30–1.47) | 1.06 (1.00–1.12) | 1.16 (1.07–1.26) |
| ≥ 30 | 1.43 (1.32–1.55) | 2.28 (2.06–2.51) | 1.25 (1.14–1.37) | 1.69 (1.48–1.88) |
| Parity | ||||
| Zero | 1.00 | 1.00 | 1.00 | 1.00 |
| ≥ 1 | 1.11 (1.09–1.12) | 1.17 (1.14–1.19) | 1.17 (1.08–1.25) | 1.17 (1.06–1.31) |
| Maternal education (yrs) | ||||
| No education | 0.88 (0.85–0.93) | 0.71 (0.67–0.75) | 1.15 (1.04–1.26) | 0.91 (0.84–0.97) |
| 0–9 | 0.75 (0.69–0.82) | 0.47 (0.41–0.53) | 1.14 (1.04–1.24) | 0.65 (0.55–0.75) |
| ≥10 | 1.00 | 1.00 | 1.00 | 1.00 |
| Living standard index | ||||
| 1st quartile (poor) | 1.01 (0.96–1.07) | 0.86 (0.80–0.93) | 1.06 (0.99–1.13) | 0.89 (0.82–0.96) |
| 2nd | 0.96 (0.90–1.02) | 0.73 (0.68–0.80) | 1.10 (1.02–1.17) | 0.81 (0.74–0.88) |
| 3rd | 0.84 (0.79–0.89) | 0.60 (0.54–0.64) | 1.06 (0.99–1.13) | 0.76 (0.68–0.84) |
| 4th quartile (rich) | 1.00 | 1.00 | 1.00 | 1.00 |
| Religion | ||||
| Muslim | 1.00 | 1.00 | 1.00 | 1.00 |
| Non-Muslim | 0.84 (0.77–0.90) | 0.78 (0.70–0.87) | 0.85 (0.79–0.92) | 0.81 (0.72–0.91) |
| Number of children (0–12yrs) in household | ||||
| Zero | 1.00 | 1.00 | 1.00 | 1.00 |
| One | 1.11 (1.05–1.17) | 1.11 (1.03–1.20) | 0.98 (0.93–1.05) | 0.90 (0.82–1.00) |
| Two or more | 1.33 (1.26–1.40) | 1.60 (1.47–1.70) | 1.13 (1.06–1.22) | 1.13 (1.02–1.26) |
| Mid-upper arm circumferenceb (cm) | ||||
| < 21.5 | 0.96 (0.92–1.01) | 0.86 (0.81–0.92) | 1.01 (0.96–1.06) | 0.97 (0.911–1.04) |
| ≥ 21.5 | 1.00 | 1.00 | 1.00 | 1.00 |
| Anemiac | ||||
| No | 1.00 | 1.00 | 1.00 | 1.00 |
| Yes | 1.27 (1.21–1.32) | 1.79 (1.68–1.90) | 1.207 (1.15–1.26) | 1.59 (1.50–1.69) |
| Infections (urinary tract infection and gastroenteritis)b | ||||
| None | 1.00 | 1.00 | 1.00 | 1.00 |
| At least one or both | 1.24 (1.16–1.32) | 1.78 (1.64–1.94) | 1.17 (1.10–1.25) | 1.59 (1.46–1.74) |
| Sex of the child | ||||
| Male | 0.98 (0.94–1.03) | 0.98 (0.92–1.04) | -- | -- |
| Female | 1.00 | 1.00 | -- | -- |
| Vitamin Supplementation Group | ||||
| Beta Carotene | 0.96 (0.91–1.02) | 0.97 (0.91–1.03) | 0.96 (0.911–1.02) | 1.02 (0.95–1.10) |
| Vitamin A | 0.99 (0.93–1.05) | 0.99 (0.93–1.05) | 0.98 (0.93–1.04) | 1.02 (0.94–1.09) |
| Placebo | 1.00 | 1.00 | 1.00 | 1.00 |
Women with no symptoms of depression was the reference group
Analyses adjust for maternal age, parity, maternal education, living standard index, religion, number of children (0–12yrs) in the household, mid upper arm circumference at third trimester, anemia during pregnancy, infection, vitamin supplementation group, and village cluster. Given child sex was not significant in bivariate analyses and did not have data on sex for stillbirths, it is not included in the multivariate analyses. In the adjusted model the total sample size was N=41,087. The number of missing values per variable was as follows: maternal age=23, maternal education =32, religion=31, living standard index=31, number of children (0–12) in household =31, and maternal upper arm circumference=229.
Measured in the first trimester of pregnancy.
Based on stratified models and interaction terms, we found no significant interaction for the sex of the child with perinatal or infant death (Wald’s t-test, p=0.23), micronutrient supplementation (p=0.72) and maternal religious affiliation (p=0.28) (data not shown). We observed, however, a significant interaction of maternal education with late neonatal and early post-neonatal deaths (Wald’s t-test, p<0.001) based on adjusted analyses stratified by maternal education (Table 3). Women with ≥10 years of education who experienced a late neonatal death, had a four-fold elevated risk of depressive symptoms (RR=4.02, 95% CI 1.94–8.10), while the risk of symptoms among women with no education was modestly increased and marginally statistically significant (RR=1.30, 95% CI 0.98–1.72). Similarly, early post-neonatal deaths were associated with an eleven-fold risk of depressive symptoms for women with ≥10 years of education (Adj RR=10.59, 95% CI 5.16–21.74), also higher than the two-fold risk observed in women with no education (RR=1.98, 95% CI 1.63–2.41). Moreover, among women with ≥10 years of education, the eleven-fold risk of depressive symptoms associated with early post-neonatal death was greater than that of women experiencing stillbirth and early neonatal death (Adj RR=2.08, 95% CI 1.41–3.07; Adj RR=1.86, 95% CI 1.15–3.01, respectively). No differences in depressive symptoms by maternal education were noted for women who experienced stillbirths and early neonatal deaths.
Table 3.
Adjusted associations between neonatal death and high postpartum depressive symptoms at 6 months among Bangladeshi women with live births, stratified by maternal educational status.
| Years of education | |||
|---|---|---|---|
| Zero | 1–9 | ≥10 | |
| Pregnancy outcome | Relative Risk (95% CI) of high depressive symptoms | Relative Risk (95% CI) of high depressive symptoms | Relative Risk (95% CI) of high depressive symptoms |
| Live birth | 1.00 | 1.00 | 1.00 |
| Stillbirth (28 weeks gestation to delivery) | 1.49 (1.33–1.69) | 1.60 (1.37–1.87) | 2.08 (1.41–3.07) |
| Early neonatal death (0–7 days) | 1.57 (1.36–1.80) | 2.02 (1.76–2.33) | 1.86 (1.15–3.01) |
| Late neonatal death (8–28 days) | 1.30 (0.98–1.72) | 1.76 (1.31–2.37) | 4.02 (1.94–8.10) |
| Early post neonatal death (29–180 days) | 1.98 (1.63–2.41) | 2.20 (1.64–2.94) | 10.59 (5.16–21.74) |
Analyses are adjust for maternal age, parity, living standard index, religion, number of children (0–12 yrs) in the household, mid upper arm circumference at third trimester, anemia during pregnancy, infection, vitamin supplementation group, and village cluster. The p-value for the interaction is <0.0001. The total sample size for this analysis was 41,087, corresponding to 19,799, 18,265, and 3,023 participants with zero, 1–9, and ≥ 10 years of education, respectively.
Risk of high depressive symptoms (3–5 symptoms) we assessed in relation to the reference group of low symptoms (0–2).
Discussion
Our study shows an elevated likelihood of depressive symptoms during the six months following a stillbirth or infant death in the first 180 days after birth among women in rural Bangladesh. These findings are important, as the impact of depressive symptoms in this population may be particularly pronounced given the dearth of mental health care services in rural low-resource settings [28], such as our study setting.
Our results suggested a higher magnitude of depressive symptom risk with longer time before the death, when comparing stillbirths to infants dying in the first 7 days and to infants dying in the period from 30 to 180 days postpartum. A three-fold increased risk of high depressive symptoms was found for women experiencing an early post-neonatal infant death between one to three months after the delivery after adjusting for important confounders, relative to women not experiencing fetal/infant death. Prior research suggests that longer time with the child may confer a higher risk of depressive symptoms; for example, Nigerian women with late pregnancy loss were more likely to have depressive symptoms than those with a fetal loss early in pregnancy [8].
A strength of our study was the use of data from a very large cohort including prospectively collected information and surveillance of women throughout pregnancy until six months postpartum, unusual in rural, resource-scarce settings. Due to limited power, it has not been possible for many studies to investigate the separate effects of experiencing a stillbirth or infant death or to study effect modification, both of which we examined in our study. A study limitation was the lack of a validated instrument for measuring depressive symptoms in Bangladesh at the time of data collection, making it unknown how our cutoff might predict a depression diagnosis. Nonetheless, the depressive symptoms included in our measure were based on standard items (e.g. crying all the time, suicidal ideation), and likely reflect depressive symptomatology on a continuum. Lack of a single validated instrument across studies may also be one possible explanation for the differences we found relative to other studies in the region, such as in Matlab. An alternative explanation may be attributable to the small number of women who experienced a perinatal death in the Matlab studies, and the smaller sample size in general. We would have liked to compare women with chronic high levels of depressive symptoms versus depressive symptoms occurring first during pregnancy. However that was not possible, due to our lack of data on depressive symptoms before pregnancy. Further, we were unable to control for social support as a potential confounding variable, due to lack of information on support. Finally, our generalizability is limited to Bangladeshi women who are married, have singleton births, and live in rural areas.
The observed association between perinatal or infant death and subsequent depressive symptoms extends prior research in Bangladesh and other developing countries. Gausia et al. reported a relation between perinatal death and postnatal depression at six to eight weeks follow-up in the rural sub-district of Matlab [9]; they reported a fourteen-fold higher odds of depressive symptoms for women with a perinatal death, but the estimate was based on only ten perinatal deaths [9]. In a later study in Matlab, the same investigators interviewed women experiencing perinatal deaths (stillbirths and neonatal deaths up to seven days postpartum) and a control group, assessing depressive symptoms at six months after the loss or birth [10]. No significant differences between groups were found at six months postpartum [10]. The latter findings for depressive symptoms among women in Matlab at six months contrast with our findings of an elevated risk of depressive symptoms during the six months postpartum. Researchers also found that women experiencing pregnancy loss or perinatal death were at increased risk of depression measured at three and six months postpartum in two Nigerian studies, respectively [8, 12]. In Benin, women from tertiary hospitals who experienced a perinatal death reported moderate to severe depressive symptoms when surveyed four weeks after the death [11].
The sex of the deceased fetus or infants was not related to risk of depressive symptoms in our study. Although loss at any point predicted elevated symptoms, the risk among women with higher education was particularly elevated compared to women with lower educational levels following a late neonatal death. Given that women in the region with higher educational status tend to desire fewer children and have lower fertility rates [29], economic theory posits a quantity-quality tradeoff of having a child suggesting that women with higher education may be more depressed if they experience neonatal loss [30]; that is, if more highly educated women tend to have fewer children because of the opportunity cost of giving birth, they may invest more in each child given a smaller family size [31].
Anthropological theory provides a possible explanation for fewer depressive symptoms among women with lower education levels following a post-neonatal loss. It has been proposed in low-resource settings with high child mortality and high fertility that grief may be reduced and anthropomorphisation may not take place until it is clear that the infant is likely to survive [32]. Given that Bangladeshi women with lower education may experience more neonatal and post-neonatal deaths [33], this phenomenon, if present in Bangladesh, may be more common among women with less education.
Our results showed increased risk of depressive symptoms following the death of a fetus and infant, which has significant implications for mental healthcare needs in this setting. Based on research from developed countries, there may be even longer-term mental health consequences resulting from these adverse events for mothers, including increased risk of hospitalization for psychiatric disorders five years or more following the death [34]. Depressive symptoms are known to be related to sub-optimal caregiving [35], which could affect children from prior and subsequent pregnancies.
Conclusions
Our results suggest that rural Bangladeshi women experiencing stillbirth and neonatal death, and in particular more educated women in this setting, could benefit from mental health initiatives. Despite challenges in mental health service delivery in resource-scarce countries [36], a pooled analysis of 13 trials from LAMI countries on interventions to improve mental health of women in the perinatal period indicated that they were effective overall in reducing depression within the first year postpartum [37]. Positive results of these studies, conducted by nonspecialist and community workers, point to possible delivery of psychological interventions by personnel without specific mental health training [37]. Mental health needs of women experiencing stillbirth or death of an infant need to be prioritized along with other perinatal mental health interventions in such low-resource rural settings.
Acknowledgments
This work was supported by the National Institute of Child Health and Development at the National Institutes of Health [1 RO3 HD069731-01A1], Bethesda, MD; The Bill and Melinda Gates Foundation (GH614, Global Control of Micronutrient Deficiency, Project Officer: Ellen Piwoz), Seattle, WA; Office of Health, Infectious Diseases and Nutrition, United States Agency for International Development (Micronutrients for Health Cooperative Agreement HRN-A-00-97-00015-00 and Global Research Activity GHS-A-00-03-00019-00), Washington DC; United States Agency for International Development Mission Bangladesh, Dhaka; Ministry of Health and Family Welfare, Government of the Peoples’ Republic of Bangladesh, Dhaka; The Sight and Life Global Nutrition Research Institute, Baltimore, MD; and the National Institute of Drug Abuse (T32DA13911), Bethesda, MD.
List of Abbreviations and Acronyms
- CI
Confidence intervals
- CES-D
Center for Epidemiologic Studies Depression Scale
- GLM
Generalized linear models
- LAMI
Low- and middle-income
- PHQ-9
Patient Health Questionnaire
- RRR
Relative Risk Ratio
- RR
Relative risk
- SD
Standard deviation
Footnotes
Details of ethics approval
The study was granted ethical approval on May 18, 2001 by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board (IRB #H.22.01.01.11.A1) and continuing approval from the same board on March 12, 2014. Ethical approval from the Bangladesh Medical Research Council (BMRC, BMRC/ERC/1998-2001/2405) was received on August 5, 2001. Clinical trial registration: clinicaltrials.gov RCT# NCT00198822.
Conflict of Interest Disclosure
The authors declare no conflicts of interest.
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
References
- 1.Global Burden of Disease Arrow Diagram. [ http://vizhub.healthdata.org/irank/arrow.php]
- 2.Ferrari AJ, Charlson FJ, Norman RE, Patten SB, Freedman G, Murray CJ, Vos T, Whiteford HA. Burden of depressive disorders by country, sex, age, and year: findings from the global burden of disease study 2010. PLoS Med. 2013;10(11):e1001547. doi: 10.1371/journal.pmed.1001547. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Sloan DM, Sandt AR. Gender differences in depression. Womens Health (Lond Engl) 2006;2(3):425–434. doi: 10.2217/17455057.2.3.425. [DOI] [PubMed] [Google Scholar]
- 4.Boyle FM, Vance JC, Najman JM, Thearle MJ. The mental health impact of stillbirth, neonatal death or SIDS: prevalence and patterns of distress among mothers. Soc Sci Med. 1996;43(8):1273–1282. doi: 10.1016/0277-9536(96)00039-1. [DOI] [PubMed] [Google Scholar]
- 5.DemographicHealthSurveys-Bangladesh: Final Report 2007. National Institute of Population Research and Training (NIPORT); Dhaka, Bangladesh, Mitra and Associates, Dhaka, Bangladesh: Macro International; Calverton, Maryland, USA: 2007. [Google Scholar]
- 6.Wang H, Liddell CA, Coates MM, Mooney MD, Levitz CE, Schumacher AE, Apfel H, Iannarone M, Phillips B, Lofgren KT, et al. Global, regional, and national levels of neonatal, infant, and under-5 mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014;384(9947):957–979. doi: 10.1016/S0140-6736(14)60497-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Cousens S, Blencowe H, Stanton C, Chou D, Ahmed S, Steinhardt L, Creanga AA, Tuncalp O, Balsara ZP, Gupta S, et al. National, regional, and worldwide estimates of stillbirth rates in 2009 with trends since 1995: a systematic analysis. Lancet. 2011;377(9774):1319–1330. doi: 10.1016/S0140-6736(10)62310-0. [DOI] [PubMed] [Google Scholar]
- 8.Obi SN, Onah HE, Okafor II. Depression among Nigerian women following pregnancy loss. Int J Gynaecol Obstet. 2009;105(1):60–62. doi: 10.1016/j.ijgo.2008.11.036. [DOI] [PubMed] [Google Scholar]
- 9.Gausia K, Fisher C, Ali M, Oosthuizen J. Magnitude and contributory factors of postnatal depression: a community-based cohort study from a rural subdistrict of Bangladesh. Psychol Med. 2009;39(6):999–1007. doi: 10.1017/S0033291708004455. [DOI] [PubMed] [Google Scholar]
- 10.Gausia K, Moran AC, Ali M, Ryder D, Fisher C, Koblinsky M. Psychological and social consequences among mothers suffering from perinatal loss: perspective from a low income country. BMC Public Health. 2011;11:451. doi: 10.1186/1471-2458-11-451. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Filippi V, Goufodji S, Sismanidis C, Kanhonou L, Fottrell E, Ronsmans C, Alihonou E, Patel V. Effects of severe obstetric complications on women’s health and infant mortality in Benin. Trop Med Int Health. 2010;15(6):733–742. doi: 10.1111/j.1365-3156.2010.02534.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Adeyemi A, Mosaku K, Ajenifuja O, Fatoye F, Makinde N, Ola B. Depressive symptoms in a sample of women following perinatal loss. J Natl Med Assoc. 2008;100(12):1463–1468. doi: 10.1016/s0027-9684(15)31548-0. [DOI] [PubMed] [Google Scholar]
- 13.Heazell AE, Siassakos D, Blencowe H, Burden C, Bhutta ZA, Cacciatore J, Dang N, Das J, Flenady V, Gold KJ, et al. Stillbirths: economic and psychosocial consequences. Lancet. 2016;387(10018):604–616. doi: 10.1016/S0140-6736(15)00836-3. [DOI] [PubMed] [Google Scholar]
- 14.Scheper-Hughes N. Culture, scarcity, and maternal thinking. Ethos. 1995;(13):291–317. [Google Scholar]
- 15.Winch PJ, Alam MA, Akther A, Afroz D, Ali NA, Ellis AA, Baqui AH, Darmstadt GL, El Arifeen S, Seraji MH. Local understandings of vulnerability and protection during the neonatal period in Sylhet District, Bangladesh: a qualitative study. Lancet. 2005;366(9484):478–485. doi: 10.1016/S0140-6736(05)66836-5. [DOI] [PubMed] [Google Scholar]
- 16.Patel V, Rodrigues M, DeSouza N. Gender, poverty, and postnatal depression: a study of mothers in Goa, India. Am J Psychiatry. 2002;159(1):43–47. doi: 10.1176/appi.ajp.159.1.43. [DOI] [PubMed] [Google Scholar]
- 17.Bairagi R, Chowdhury MK. Effects of parental gender preference on fertility and mortality in Matlab. In: Dhaka Fauveau V., editor. Matlab: Women, Children and Health. Volume ICDDR, B Special Publication No 35. Pioneering Printing Press; 1994. pp. 309–322. [Google Scholar]
- 18.Lorant V, Deliege D, Eaton W, Robert A, Philippot P, Ansseau M. Socioeconomic inequalities in depression: a meta-analysis. Am J Epidemiol. 2003;157(2):98–112. doi: 10.1093/aje/kwf182. [DOI] [PubMed] [Google Scholar]
- 19.Nikcevic AV, Kuczmierczyk AR, Nicolaides KH. Personal coping resources, responsibility, anxiety and depression after early pregnancy loss. J Psychosom Obstet Gynaecol. 1998;19(3):145–154. doi: 10.3109/01674829809025692. [DOI] [PubMed] [Google Scholar]
- 20.Abadian S. Women’s autonomy and its impact on fertility. World Dev. 1996;24(12):1793–1809. [Google Scholar]
- 21.Basu AM, Stephenson R. Low levels of maternal education and the proximate determinants of childhood mortality: a little learning is not a dangerous thing. Soc Sci Med. 2005;60(9):2011–2023. doi: 10.1016/j.socscimed.2004.08.057. [DOI] [PubMed] [Google Scholar]
- 22.Miah MMR. Determinants of high fertility in Bangladesh: Their implications for social development. Int Rev Mod Sociol. 1993:75–89. [Google Scholar]
- 23.Labrique AB, Christian P, Klemm RD, Rashid M, Shamim AA, Massie A, Schulze K, Hackman A, West KP., Jr A cluster-randomized, placebo-controlled, maternal vitamin A or beta-carotene supplementation trial in Bangladesh: design and methods. Trials. 2011;12:102. doi: 10.1186/1745-6215-12-102. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Nasreen HE, Kabir ZN, Forsell Y, Edhborg M. Prevalence and associated factors of depressive and anxiety symptoms during pregnancy: a population based study in rural Bangladesh. BMC Womens Health. 2011;11:22. doi: 10.1186/1472-6874-11-22. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Gausia K, Fisher C, Ali M, Oosthuizen J. Antenatal depression and suicidal ideation among rural Bangladeshi women: a community-based study. Arch Womens Ment Health. 2009;12(5):351–358. doi: 10.1007/s00737-009-0080-7. [DOI] [PubMed] [Google Scholar]
- 26.Gunnsteinsson S, Labrique AB, West KP, Christian P, Sucheta M, Shamim AA, Rashid M, Katz J, Klemm R. Constructing indices of rural living standards in Northwest Bangladesh. J Health Popul Nutr. 2010;28:509–519. doi: 10.3329/jhpn.v28i5.6160. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Cummings P. Methods for estimating adjusted risk ratios. Stata J. 2009;9(2):175–196. [Google Scholar]
- 28.Saxena S, Thornicroft G, Knapp M, Whiteford H. Resources for mental health: scarcity, inequity, and inefficiency. Lancet. 2007;370(9590):878–889. doi: 10.1016/S0140-6736(07)61239-2. [DOI] [PubMed] [Google Scholar]
- 29.Borkotoky K, Unisa S. Female Education and Its Association with Changes in Socio-Demographic Behaviour: Evidence from India. J Biosoc Sci. 2014:1–20. doi: 10.1017/S002193201400039X. [DOI] [PubMed] [Google Scholar]
- 30.Becker GS, Lewis HG. On the interaction between the quantity and quality of children. J Polit Econ. 1973;81:S279–288. [Google Scholar]
- 31.Becker GS. A treatise on the family. Cambridge: Harvard University Press; 1991. [Google Scholar]
- 32.Scheper-Hughes N. Social indifference to child death. Lancet. 1991;337(8750):1144–1147. doi: 10.1016/0140-6736(91)92800-h. [DOI] [PubMed] [Google Scholar]
- 33.National Institute of Population Research and Training (NIPORT), Mitra and Associates, Macro International. Demographic and Health Survey - Bangladesh 2007. Dhaka, Bangladesh: 2009. p. 103. [Google Scholar]
- 34.Li J, Laursen TM, Precht DH, Olsen J, Mortensen PB. Hospitalization for mental illness among parents after the death of a child. N Engl J Med. 2005;352(12):1190–1196. doi: 10.1056/NEJMoa033160. [DOI] [PubMed] [Google Scholar]
- 35.Lovejoy MC, Graczyk PA, O’Hare E, Neuman G. Maternal depression and parenting behavior: a meta-analytic review. Clin Psychol Rev. 2000;20(5):561–592. doi: 10.1016/s0272-7358(98)00100-7. [DOI] [PubMed] [Google Scholar]
- 36.Jacob KS, Sharan P, Mirza I, Garrido-Cumbrera M, Seedat S, Mari JJ, Sreenivas V, Saxena S. Mental health systems in countries: where are we now? Lancet. 2007;370(9592):1061–1077. doi: 10.1016/S0140-6736(07)61241-0. [DOI] [PubMed] [Google Scholar]
- 37.Rahman A, Fisher J, Bower P, Luchters S, Tran T, Yasamy MT, Saxena S, Waheed W. Interventions for common perinatal mental disorders in women in low- and middle-income countries: a systematic review and meta-analysis. Bull World Health Organ. 2013;91(8):593–601I. doi: 10.2471/BLT.12.109819. [DOI] [PMC free article] [PubMed] [Google Scholar]