Perception of Mothers and Selected Informal Maternity Caregivers Regarding Maternal Depression in Two Communities of Ibadan In Nigeria

Abstract

This article described the perception of young mothers and selected informal maternity caregivers with no known antecedents of depression residing in two communities in Ibadan, Nigeria about maternal depression. This study is qualitative in design. We purposively selected fifty-one pregnant women and nursing mothers (young mothers) within the communities and the clinics. Thirty-three informal caregivers (Community Birth attendants (CBAs), elderly mothers and men of reproductive age) were also selected. We utilized Focus Group Discussions (FGD), Key Informant Interviews (KIIs), open-ended interviews and document consultation to obtain information about maternal depression. Discussions and interviews were digitally recorded, transcribed verbatim and analyzed using thematic analysis with Nvivo version 15. Common phrases used to describe maternal depression were “severe worrying” and “chronic unhappiness”. Young mothers opined that maternal depression was caused by lack of partner support while more of the men and elderly mothers felt spiritual causes were responsible. Symptoms of maternal depression described by the participants included prolonged loss of interest in pleasurable activities and being moody. Common consequences of maternal depression mentioned were premature onset of labour and low birth weight babies. The perceived help-seeking behaviour included special rituals and deliverance. CBAs mentioned referral to a psychiatrist as a last resort. Participants were aware of maternal depression and its symptoms, however, there were misconceptions about the causes which influenced the perceived help-seeking of elderly mothers and men. Health education interventions to dispel these misconceptions should therefore target the mothers and informal caregivers in the study area.

INTRODUCTION

“Maternal depression refers to a range of depressive conditions which can be experienced by mothers or mothers-to-be from pregnancy up to twelve months after birth,” (National Institute of Health Care Management, 2010) and “depression is a leading cause of disability worldwide” (Hyman et al., 2006). The disability effect reduces mother’s ability to care, and it disrupts the entire family (Patel and Raman, 2004). Globally, mental health care is emerging on the front global health agenda for women health (Peters et al., 2016).

The prevalence rates of maternal depression in the developed countries are as high as 12% to 16% for post-partum depression and 20% for prenatal depression (Leung, 2009). Contrary to the earlier beliefs that depression is an uncommon phenomenon in Africa, prevalence studies are showing antenatal depression’s presence in different African countries. Nigeria has 8.3% in tertiary health facilities, (Adewuya et al., 2007) 56% in Primary Health Care (PHC) from an unpublished data of Aransi 2015, 26.3% in Ghana, 28.3% in D'Ivoire, (Guo et al., 2013) and 39% in South Africa (Hartley et al., 2011).

However, in Nigeria, studies related to maternal depression have moved beyond examining prevalence to intervention: Training intervention on maternal/mental health (Odejide et al.,2002; Adeyanju 2015’s Unpublished Master thesis), expanding care on perinatal depression by (Gureje et al., 2015) and the integration of mental health into PHC (Gureje et al., 2015).

Despite the movement, studies on the perception of maternal-child health clients about mental health conditions are few in Nigeria. Only Adeponmile et al. (2017) was found in the recent time ; Perinatal Depression in Nigeria: Perspectives of Women, Family Caregivers and Health Care Providers. Meanwhile, there is a call for indigenous studies which could address local problems related to maternal depression in every country (Connelly et al., 2010); (Fisher et al., 2011). O’Mahen and Flynn (2008) explored perception and found that mothers who have myths around their knowledge of depression may probably not ask for health care help for their depressive symptoms. Exploring perception is one of the ways of discovering indigenous problems. Hence, this study explored the perception of mothers and culturally recognized informal maternity caregivers in Nigeria about maternal depression.

MATERIALS AND METHODS

Study design

This study is a qualitative study which is exploratory in design. It is a part of a larger study titled ‘Effect of training and supervision on health talk delivery on maternal depression among PHC workers in Ibadan, Nigeria.’ Within this larger study, we used Rapid Ethnographic Appraisal (REA) methodology to explore the concept of maternal depression in the community within a time constraint. (Buckhoy et al., 2016 and Mignone et al., 2009. Focus group discussion, interviews, and document consultation were employed to capture key information, diversity in views and facts about maternal depression.

Sampling

Study area and sampling

This study was carried out in Ibadan metropolis among the Yoruba people. The city has 11 Local government areas (LGAs) but only five are in the metropolis among which this study took place. Two LGAs were selected randomly out of five LGAs in the Ibadan metropolis; Ibadan North Local Government (IBNLG) and Ibadan South East Local Government (IBSELG). The two communities for the study were purposively selected from each LGA (Table1). The location for the research activities was either a community school or a community hall

Table 1.

Selection criteria for the study community

LG	Community	Reason for selection
Ibadan South East (IBSE)	Adesola	Adesola community was purposively selected because It has formidable community union and leaders who could make accessing participants from the community easy without unnecessary inducement or presenting the work as the activities of political parties in the state. Despite the fact that the community is in the metropolis, they still hold the values of Yoruba culture like language, dressing and beliefs and equally embrace health care by building health centre through communal effort
Ibadan North (IBN)	Ireakari	Ireakari community was purposively selected because It has formidable community union and leaders who could make accessing participants from the community easy without unnecessary inducement or presenting the work as the activities of political parties in the state. Despite the fact that the community is located in the metropolis, the people still hold the values of Yoruba culture like language, dressing and beliefs and equally embrace health care

Key: LG = Local Government

Study participants sampling

Study participants included pregnant women and nursing mothers (young mothers), men of reproductive age, elderly mothers (grandmothers) and the Community Birth Attendants (CBAs) with no known history of any related mental illness. (Table 2). The community leaders pulled out eight eligible people per each group and researcher randomly selected at least a small number of six per group (for active participation) for the focus group discussion. The randomization was done to reduce any unknown bias introduced by the community leaders during their initial selection (Silverman, 2013).

Table 2.

Selection criteria for participants and data collection method used with them

Local Government Area (LG)	Participants	Selection criteria	Communities		Methods
	Total	Criteria	Ireakari Community	Adesola Community
Ibadan North LG and Ibadan South East LG Community(All participants Were selected in the community except open ended interview participants who were selected in the clinic)	8 Pregnant women (6 women were selected from each community but 4 withdrew after starting)	Pregnant women in their 3rd trimester, who are willing to participate in the study	3 (3 women declined participation to attend to domestic issues)	5	Focus Group Discussion (FGD). (This method gathered information from diverse group of service users and stakeholders. Activities stopped when saturation was reached)
	13 Nursing mothers	Mothers who have ≤12months old babies who are willing to participate in the study	6	7	FGD
	13 Men of reproductive age	Men whose wives nurse ≤12months old babies. who are willing to participate in the study	6	7	FGD
	12 Old mothers	Elderly mothers who has provided postpartum care to her daughter and her daughter in-law. Who are willing to participate in the study	6	6	FGD
	7 Community Birth Attendants They were nominated by their group	Two representatives of each religion + the state president (Christian, Muslim and traditional), whose years of experience is ≥ five years who are willing to participate in the study	5	2	Key Informant Interview (KII) (This method gathered rich information about emotional care giving of the CBAs and the existence of maternal depression)
Ibadan North and Ibadan South East Clinics (randomly selected 3 clinics in each LG) 5 pregnant women were randomly selected in the each 1st and 2nd clinics while 5 Nursing mothers were randomly selected in the 3rd clinic) were first selected. The selection stopped at repetition of similar responses from participants	20 Pregnant women 10 nursing mothers who attended immunization clinic	Pregnant women in their 3rd trimester, and nursing mothers who attended immunization clinics, who were willing to participate in the study were picked at random	10	10	Open-ended interview on symptoms and consequences of maternal depression (This method validated the local terms for depression(aidunnu,ironu and irewesi okan)and activities stopped at the saturation of information
			5	5

Recruitment

Development of early familiarity with the culture of participating communities

We gained entrance into the community through the ward leaders in the LGAs. The community leaders paved the way for us to the community people and clinics. We paid more than two visits to familiarize ourselves with the community culture. We found that community leaders usually work for political parties’ leaders. With this understanding, we trained them intensively on the purpose of the study and the public health significance including the need for them to be transparent to the study participants. We gave them the criteria for selection of participants which they followed strictly as we crossed checked the instruction during the collection of socio-demographic characteristics of participants. Research assistants were recruited and they were trained to explain the purpose of the study to the participants during consents taking.

Data collection

i) Methods of data collection

Focus Group Discussion

Eight focus group discussions (four sessions of homogenous group discussion comprising of a group of pregnant women, nursing mothers, grandmothers, and men of reproductive age each was conducted in each of the 2 LGAs) (Table 2). A validated vignette in box1 was used to stimulate the discussion and the discussion for each group lasted a minimum of one hour

BOX 1. Situational vignette showing a scenario of maternal depression.

Situational Vignette: Abike

Abike, a 26 years old woman pregnant and at a stage during the pregnancy, she started feeling unhappy, moody, irritable, disturbed sleep and appetite. She even lost interest in pleasurable things and fatigued. After she gave birth she started weeping for no reason, she won’t even pay attention to her child.

Key informant interview

Seven Key informant interviews were held with CBAs who were selected by religion. It lasted for at least one hour

Open-ended interview

Thirty interviews among 20 pregnant women and 10 nursing mothers were conducted. Each lasted for 10 minutes (Table 2). All the discussions ended when there were repetitions in the responses.

Document consultation

Diagnostic Statistical Measures DSM-V(American Psychiatric Association 2013) and Yoruba dictionary (A Dictionary of the Yoruba Language) were consulted on the definition/symptoms of depression and the local name respectively.

ii) Instruments for data collection

A vignette describing perinatal depression found in the Diagnostic and Statistical Manual-Five was used. It was a scenario of the hypothetical story of maternal depression in Box1, it was used to stimulate discussion on local terms, signs, consequences, causes and help seeking for maternal depression in the focus group discussion and it lasted for one hour in each group. A Short Explanatory Model Inventory (SEMI) by (Kleinman 1981) was used to organize FGD guide questions exploring the maternal depression (Table 3). Sequentially, Key Informant Interview (KII) guide was used to explore the emotional care provision by the CBAs, and their perception of maternal depression. Finally, an open-ended interview guide using the term irewesi found in Yoruba–English was used to explore signs and consequences of depression. Finally, an open-ended interview guide using the term irewesi found in Yoruba–English was used to explore signs and consequences. (Table 2)

Table 3.

Short Explanatory Model Interview on maternal depression

Questions	Themes from questions
General description of an unhappy person	General description of sad person, local name given to state of low mood
When a pregnant woman or nursing mother experience this, what is the name given to it?	Local terms or name to describe maternal depression
What interpretation do you give such state in pregnancy or after birth?	Perceived interpretation of the state of maternal depression
Probes What causes it?	Perceived causes of maternal depression
Probes What are the consequences of this state?	Perceived consequences
Who such woman see for help about it?	Perceived help
What can be done about it?	Perceived solution
What can health workers do about it?	Perceived role of health workers in managing the condition

iii) Use of triangulation of methods in data collection

We used four methods to explore maternal depression in different settings among diverse participants. Book consultation, FGD in the community among young/elderly mothers and men, and interview among health centres users and among CBAs

iv) Use of member checking in data collection

The majority of the participants for this study did not have a telephone. Therefore, the plan had been put in place to cross-check every response that was not clear to the researcher on the spot. As a result, participants’ responses which tallied with researcher’s preconceived ideas were probed further to check researcher’s bias.

Role of researchers

The Principal Investigator is a Health Promotion and Education professional who has been trained in qualitative research by Consortium for Advanced Research in Africa (CARTA), in other to ensure the credibility of the study (Merriam 1998). Researchers trained the community leaders and two research assistants well on the protocol of the study. Researchers also obtained ethical approval from Oyo state Ministry of Health. Researchers personally anchored the discussion and the interviews because necessary probes following the research question can only be introduced by them. Researchers ensured that the voluntarism of participation was maintained throughout as participants were allowed to decline at any stage of the study. Lastly, researchers arranged for light refreshments for all the participants, as the discussion and interview lasted one hour and more.

Ethical considerations

Ethical approval was obtained from Oyo state Ministry of Health Ethical review Committee for the larger study titled “Training effect on knowledge and skill of Primary health workers in maternal depression education delivery using locally developed education materials in Ibadan Nigeria”. It was dated January 2016, and the ref no is AD/13/479. Permission was also obtained from the community leaders and clinic matrons while thumb prints consents were obtained beside participants’ codes because majority could not write. Verbal consent was taken from participants for the recording and note taking of all their responses. No name was mentioned during the discussion and interview. No name was also collected on the socio-demographic information but codes representation were used to ensure animosity.

Analysis

Thematic analysis

Recordings were transcribed by an independent transcriber. Two translators translated the scripts from Yoruba to English and the principal investigator crosschecked by reading through the translated copy alongside with the field note which was written in English and correct editing was made on the translation. The translated English script was uploaded into NVIVO as memos of sets of interviews while the readily available themes deduced from the SEMI question guide in Table 3 were imputed into nodes, and we generated more themes as induced from reading through of the memos.

Thematic analysis based on patterns was used to pull responses which were common and similar together. The themes deduced from the discussion guide included perceived causes, perceived consequences and help-seeking, while the induced themes from the discussion included perceived type of illness and perceived part of the body affected. Following this, researchers read through the memos and the responses were cross-checked with the evidence in the peer-reviewed literature to identify facts and misconception.

Positive perception (PP) and negative perception (NP) were used to categorize the perceptions. Responses which have evidence in literature were positive perception while misconceptions were negative perception. However, few themes have a mix of the two categories under them. Lastly, we summarized all the themes into three main themes for an easy explanation: 1. Awareness of maternal depression 2.Negative Perception (NP) 3. Positive Perception (PP) and the responses which cut across or differ across groups were teased out within the three themes in Table 4.

Table 4.

Summary of Perception of mothers and informal caregivers in the community about maternal depression.

Serial no	Themes Perception	Nursing mothers (FGD Participants)	Pregnant Women (FGD Participants)	Old mothers (FGD Participants)	Men of reproductive age (FGD Participants)	CBAs (KII participants)	Women from clinic (Open- ended interview Participants)
1.	Perceived seriousness of condition	NP/PP	NP/PP	NP/PP	-	-	-
2.	Perceived type of sickness MD is	NP	NP	NP	NP	NP	-
3.	Perceived symptoms of depression	PP	PP	PP	PP	PP	PP
4	Perceived consequences of MD	PP	PP	PP	PP	PP	PP
5	Perceived cause of MD	PP	PP	NP	NP	PP	-
6	“Should be” help-seeking	PP	PP	NP	NP	PP	-
7	Perceived role of health workers in caring for maternal depression	PP	PP	PP	PP	PP	-

PP Positive perception, NP Negative Perception

Study limitation

The result of our study may not necessarily represent the views of the whole Yoruba maternal-child care clients because data were collected from participants selected from only two communities in the South West (Yoruba region) of Nigeria. The focus group discussion was only conducted in two sessions for each group due to the availability of resources. By the end of the second session, information from the participants had become a repetition which could be because maternal depression was never seen as an epidemic, hence information flow was reduced. However, this repetition was assumed by the researchers to be a saturation of information from the participants.

RESULTS

i) Socio-demographic characteristics

Mean age of the all participants: Pregnant mothers 24 ±4.4years, nursing mothers 32±6.9 years, elderly mothers 65±9.4 years, men of reproductive age 39± 5.4 years and CBAs 51±15.9 years. The majority, 80% of them are in monogamy marital union and they all achieved at least, Primary school education. Only one person has National Diploma in Education (NCE). Christianity and Islamic religion are found among them.

ii) Awareness of maternal depression

The term “irewesi” was found in the Yoruba-English Dictionary and it means depression. Likewise in the DSM-V, the term postpartum and perinatal mood disorder was found for maternal depression. The participants commonly used these two terms; ironu (severe worry) and aidunnu (chronic unhappiness) for depression. They added ninu oyun ati leyin ibimo (in pregnancy and after delivery) to describe ‘maternal’. (See Table 5 below). There were responses about personal experiences or knowing someone who experienced the described condition in the vignette.

The thinking I experienced when I was pregnant, the same I experienced after birth. I did not talk to any one since the night I delivered until the third day. I did not say anything to a single soul. (Nursing mother 37years Ireakari community FGD) During this period, whenever I wanted to carry my child once I remember all the bad words my husband spoke to me I will not be happy to carry the child (Nursing mother 38years Adesola community FGD). The one I have seen before was that, I did not know that this person was pregnant because the pregnancy has not developed well, but when we talked she will just be saucy, at last, she told us that nobody should move near her.(Pregnant woman 32yrs Adesola community FGD).

Table 5.

Terms for maternal depression mentioned among participants

Term for condition in vignette	Explanations and reference
It is severe thinking/worry (Ironu) or chronic unhappiness (aidunnu) for women during pregnancy or after delivery	It occurs within the heart (All young mothers, all men of reproductive age, all old mothers and all CBAs)
It is called sickness of the mind (are okan) for women during pregnancy or after delivery	It is caused by poverty, when pregnant women or nursing mother does not have money (38 years old man IBSE Adesola community FGD)
We can call it melancholic personality (osonu).	If one is extrovert (jovial), she will but pour out her mind to someone, but if one is an introvert, till she kills herself with thinking, something which is small is what will kill her. (51 years old, older woman IBSE adesola community)
This is what is called wounded heart (ogbe inu) for women during pregnancy or after delivery	If one is extrovert (jovial), she will but pour out her mind to someone, but if one is an introvert, till she kills herself with thinking, something which is small is what will kill her. (51 years old, older woman IBSE adesola community)
It can also be called anxiety (ikoleya)	or a disturbed heart (idaamu okan) (60years old CBA KII)
We call it low mind or down mind (Irewesi okan) for women during pregnancy or after delivery	(35 years old pregnant woman NCE holder IBSE Adesola community)
It is puerperia psychosis (abisinwin)	Look, we have seen it before, abisinwin, that is what it is called. Even in pregnancy, it’s the pregnancy that protects her which does not make it be known, after giving birth it will now be seen, We don’t call it anything in pregnancy until she gives birth (51 years old, older woman IBSE adesola community)

iii. Positive Perception

Perceived signs of maternal depression (Table 6 below)

Table 6.

Perception of signs of maternal depression across among participants

Loss of interest in pleasurable thing: (moody, isolation plus being irritable) this is (daadi), keeping to self (didawa), being tearful or crying (ekun sisun) (open –ended interview participants)

Crying: Some people cannot endure hardship, to the extent that they will be crying at a little problem that it is the terrestrial power that is at work. {Man 37yrs IBN Ireakari community FGD}

Keeping to self: One will want to keep to one’s sel, what Yoruba calls (daadi),, they would say do not go to her, she is keeping to oneself (daadi) (51 years old older mother IBSE adesola community FGD)

Poor self-care: The person’s mode of dressing will not look normal, her hair will be unkempt, where she supposed to wear good shoe to, and she will just put on slip on (38 years old man IBSE Adesola community FGD)

Low mood: My own contribution is that if someone is not happy, the person might be moody and bend her head down, if one now asks what the problem is with her, the person will now answer that she is not just happy that he or she cannot explain what the problem is but when one finds out what the problem is you now discover that the person does not have money {Man 39yrs IBSE Adesola community FGD}

Lack of attention and concentration: “Her mind will not be in the discussion” (51years old grandmother IBN Adesola FGD)

Low mood: Will be down and thinking, she will not be jovial (50years old grandmother IBN Adesola FGD)

Loss of interest in pleasurable things: for example, if there is a function to attend and they ought to purchase group attire such person will say what does she wants to go and do there, that is it in her present condition that’ll be attending function, that am not going, what’s her joy that will be going for functions and buying cloths, will not be happy with the function because the brooding and that’s how to know when someone is brooding (60 years older mother, Adesola IBSE).

Isolation: The person will want to be isolated in order to think, somebody who is not happy cannot seat with anybody, she place hands on the chin (25 years old Nursing mother IBSE Adesola Community FGD).

Low energy: When one is not happy, one cannot single handedly do anything well, it is what one is thinking about, one will continue to think about that what can I do to get out of this problem (25 years old Nursing mother IBSE Adesola Community FGD)

Heart beat: if one is not happy, her body will not be healthy, such person will be in half health, the heart will be sounding (ku,ku, ku,ku,) once the heart makes such sound, (ku ku ku ku), it leads to raised Blood Pressure, (80years old grandmother IBN Ireakari FGD)

Irritability: She will be touchy, she will not be able to smile no matter how lively her environment is (25 years old pregnant woman IBN Ireakari community FGD)

Thinking: She will be thinking all the time. (22years old pregnant woman IBSE Adesola community FGD)

DSM-V’s documentation shows the following criteria for perinatal depression: “Depressed mood or anhedonia (decreased experience of pleasure in usually pleasurable experiences) plus four or more symptoms. Depressed mood and anhedonia plus three or more of the following symptoms: weight or appetite disturbance, sleep disturbance, psychomotor disturbance (agitation or psychomotor retardation), fatigue or loss of energy, difficulty concentrating, feelings of worthlessness or guilt, and recurrent thoughts of death”

Perceived consequences of maternal depression

Pre-eclampsia

Thinking is not good at all for pregnant women because they may have “giri” pre-eclampsia due to raised BP (All CBAs KII)

Inter-uterine death/ Premature delivery

The environment, where the child lives in the womb, will not be healthy, hence the baby will leave it prematurely (CBA KII, Christian and traditional)

Low Birth Weight

The baby such a mother will bear will not have weight because she will not feed well during pregnancy (CBA KII, Christian and traditional and All old mothers)

Marital conflict

Yes, the husband will marry another wife (ALL MEN: IBSELGA ireakari and adesola community FGD). She and the husband cannot have a fruitful marriage. There will not be love between both of them, the husband himself will not be at peace (25yrs pregnant woman IBNLGA FGD)

Kwashiorkor

The baby will not be okay, the baby that does not feed well. How do you want the baby to look like, she did not breastfeed the baby, and when a mother is breastfeeding the baby always look into their mother’s eyes. However, the baby which has been breastfeed with sadness will not be good looking…‥if a baby is well breastfed, the baby will look at her mother and be happy, otherwise, the baby will always cry. It is not a good thing for the baby, the baby might even have kwashiorkor from underfeeding (38 years old man IBSELGA adesola community FGD)

Perceived role of health workers in addressing maternal depression

In response to the questions on help seeking, participants responded based on their experiences. The young mothers perceived that health workers should be able to take care of maternal depression but such service is not yet available. They also expect health workers to invite husbands to the clinics occasionally for education. The elderly mothers and men expect warm attitude from Health workers and why the CBAs are preferred.

Such care is not well set up at the same time, it exists. The reason why I said it is not well set up is that the nurses do not yet understand this kind of problem in the scenario. If they do they will educate us about it regularly. There is also need to invite husbands with wives to the hospital (32years old nursing mother IBSELGA Adesola community FGD)

The nurses can be irritable but, it is someone who is pinched by thorn supposed to look for the person who has a blade to remove it. Any insult or maltreatment family member receive during caring for loved ones, one overlooks it but Nurses should educate their service users to worry less (80years old grandmother IBN ireakari community FGD)

You see, some of this nurses are not nice and simple,….I said before, there is supposed to be a seminar from time to time for the nurses on patience in human relation. You know poverty could make one miss direction, which is the reason most people go to all this Mission Community Birth Attendants house to deliver their babies coincidentally, the CBAs too are very kind to them (50years old man IBSELGA Adesola community FGD)

Health workers are very useful because we refer to them, after doing all we could do to help the mother, if no changes occurs we refer to health facilities(70 years old Christian CBAs IBNLG).

Negative Perception

Perceived risk for maternal depression

Young mothers mentioned the lack of partner’s support and debt, men mentioned the lack of money or job, elderly mothers mentioned the death of an adult child, CBAs mentioned partner violence and lack of money as risk for depression. However, when the scenario (maternal depression) in the vignette was read, there were diverse perceptions; men and old women mentioned more of spiritual attributed causes than social causes (negative perception) in Table7.

Table 7.

Perception of attributed causes/risk factors for maternal depression

Perception of attributed causes/risk factor	Quotes and references across the groups
Conflict with partner/partner violence	So many women thinking now, not that somethings is wrong with them or any part of their body, what the men cause is more, they do not what to do anything than to disorganize things, they destroy and they beat. It is women who will choose lift it from their mind so that it will not turn to another thing in her body (FGD 39 years old Nursing mother IBNLGA Ireakari community FGD).Women report their husband beating them which makes them very sad (67yrs CBA IBN)
Debt or financial problems	There are some who are in debt, if the debt is too much and one has been thinking too much, if there are no means of settling the debt, such can kill his/herself suddenly (23yrs old Nursing mother IBSE Adesola Community, All male participants FGD
Spiritual Factors	We have seen such before, it has happened before, anyone who is evil spirited (emere) who belongs to cult, in a situation where she had said that the day she will give birth, she will return to spirit world but she was arrested by prayer, that kind of feelings happen (70years old grandmother IBN Ireakari community FGD) The mother of the woman with the emotional problem might have offended some people with the words of her mouth. As a result of this, the wicked people might have shot evil arrow ……‥ (70years old grandmother IBN Ireakari community FGD)
	To support that, it might be prayer or go on tradition line that will work. Like one of my sisters, she got married to an Ife man, who overlooked some vital history of his background. It was after his wife delivered that he remembered to tell her that for the first seven days after delivery she will be eating food that was cooked without salt or seasoning, the one Yoruba people call ”Ate” (bland) food. That is their traditional way of protecting their babies and mother from “abisinwin” puerperia psychosis. One needs to find out the tradition of the family one wants to marry. (50years old man IBSE Adesola community FGD).

Perceived help-seeking behaviour

Perception of help-seeking behaviour for maternal depression were of diverse views which were similar to the diversity found in the perceived causes. Most young mothers mentioned health care seeking and the mother of the woman as preferred postpartum career, while elderly mothers and men who expressed spiritual factors risk factors also mentioned spiritual help-seeking (Table 8 below). Their preferred postpartum career was the mother-in-law according to culture. However, the young mothers mentioned emphatically that help-seeking behaviour to health problems in the family of husband matters a lot.

Some people if they are using traditional ways in their husband family she may follow the same step, but if she did not agree with it, she might go to the hospital, but for me hospital is better than traditional medicine. (Nursing mother37yrs Ireakari community FGD).

Table 8.

Perception of help-seeking for maternal depression across groups

Hospital help depending on one’s family help seeking: The hospital is better, but there are some people that usually go for traditional medicine in the family, (25years old nursing mother IBNLGA Ireakari community FGD)

Hospital help depending on the husband’s family help seeking: Some people if they are using traditional ways in their husband family she may follow the same step, but if she did not agree with it she may go to the hospital, but for me hospital is better than traditional medicine (29years old nursing mother IBNLGA ireakari community FGD)

Hospital with Christian prayer from own mother: It is the hospital which will help, in the traditional one, they will just be beating, and they will just be punishing her for nothing. If she is in the hospital if the mother is a Christian, they will just be helping her with prayer ……‥ (32years old nursing mother IBSE Adesola community FGD)

Hospital can help, like UCH, they will just be joking with her for example, like in the health centre, you will see that they really make things lively, they talk with us they told the usefulness of the injection (immunization) we have come to collect. The four immunization was explained in full, if someone like Abike (in the vignette) is there to hear the way they talk, Her mind will settle gradually, but if it is the traditional one, they will just be beating her, as if one is being punished upon suffering. Beating cannot help her, except she is in the midst of people, joking with her, she should be in a place where she will be happy all the time, and little by little her memory and emotion will pick up (39 years Nursing mother IBSE LG FGD)

Spiritual help seeking: If such things happens,(the emere issue) they would say when she starts disturbing her relatives, when she’s grown up she up till the time of giving birth, the family will be asked to bundle up a load for her spiritual group (eru egbe) so that the spiritual group does not disturb her again. So that she can be separated from the group(70years older mother IBSE LG FGD)

Spiritual Help seeking: It cannot be cured with medicine. (37years old man IBN Ireakari community FGD)

Thank you, you see there are some diseases that if they ask you from hospital to go for x – ray and nothing is detected they will ask her to go for alternative medicine (i.e traditional medicine) to solve the problem. It means that there is no help for her. (37years old man IBNLGA Ireakari community FGD)

HA! There is no doctor that can cure sorrow, its only God that can take away sorrow from the life of a human being it is the only sickness that the doctor can treat. They cannot heal sorrow in the life of human being because there is no X – ray that will reveal sorrow…‥ (37years old man IBNLGA Ireakari community FGD)

The only thing is that it requires love and care to care of such state. We may give novagin or piriton, we pet her, give pap (eko), she will sleep off and get better(65 years old Traditional CBAs)

We ask her to bring her husband, we counsel both of them, if there is no improvement, we do deliverance, if there is no improvement we refer to psychiatrist (55years Christian CBA)

Postpartum care and support: The path way to care is traditional because such does not have medication. Naturally the care of pregnant women and nursing mothers should be both traditional (spiritual help seeking, Christian way, Muslim way or juju) and medical. The cultural way of taking care of nursing mothers is that the mother in law moves in with the couple or the nursing mother goes to the mother in law for care but the fact that women do not want their mother in law again, who knows the traditional practice of the husband’s family, this is the cause of problem for most younger women.(Old mothers and men of reproductive age)

The mother of such woman should be with her during postnatal care, because mother in law will add to her problem (All young mothers except two)

iii) Mixed Positive and Negative Perception

Perceived part of the body affected by depression

Participants were not too sure if maternal depression is a physical illness or a mental illness, if it is the heart or the brain which is affected but all of them touched the heart except only one person who touched the brain as the affected part of the body when experiencing depression.

Yes, we breathe and think, we do both from the heart, her heart is involved (all men, young mothers, and old mothers IBSE Adesola community FGD).

Yes, it is both the heart and the brain (all men, young mothers, old mothers IBN Ireakari community FGD)

Perceived severity of maternal depression

The perception of participants about the symptoms severity of maternal depression was a mix of fact and misconception. The participants did not perceive maternal depression as an illness in its mild state but they said such a person is not well, the husband or her mother could be of help if she decides to speak out but in the severe state, it can lead to hypertension or brain problem. These are facts. They also said that a depressed mother should not breastfeed, this a cultural belief and it is a misconception.

Some thinking or worry can lead to brain damage, it is not that everything is all about spiritual, if thinking is too much in the body and everything is not handed over to God………., (51years old mother IBSELGA Adesola community FGD)

We make sure her child does not suck her breast, because such breast which she sucks from her mom will become a problem (bad luck/misfortune) for the child. It is prayer one will continue to pray for her (51years old mother IBSELGA Adesola community FGD, 41yrs nursing mother IBSELGA Adesola community FGD)

DISCUSSION

The findings of this study show that mothers and informal maternity caregivers in the selected Yoruba communities in Nigeria, were aware of some facts about maternal depression, and they also had misconceptions about it. Findings also show that maternal depression exists in the Yoruba culture, as similar experiences were cited by the participants. The experiences sited corroborate the fact that depression exists in all culture (Affonso et al., 2000). However, the possible ways help could be sought depend on how the probable cause is perceived and how such help is sought in the husband’s family. Mother in law and wife’s mother were controversially expressed as postpartum caregiver for a depressed mother. Furthermore, participants expressed that the care of maternal depression was not available in the Primary health care centres and if it should be made available, partners/husbands of women should be involved. Health workers also have to be trained to be warm with patients who have such condition.

The terms for depression among FGD participants included; ironu (severe worry) or aidunnu (chronic unhappiness) and irewesi okan (low mood in the mind) while the Yoruba dictionary’s term is irewesi (low mood). These terms revealed that there is no two Yoruba words for maternal depression as it obtains in English language. All the local terms mentioned for depression has to end with the phrase “in pregnant woman or nursing mother” (maternal) to mean maternal depression. For example, Irewesi okan ninu oyun ati leyin ibimo (depression in pregnancy and after delivery), but puerperal psychosis has one-word abisinwin.

Positive perception were found around signs and consequences facts mentioned by participants. Strikingly, despite the diverse terms used for maternal depression mentioned by FGD and KII participants, the signs and symptoms mentioned were same as the ones mentioned by the open-ended interview participants who were interviewed using the Yoruba dictionary term irewesi (low mood). They were also same as the diagnostic symptoms of peripartum depression described in the DSM-V. To corroborate this, the symptoms or signs of maternal depression mentioned by participants of this study are also not different from what sufferers of maternal depression expressed in a recent study in the Yoruba setting of Nigeria (Adeponle et al., 2017). However, there is no difference between the symptoms of maternal depression and the depression experienced by the general population except the context of a baby in maternal depression and when it starts (onset).(American Psychiatric Association, 2013).

Perceived consequences that during pregnancy the baby may become affected to the extent of having a low birth-weight can be buttressed by a study carried out in South Africa which shows an association between depressive symptoms in pregnancy and low birth weight (Andrew and Charlotte, 2015). Participants also mentioned that the child's growth might be retarded in the womb, similarly, another study found a relationship between increased cortisol levels in a depressed mother with restricted fetal growth, low birth weight and gestation birth age of the baby (Diego et al., 2009). One other consequence mentioned by the participants was that when a pregnant mother is depressed, the mother may have raised blood pressure and pre-eclampsia, this is related to the study which found depressive symptoms to be risk factors for pre-eclampsia (Qiu et al., 2007). Concurrently, Participants expressed that depression does not only affect pregnancy outcome, but the born baby, older children, and husband will suffer neglect. As a result, thoughts of self-harm or death may fill the mother's mind. These findings corroborate the fact that maternal depression disrupts the family, individuals' life and child's development (Patel and Rahman, 2004).

The negative perception; perceived risks and help seeking included misconceptions. The diversity in the perception of the risks for maternal depression and help-seeking behaviour among the young mothers and the selected caregivers revealed associations. Young mothers attributed causes of maternal depression to a weak relationship with husband, rejected pregnancy, bereavement, and financial problem, these are similar to the findings of Milgron et al. (2008) in Australia. In their prospective study on the antenatal risk of postpartum depression, marital conflict, bereavement, unwanted pregnancy and financial problems were found. The selected caregivers had different views. They attributed maternal depression to spiritual reasons, emere (spirit group membership) neglect or not-observance of rituals of husband’s family and spirit husband’s attack.

The perceived attributed causes was found to link perceived help-seeking. Just as attribution theory explained that perceiver uses information of causal judgment to link how help should be sought. (Fiske et al., 1991). The informal caregivers had spiritual myths in their perception of the condition compared to the young mothers. However, the former are the primary maternity caregivers by culture. Medical health care seeking was mentioned among young mothers while informal caregivers mentioned spiritual help-seeking or both. On the other hand, young mothers will likely follow husband’s family help-seeking, either spiritual or medical. More so, the care of maternal depression was not yet available in the health centres. The CBAs said they always provide spiritual help as the first line of help and last line of help is making a referral to psychiatry hospital. Their expressions show that there is still inadequate understanding of emotional and mental health care. Young mothers were more enlightened because they were exposed to routine maternity health education in the clinics. The elderly mothers’ and men's perception were similar to the spiritual knowledge around mental illness before the 18th century (Nemade, 2017). The men of reproductive age had such old perception because the protocol of the maternal child health care does not mandate their involvement. Therefore, there is the possibility of multi-approach (spiritual and medical) to help-seeking for maternal depression in the community.

One perception which emerged among the participants was the preferred caregiver in the postpartum period for a depressed mother, which was controversial. Elderly mothers and men expressed preference for husband’s mother according to culture while young mothers expressed preference for their own mother or mother figure. The reason for this could be explained by Aderibigbe et al’s study which found from their respondents that the presence of the mother in law as a postpartum caregiver could be stressful (Aderibigbe et al., 1993). However, the decision of men culturally hold air in every culture in Nigeria and the influence of informal maternity caregivers cannot be overlooked.

The mixed perception revealed that participants were not sure of the part of the body affected by depression and the severity of maternal depression. All the participants linked depression more to the heart than to the brain. This linkage is quite contrary to the definition of depression by Merriam-Webster Dictionary (1998) that “Depression is a state of being depressed, a state of feeling sad: a mood disorder marked especially by sadness, inactivity, difficulty with thinking and concentration, a significant increase or decrease in appetite". All the processes mentioned can only take place in the brain, not the heart. On the other hand, the misconception around the perceived seriousness of the condition was that a mother who is sad should not breastfeed because she will transfer bad luck to the child. The idea shares similarities with the Yoruba taboo that mental illness can be transmitted through breastfeeding, these ideas are also contrary to evidence in the literature. The deprivation of breastmilk will only lead to undernutrition (Onayade et al. 2004). The issue of breastfeeding and postpartum depression is controversial, but the argument found in the literature is only based on the question that “does breastfeeding reduce the risk for Postpartum depression or not?” (Ruta et al., 2014).

However, peuperial psychosis abisinwin was commonly mentioned for maternal depression as it was believed that maternal depression starts in pregnancy, but the child in the womb protects it from being psychotic until after delivery. Similarly, Adewuya et al. (2006) cited and disagreed with the Yoruba belief that pregnancy is a protection from depression because it is a source of joyful expectation. Moreover, participants were not able to regard maternal depression as an illness in the mild state but it was perceived that it can lead to illness like hypertension or mental illness at the severe state. They also had a sense of the measure of it as mild or severe, which is similar to what obtains in Edinburg Postnatal Depression Scale (EPDS)(Cox et al.,1987). In the mild state, sharing the problem with close relation was perceived to be a solution, and this corroborates the findings of (Rickwood et al., 2005) that the next step after awareness of the emotional problem among women seeking help was seeking help among close relations.

Health workers are expected to involve men in maternal mental health care and to provide mental health service to mothers actively through health talk coupled with warm behavior. Hence, training of health workers to provide active service in health education addressing maternal depression in the clinic or public vis a vis partners’ involvement in maternal-child care/ maternal mental health care will go a long way to clear misconceptions about the condition so that help could be appropriately sought.