i

ASSOSA UNIVERSITY COLLEGE OF HEALTH SCIENCES DEPARTMENT

OF MIDWIFERY

PREVALENCE AND ASSOCIATED FACTORS OF POSTPARTUM

DEPRESSION AMONG MONG MOTHERSIN ASSOSA HOSPITAL, ASSOSA,
ETHIOPIA, 2019.

BY: DAWIT TESFAY (BSCMW.)

A RESEARCH PROPOSAL SUBMITTED TO ASSOSA UNIVERSITY,

COLLEGE OF HEALTH SCIENCE, DEPARTMENT OF MIDWIFERY IN
ACCOMPSHMENT OF BSC MIDWIFERY

MAY, 2019
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ASSOSA, ETHIOPIA
ASSOSA UNIVERSITY
COLLEGE OF HEALTH
SCIENCES DEPARTMENT OF
MIDWIFERY

PREVALENCE AND ASSOCIATED FACTORS OF POSTPARTUM

DEPRESSION AMONG MOTHERS IN ASSOSA HOSPITAL, ASSOS,
ETHIOPIA, 2019.

A RESEARCH PROPOSAL SUBMITTED TO ASSOSA UNIVERSITY,

COLLEGE OF HEALTH SCIENCE, DEPARTMENT OF MIDWIFERY IN
PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR DEGREE
PROGRAM IN MIDWIFERY

MAY, 2019

ASSOSA, ETHIOPIA
 iii

Summary

Mental health problems in mothers can lead to increased maternal mortality and morbidity. Post
partum depression is one of the major global maternal mental health problem which leads to
greater maternal mortality rate related with suicide. Globally, about 10% and 13% of pregnant
women and who just gave birth respectively are suffering from mental health problems. Almost
all women are vulnerable for mental health problems during pregnancy and after childbirth in the
first year, but there are major factors which can lead a woman for postpartum depression. The
aim of this study is to assess the prevalence and associated factors of postpartum depression
among mothers attending post partum care in Asossa hospital, Assosa, Ethiopia, 2019. Facility
based cross-sectional study design will be used to collect data on the prevalence and associated
factors of postpartum depression in Assosa hospital , Assosa, Ethiopia from May to June, 2019.
Mothers who come for post natal care and vaccination within six month of delivery will be
included in the study and sampling will be done by consecutive sampling until the required
sample size 259 will be achieved. The proposed total budget to conduct this study will be
21083.00 ETB.
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Table of contents

Summary ........................................................................................................................................ iii

Table of contents ............................................................................................................................ iv

List of abbreviations and acronyms ............................................................................................... vi

1. Introduction ................................................................................................................................. 1

1.1Background ............................................................................................................................ 1

1.2. Statement of the problem ..................................................................................................... 2

1.3 Literature review ................................................................................................................... 3

1.4 Rational of the study ............................................................................................................. 5

2. Objectives ................................................................................................................................ 6

2.1. General objectives ................................................................................................................ 6

2.2. Specific objectives................................................................................................................ 6

3. Methods and Materials ................................................................................................................ 7

3.1 Study area and period ............................................................................................................ 7

3.2 Study design .......................................................................................................................... 7

3.3. Population............................................................................................................................. 7

3.3.1. Source population .......................................................................................................... 7

3.3.2 Study subjects ................................................................................................................. 7

3.4 .Inclusion and exclusion criteria............................................................................................ 7

3.5. Sample size determination ................................................................................................... 8

3.6 Sampling procedure and technique ....................................................................................... 8

3.7 .Variables of the study ........................................................................................................... 8

3.8. Operational definitions ......................................................................................................... 9

3.9 Data collection tool and procedure........................................................................................ 9

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3.10. Data quality control management .................................................................................... 10

3.11 Data analysis procedure .................................................................................................... 10

3.12. Ethical Considerations...................................................................................................... 10

3.13. Dissemination and utilization of results ........................................................................... 11

4. Work plan.................................................................................................................................. 12

5. Budget break down ................................................................................................................... 13

6. References ................................................................................................................................. 14

7. Annexes..................................................................................................................................... 16
 vi

List of abbreviations and acronyms

CDC Communicable disease controls

CI Confidence interval

CMD Common mental disorder

DMS IV Diagnostic and statistical manual of mental health disorder

EPDS Edinburg Postnatal Depression Scale

HIC High income countries

HSDP IV Health Sector Development Program

LLICs Low and lower Income Countries

MDGs Millennium Development Goal

PHC Primary Health Care

PI Principal Investigator

PNC Postnatal Care

PPD Postpartum Depression

SPSS Statistical package for social sciences

WHO World health organization

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1. Introduction
1.1 Background

Depression is a debilitating disorder with symptoms such as depressed mood, tiredness,

insomnia, lack of energy, low self esteem and lack of interest in ones environment.
Postpartum depression also known as postnatal depression is a non psychotic depressive disorder
of variable severity and it can begin as early as two weeks after delivery and can persist
indefinitely if untreated. The illness can cause distress and impair a mother’s ability to carry out
her normal tasks, care for herself and care of her baby(1).
Puerperal mental disturbances can be categorized in to three in order of ascending severity:
maternity blues, postpartum depression and postpartum psychosis (2).
Maternity blues is a common, benign, transitory condition occurring in the first days after
delivery. Its incidence ranges from 30 – 80 %. Maternity blues typically begins 3-4 days after
delivery and peaks on days 4-5 (3).

Postpartum depression is the other category by which Onset can range from 24 hours following
delivery to 4 - 6 weeks or 6 -12 months postpartum. However, symptoms are generally seen
within the first month.12 Onset can be abrupt or gradual. Untreated postpartum depression may
last for 3 to 14 months. Symptoms of postpartum depression include: depressed mood,
tearfulness, mood swings, inability to enjoy activities that used to be of interest, sleep
disturbance, fatigue, difficulty concentrating, and altered appetite. However, postpartum
depression is a non-psychotic depression and only very rarely will a woman carry out harmful
thoughts (4-7).
Postpartum psychosis is a severe and rare disorder with an acute onset after a symptom free
phase. Most postpartum psychoses begin within the first 3 weeks after delivery. Its incidence is
0.1 – 0.2 %. Symptoms include delusions, hallucinations and gross impairment in functioning.
Affective symptoms are most prominent (3).
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1.2. Statement of the problem

Mental health problems are a major public health issue for women of reproductive age (15–44
years) in both high and low-income countries. About 7% of the global burden of diseases among
women is contributed to mental health problems, especially among women of reproductive age
(8, 9). Post partum depression is one of the major global maternal mental health problem which
leads to greater maternal mortality rate related with suicide (10).

Globally, about 10% and 13% of pregnant women and who just gave birth respectively are
suffering from mental health problems .In developing countries it is more higher 15.5% through
pregnancy and 19.8% after child birth. Studies show that the prevalence of postpartum
depression is 9.2% in Sudan, 28.8% in Pakistan, 43% in Uganda, 31.7% in South Africa and
56% and 34% during pregnancy and after childbirth respectively in Jamaica. On the other hand
reports show that self reported postpartum depression in 17 U.S states ranged from 11.7% to
20.4% ,and 8.4% and 8.6% in Canada for minor and major mental disorders(10-13,18,19,20) .

Almost all women are vulnerable for mental health problems during pregnancy and after
childbirth in the first year, but there are major factors which can lead a woman for postpartum
depression (10). This include poverty(13), unintended pregnancy(3, 18),low social support(1,
4),low educational level(19-21), stress full life events and traumatic experience (8, 12),domestic
violence (12), previous psychiatric illness(1, 23) ,unemployment(21, 24) , poor husband
support(9) and losing a baby or having an infant who is hospitalized (16).

Postnatal depression affects 10-15% of mothers (10, 14, and 15). Untreated postnatal depression
is associated with impairment of the mother’s ability to care for her infant, marital instability,
impairment in the cognitive and emotional development of the child and increased utilization of
health care services. Yet most of these mothers are unrecognized, undiagnosed and therefore not
treated (15, 16). In severe cases mothers may commit suicide due to that children’s growth, mother-
infant attachment and breast feeding will be negatively affected. But treating this disorder helps to tackle
this troubles in addition it will help to reduce malnutrition and diarrhea of children’s (10).
 3

Although prior studies provide valuable information, most were conducted in highly developed
countries and regions and there is little research examining the prevalence and determinants of
post partum depression in developing countries, such as Ethiopia. In addition, research on factors
that contribute to postpartum depression is still scarce in Ethiopia. These gaps in previous studies
of postpartum depression signal a need for research that can shed light on what percentage of
mothers during six week postpartum period will have depression and the multiple factors
associated with postpartum depression.

1.3 Literature review

The postnatal period is well established as an increased time of risk for the development of
serious mood disorders. Which can range from transient “ blue” immediately following child
birth to an episode of major depression and even sever, incapacitating, psychotic depression. The
problem occurs in 10-15% of women’s after childbirth (2).

1.3.1 Prevalence of postpartum depression

Prevalence rates of PPD vary widely from region to region, from race to race and among women
of the same cultural backgrounds (1, 2,). According to the WHO global review of literature 10-
15% of women in developed countries experienced non psychotic clinical depression in the year
after giving birth. Most of them experienced this health problem in the first five weeks of
postpartum period. The rate of postpartum depression was higher in developing countries in
which 15.6% of women developed during pregnancy and 19.8% after child birth (9).

According to the CDC report of 2012 the global estimation of post partum depression ranges
from 5%-25%, but the procedural discrepancy with the studies formulate the real prevalence rate
unclear (5). Considering the prevalence of PPD on continent basis in India ,Germen, Canada,
Greenland, brazil and Portugal had a prevalence of 23% , 6.1%, 8.46% (minor/major) and 8.69
%( major) and 8.6% ,7.2% and 17.6% respectively (10, 21,).

A study done in Lebanon on the prevalence and determinants of post partum depression among
post partum women’s show that, the overall prevalence of PPD was 21%(12). Similarly
according a study carried out in Pelotas, a city in the Southern region of Brazil, between October
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and November 2000, on prevalence of postpartum depression and associated factors among post
natal mothers show that the prevalence of post partum depression was 19.1%(22). A recent study
carried out in Enugu Hospital, South East Nigeria, 2015 among mothers who attended
postpartum clinics from two teaching hospitals and three private hospitals on the prevalence of
postpartum depression confirmed that the prevalence was 22.9%(23).

A cross-sectional survey was conducted in two primary health care facilities in Mzuzu city,on
prevalence and determinants of depression among post partum mothers. The result of this study
confirmed that the prevalence of depression among post partum mothers were 12.4% (17). From
a study done in Uganda in a peri urban primary care centre, the Prevalence of major depression
at six weeks postpartum was 6.1%(24). In addition according to a study done in South Africa
Cape Town to determine the prevalence and correlates of mood disorders in pregnancy, found
that prevalence rate was 39%.The importance of this was that evaluation of antenatal depression
was important as it is a predictor of PPD(1). a prospective study on the socio demographic and
clinical features of PPD among Turkish women in 2008, PPD was responsible for about 15.4%
of all depressive mental disorders (25).

In sub Saharan countries the problem is also getting an attention for example in 2010-2011 a
community based study in prenatal screening for PPD was conducted in south Africa and related with
it the prevalence was known to be 31.7%(1),and according to a study which was conducted by the
year 2013-2014 in Sudan the prevalence was 9.2%(13) in other sub-Saharan countries like Uganda
the prevalence was as high as 43% (19) .

A community based study on the prevalence and associated factors of postpartum depression
among postpartum mothers in western zone benshangul point out that significant proportion of
mothers (19%) who gave birth in eastern benshangul demonstrated depression n during post
partum period (16).

1.3.2 Determinant of postpartum depression

Research suggests that women with various risk factors related to health and environment may
have a higher likelihood of developing a postpartum depressive disorder. It is generally believed
that risk factors can help identify women who may develop postpartum depression (2).
Consequently; these women may receive appropriate care during pregnancy or follow-up after
 5

delivery. Regarding factors associated with maternal postpartum depression, existing studies
have examined predictors from socio-demographic, psychological, and cultural perspectives.

Prior researchers have found that lower maternal education level and poor family economic
status were related to a higher prevalence of postpartum depression (26). Empirical literature has
consistently demonstrated that poor relationships with husbands or family members (i.e.,
relationships with mothers and/or mothers-in-law) are linked to a greater likelihood of women
experiencing postpartum depressive symptoms post- delivery (22). Furthermore, studies have
shown that a lack of psychological preparedness for pregnancy and insecure attachment styles to
partners (i.e., avoidance and anxiety) are associated with a higher risk of postpartum depression
(27). Moreover, there is a preference for giving birth to a boy in some Asian societies, and the
association between infant’s sex and postpartum depression has attracted scholars’ interest (22).
Several studies based in Asian contexts (e.g., India, Hong Kong, Vietnam) have shown that the
delivery of a baby girl led to a greater risk of postpartum depression among women compared to
the delivery of a baby boy (27). Other factors thought to put women at risk of depression in the
postpartum period include low social support, depression during pregnancy, preference of sex of
the baby, history of depression (12,22)

1.4 Rational of the study

Early identifying maternal mental health problems and associated factors are potentially an
effective strategy for decreasing maternal mortality and morbidity related to mental health
problems. So early screening for postpartum depression would improve the ability to recognize
these disorders and hence necessitate enhanced care that ensures appropriate clinical outcomes.
Taking this into consideration, this study will be conduct to identify the prevalence of post
partum depression and its associated factors which will help in the design and implementation of
postnatal mental health assessment intervention in all child bearing women. The evidence from
this study will assist policy makers and program planners to take action to reduce morbidity and
mortality related with postpartum depression, So that they can take appropriate measure which is
suitable for our country. In addition to that the communities will gain a better insight about the
factors that may cause postpartum depression in postpartum women. Lastly it also helps other
researchers use this research’s findings as a stepping stone for additional research on the same
topic.
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2. Objectives
2.1. General objectives

To assess the prevalence and associated factors of postpartum depression among mothers
attending post partum care in Assosa hospital, assosa, Ethiopia, 2019.

2.2. Specific objectives

To determine the prevalence of postpartum depression in Assosa hospital, Assosa, Ethiopia, 2019.

To identify factors associated with postpartum depression in Assosa hospital, assosa, Ethiopia,
2019.
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3. Methods and Materials

3.1 Study area and period

The study will be conducted from May to jan 2019 Assosa hospital, Benshangul, Ethiopia.
Assosa is found at 676 Km weast of Addis Ababa with latitude and longitude 130
29’N39’E13.4830N39.4570E and at elevation of 2084 meters above sea level. It is Assosa 4
Kebeles which are named corner by corner. Assosa has 1 governmental hospitals, 1
governmental health centers all of them are giving delivery service, postnatal care according to
regional health bureau. Assosa hospital starts to give service in april, . currently it serves about
population in its catchment area of the Oromia, Amhara regional part of Ethiopia .

3.2 Study design

Institutional based cross-sectional study design will be used to collect data on the prevalence and
associated factors of postpartum depression in Assosa hospital, Assosa, Ethiopia from May to
June, 2019.

3.3. Population
3.3.1. Source population

The source populations were all women who came for postnatal care and vaccination services
within 6 weeks after delivery in Assosa hospital, Assosa, Ethiopia.

3.3.2 Study subjects

Each eligible women who came for postnatal care and vaccination service within 6 weeks after
delivery in Assosa hospital.

3.4 .Inclusion and exclusion criteria

3.4.1. Inclusion criteria

All women who came for postnatal care and vaccination service within 6 weeks after delivery in
Assosa hospital during data collection period and who are volunteer to participate in the study
and those who are within six weeks of delivery will be included.
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3.4.2. Exclusion criteria

Those mothers who are unable to respond due to different health problems, those mothers with
known mental problems who are on anti psychotic drugs and known psychiatric disorder will be
excluded from the study

3.5. Sample size determination

The required sample size will be determined using single population proportion formula as
follows

N = (Z α/2)2 p (1-p)/ d2

N=Sample size.
Z=Standard error from the mean corresponding to 95% confidence level=1.96
P=19% taken from previous studies (16)
d = margin of error taken as 5%

The sample size calculated using the above formula is

N = (Z α/2)2 p (1-p)/ d2
N = (1.96)2 X (0.19 (1-0.19)/ (0.05)2
N = 236.48~ 236 Participants
By adding 10% of non-response rate, the final sample size will be 259

3.6 Sampling procedure and technique

Eligible participants will be approached and will request to consent voluntarily to participate into
the study. Upon consenting, a study number with a code will assigned for identification.
Inclusion into the study will be done by consecutive sampling until the required sample size 259
will be achieved.

3.7 .Variables of the study

3.7.1. Dependent variable

 Postpartum depression
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3.7.2. Independent variable

Socio-demographic characteristics (age, educational status, economic status, marital status and
employment)
Social support (Poor husband support, domestic violence, Child birth without the presence of
any relatives, unsatisfactory relationship with mother-in-law, unsatisfactory relationship in
marriage)

Obstetrics factors (parity, unplanned pregnancy, losing or hospitalizing a baby, mode of

delivery, pregnancy complication or illness, Stressful life event during pregnancy and undesired
fetal sex)

Previous psychiatric history (history of depression and family history of psychiatric problems)

3.8. Operational definitions

Postpartum period; it’s a period beginning immediately after the birth of a child and extending
for about six weeks.
Postpartum depression; women who experience depressed mood or sever mood swing,
excessive crying, difficult bonding with baby, withdrawing from family and friends, loss of
appetite or eating much more than usual, inability to sleep, overwhelming fatigue or loss of
energy.
Mental health; it’s a level of psychological well being or an absence of mental disorder it’s a
psychological state of someone who is functioning at satisfactory level of emotional and
behavioral adjustment
Social support; the perception and actuality that one is cared for, has assistance available from
other people
Socio-cultural; a set of belief, customs, practice and behavior that exist in a certain society.

3.9 Data collection tool and procedure

A structured interviewer administered questioner will be used to collect information from study
participants. The instrument will be adopted from previous published literatures ( 1,8,10,) and
edited .The questioner will be designed in English and translated to local Amharic language and
then back translated in to English by the third person to cheek for consistency
 10

The 10 questions of Edinburg postnatal depression scale (EPDS) is a valuable and efficient way
of identifying patients at risk for postnatal depression. It indicates how the mother has felt during
the previous 7 days. Data will be collected with an interviewer administered questionnaire to
gather information from mothers who come for postnatal and vaccination service. Data will be
cheeked for completeness every day and entered in to computer. Three nurses who graduated
diploma in nursing will be required as data collectors and they will be trained for one day on
information about the research objective, eligible study subjects, data collection tools and
procedures, and interview methods.

3.10. Data quality control management

The data collection instrument will pretest for accuracy of responses, language clarity,
appropriateness of data collection tools, estimate the time required and the necessary amendments
will be considered based on it prior to the actual data collection. It will be carried out one week
proceeding to the actual data collection period in health center, in five percent of non study
participants that fulfill the inclusion criteria. In addition, the data collectors will be trained for one
day on the techniques of data collection. The training also included importance of disclosing the
possible benefit and purpose of the study to the study participants before the start of data collection.
Maintaining confidentiality of the participants throughout the whole process of data collection will be
discussed and ascertained during the training. The researcher will check for completeness and
consistency of questionnaires filled by the data collectors to ensure the quality of the data, and also
visit the data collectors as many times as possible to check whether he/she collect the data
appropriately. The researcher will also appraise the data during the data analysis stage to verify the
completeness of the collected data.

3.11 Data analysis procedure

After data collection, filled data will be entered and analyses with IBM SPSS version 21 statistical
software and will subject to cleaning using simple frequency and tabulation to ensure its validity.

3.12. Ethical Considerations

Ethical approval will be obtained from research ethical committee of assosa university department of
nursing. Written consent will obtained from Assosa hospital administrative office of medical
director. Permission will attained from the responsible body to hospital. Written informed consent
 11

will be obtained from each participant after the investigator had explained the nature, purpose and
procedure of the study. Participants will be completed the questioner in a separate room whenever
they asked for it. Anonymity and confidentiality of the data providers will be strictly maintained.
Participants will be assured that their participation is voluntarily, and they have every right to
withdraw or refuse to give information at any time in the study without any penalty. Participants who
will be identified with depressive symptoms will be linked with mental health clinics.

3.13. Dissemination and utilization of results

Primarily, the result of this study will be submitted to, assosa university department of midwifery and
defended as partial fulfillment of the requirements for the degreedegree in bsc midwifery. The
information will be disseminated to the respective bodies and the results will be published in national
and international journal and presented in annual scientific meeting and conferences
 12

4. Work plan
Table 1: work plan for a proposal project among mothers in assosa hospital, 2019

sno Planned activities Site Responsible Time

body

2009/2017
May June July august
Title selection and ASU Investigator
Development of
research proposal
Submitting ASU Investigator+AS
proposal and U+ECC
obtaining ethical
clearance from
MU ethical
clearance
committee
Production of data ASU Investigator
collection tools
Recruiting and ASSOS Investigator
training of data A
collectors
Field work data Data Investigator and
collection collectio data collectors
n site
Data entry, ASU Investigator
cleaning and
analysis
Report write up ASU Investigator
and presentation
Report submission ASU Investigator
Finding ASU Investigator
dissemination
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5. Budget break dow Table 2: budget break down for a proposal among mothers of post
partum depression in assosa hospital, 2019

category Description Unit Quantity Rate unit Number of Total birr

cost days
personnel Perdiem for data Person 3 100.00 25 7500.00
collectors
Perdiem for Person 2 100.00 15 3000.00
supervisors
Perdiem for Person 3 100.00 30 9000.00
principal
investigators
Perdiem for Person 2 100.00 2 400.00
translators
Sub total 19500.00
Stationary Computer paper Ream 3 80.00 240.00
materials
Pencil Pieces 5 1.00 5.00
Photo copying Pieces 300 .50 150.00
costs
Note book Pieces 4 12.00 48.00
Binder Packs 4 10.00 40.00
CD RW Pieces 1 100.00 100.00
Sub total 583
supplies Tape recorder 3 200.00 600.00
Battery 5 20.00 100.00
Mobile card 3 100.00 300.00
Sub total 1000.00
Grand total 21083.00 ETB
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6. References

1. Warfa, K. Prevalence of postpartum depression using the EPDS at the Aga Khan
University Hospital Nairobi. Unpublished MMED thesis AKUH 2011.
2. Burns, D. Aspects of Postpartum Depression. London, Ontario: Middlesex-London
Health Unit. 2003.
3. Boyce P. Personality dysfunction, marital problems and postnatal depression. In Cox J,
Holden J, eds. Perinatal Psychiatry: use and misuse of the Edinburgh Postnatal
Depression Scale. London. Gaskell. 1994.
4. Nonacs, R., & Cohen. Postpartum mood disorders: Diagnosis and treatment guidelines.
Journal of Clinical Psychiatry,1998: 59(2), 34-40
5. Epperson, C.N. Postpartum major depression: Detection and treatment. American Family
Physician.1999: 59, 2247-2254
6. Seidman, D. Postpartum psychiatric illness: The Role of the pediatrician. Pediatrics in
Review, 1998:19, 128-131
7. Jennings, K., Ross, S., Popper, S., & Elmore, M. Thoughts of harming infants in
depressed and nondepressed mothers. Journal of Affective Disorders,1999: 54, 21-28.
8. Giri et al. Prevalence and factors associated with depressive symptoms among post-
partum mothers. BMC Research Notes. (2015) 8:111
9. World Health Organization. Maternal Mental health and Child Health and Development
in Low and Middle Income Countries. Geneva: 2008.
10. Lanes et al. Prevalence and characteristics of Postpartum Depression symptomatology
among Canadian women: a cross-sectional study. BMC Public Health 2011, 11:302
11. 47. Martin O’Malley GAGB, Lieutenant Governor; John M. Colmers. Postpartum
Depression Among Maryland Women Giving Birth 2004-2008. Maryland Department of
Health and Mental Hygiene Center for Maternal and Child Health, Vital Statistics
Administration. January 2011:1-4.
12. Chaaya M. et al. Postpartum depression: prevalence and determinants. Arch Womens
Ment Health. 2002; 5(2): 65–72
13. Khalifa DS, Glavin K, Bjertness E, et al. Determinants of postnatal depression in
Sudanese women at 3 months postpartum: a cross-sectional study. BMJ Open 2016;6
14. Kumar R. Postnatal mental illness: Transcultural perspective. Social psychiatry
epidemiology ,1994: 29: 250-264….14
 15

15. Murray L and Cooper P J . Effects of postnatal depression on infant development.

Archives of Disease of Children, 1997:77, 99-101
16. Deribachew H. Berhe D. Zaid T. and Desta S. prevalence and associated factors of
postpartum depression. Ejpmr. 2016;3(10)
17. O’Hara M W and Swain A M Rates and risks of postnatal depression: A meta analysis.
International Review of Psychiatry. 1996:8, 37-54
18. 12. Niloufer S Ali B, Iqbal S Azam. Post partum anxiety and depression in peri-urban
communities of Karachi, Pakistan: a quasi-experimental study. BMC Public Health.
2009; 9:384
19. 13. Kakyo TA, et al., Factors associated with depressive symptoms among postpartum
mothers inarural district in Uganda. Science Direct journal Midwifery. 2011
20. 15. Wissart et al.,Prevalence of pre- and postpartum depression in Jamaican women.
BMC Pregnancy and Childbirth. 2005, 5:15
21. . cdc. depression among women of reproductive age reproductive health. [on-line].
Available: wwwcdcgov/reproductivehealth/depression 2012;21(8):(830-6) Accessed date
november 28, 2017
22. Moraes.I et al. Prevalence of postpartum depression and associated factors. Rev Saude
Publica 2006:40(1)
23. Josephat Maduabuchi Chinawa et al. Postpartum depression .The Pan African Medical
Journal. 2016; 23:180
24. Juliet E.M Nakku. Postpartum major depression at six weeks in primary health care:
prevalence and associated factors. African Health Sciences 2006; 6(4)
25. Chojenta CL, Lucke JC, Forder PM, Loxton DJ Maternal Health Factors as Risks for
Postnatal Depression: A Prospective Longitudinal Study. PLoS ONE 2016:11(1)
26. Schmied,V.,Johnson,M.,Naidoo,N.,Austin,M.P.,Matthey,S.,Kemp, L., etal..Maternal
mental health in Australia and NewZealand: a review of longitudinalstudies. Women
Birth 2013:26, 167–178
27. Sabuncuoˇglu, O.,andBerkem,M. Relationship between attachment style and depressive
symptoms in postpartumwomen:findingsfromTurkey. Turk PsikiyatriDerg 2006:17, 25
 16

7. Annexes

Annex 1: information sheet

How are you: my name is___________________________ and I am a post graduate student
from assosa University College of health science department of midwifery. I am conducting a
research concerning on prevalence and associated factors of postpartum depression .This
research is aimed to help the government and the country health office, besides to that
communities including the people who participate in the study will be also benefited. I have
come to ask for permission from you to participate in this study. Am asking you to read (or have
it read to you) this consent form carefully. Participation into this study is voluntary and you are
free to or not accept to participate. There will be no any form of payments or rewards to be given
to the participants. Your services in the hospital will not be affected in any way by choosing to or
not to participate. I however, do hope that you will participate in the study since the data that will
come from you will be important for us. I would like to inform you that all information you give
as is Confidential, Except for the purpose of the study it will never be disclosed to the third party.
If you have any question regard to this study, you can ask immediately the interviewer or the
investigator by using the contact address.
May I now begin the interview? If yes, continue interviewing, if no thanks and stop interviewing.
Name of the interviewer……………………… sign………………… date
Addresses
Tell; 0945073378

Annex 2: consent form

I (the respondent),the undersigned , am told that the researcher is going to conduct the study, to
determine the prevalence and associated factors of postpartum depression, and I am also
informed that the result of the study will be used by both the government and the hospital, to
commence appropriate strategies to bring a change. I am, too, told the research will benefit the
community in general including me, the respondent, and that the research will not inflict any
harm to me. I have been told that I have full right I have enough time to understand and then take
 17

part in the study on the basis of my interest besides; I am briefed that I will be interviewed for
not more than 20 minutes. Moreover am notified that my participation in the study is entirely
volunteer, and that I can quite from the study any time I want. Likewise am enlighten that I will
not be subject to any form of punishment following my failure to participate in the study. In the
same way am explained that the information collected will not be disclosed by any means to any
people other than those participating in the study unless obtained permission from me. Equally,
am told that I can ask them question I found difficulty or any type otherwise.
Client signature/Thumb print ………………… Date……..

Annex 3

Questionnaire: Prevalence and associated factors of postpartum depression among

postpartum women
Date _________________
Patients’ study number _________________
Date of delivery _________________

Part I: socio-demographic characteristics

No Questions Coding category Skip

101 Age in completed
years?
102 Religion a) Chiritian orthodox
b) Catholic
c) Protestant
d) Muslim
e) Others specify…….
103 Do you Follow any a) Yes If your response
religious/cultural b) No for no 103 is “B”
rituals? skip to no 105

104 What kind of

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religious/cultural
rituals do you
follow?
105 Current marital a) Single
status? b) Married
c) Divorced/separated.
d) Widowed
106 Have you ever a) Yes If your response
attended school? b) No for no 106 is “B”
skip to no 108
107 Level of school you a) Primary school (1-8
attend b) Secondary school(9-12)
c) Technical/vocational
d) Diploma
e) First degree and above-
108 Occupational status a) Student If your response
b) paid worker for no 108 is “B”
c) unpaid employee go to no 109 but if
d) House wife without “B” skip
e) Merchant to no 110
f) Pensioner
g) Farmer
h) Unemployed
i) others-specify………..
109 If you are paid a) Civil servant
worker what is your b) non civil servant
occupational c) NGO employee
condition? d) daily laborer
e) house maid
f) Others-specify------------
110 Husbands a) Student
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occupation b) Merchant
c) civil servant
d) non civil servant
e) Unemployed
f) day laborer
g) others specify ------------
111 Average monthly a. < 445 birr
income? b. 446-1200
c. 1201-2500
d. 2501-3500
e. >3501
f. I don’t know
g. I don’t have my own
income
112.1 Sex of your baby a. Male
b. female
112.2 sex for the last a. Desired
baby? b. Undesired
c. I don’t mind
Part II : factors associated with postpartum depression
201 Number of pregnancy
202 Number of living children do
you have?
203 Have you ever had an abortion? a) Yes
b) No
204 Number of abortion you
experienced?
205 Have you ever experienced a) Yes
death of your baby? b) No
206 Did any of your children are a) Yes
hospitalized? b) No
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207 The mode of delivery for your a) Vaginal

last pregnancy was? b) Caesarian section
c) instrumental
208 Was your last pregnancy a) Yes
planned? b) No
209 Any illness/complication during a) Yes
your last pregnancy? b) No
210 Was there any negative life a) Yes If your
event during your last b) No response for
pregnancy? no 210 is “B”
skip to no
212

211 What kind of events do you

experienced?
212 Any of your relative suffered a. Yes near relative
from mental illness? b. Yes distant relative
c. No
213 Previous history of depression? a. Yes
b. No
215 Have you ever experienced any a. Yes
abuse in your home? b. No
216 What kind of abuse do you ever a. Verbal
experienced? b. Physical
c. Verbal and physical
217 Are you satisfied with your a. Yes
marriage? b. no
c. more or less
d. Others-specify
218 Father of your child is a. Yes
supporting both of you enough? b. No
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c. more or less
d. Others-specify
219 Did any of your relatives present a. Yes
in health facilities during your b. No
last child birth?

220 Are you satisfied by the a. Yes

relationship you have with your b. No
mother-in-law? c. more or less
d. Others-specify
Part III : Edinburgh Postnatal Depression Scale (EPDS) In the past 7 days
301 In the past seven days have u a) As much as I always could
ever experienced laugh and see b) Not quite so much now
the funny side of things? c) Definitely not so much now
d) Not at all
302 In the past seven days have u a) As much as I ever did
ever looked forward with b) Rather less than I used to.
enjoyment to things? c) Definitely less than I used to
d) Hardly at all
303 In the past seven days have you a) Yes, most of the time
blamed yourself unnecessarily b) Yes, some of the time
when things went wrong? c) Not very often
d) .No, never
304 In the past seven days have you a) No, not at all
ever been anxious or worried for b) Hardly ever
no good reason? c) Yes, sometimes
d) Yes, very often
305 In the past seven days have you a) Yes, quite a lot
felt scared or panicky for no b) Yes, sometimes
very good reason? c) No, not much
d) No, not at all

306 In the past seven days things
have been getting on top of you?
307 In the past seven days have you
been so unhappy that you have
had difficulty sleeping?
308 In the past seven days have you
felt sad or miserable?
309 In the past seven days have you
been so unhappy that you have
been crying?
310 In the past seven days did you
have the thought of harming
yourself?
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a) Yes, most of the time I
haven’t been able to cope at
all
b) Yes, sometimes I haven’t
been coping as well as usual
c) No, most of the time I have
coped quite well
d) No, I have been coping as
well as ever
a) Yes, most of the time
b) Yes, sometimes
c) Not very often
d) No, not at all
a) Yes, most of the
b) Yes, quite often
c) Not very often
d) No, not at all
a) Yes, most of the time
b) Yes, quite often
c) Only occasionally
d) No, never
a) Yes, quite often
b) Sometimes
c) Hardly ever
d) Never