Review
Pre- and postnatal psychological wellbeing in Africa: A systematic review

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Abstract

Background

Perinatal mental health disorders are recognised as an important public health issue in low-income countries as well as in developed countries. This paper reviews evidence on the prevalence and risk factors of maternal mental health disorders in African women living in Africa.

Methods

A systematic review of the literature was conducted. Studies were mainly located through computerised databases, and additionally through hand searching references of identified articles and reviews. Thirty-five studies, with a total of 10,880 participants, were identified that reported prevalence rates of maternal psychological health in eight African countries.

Results

Depression was the most commonly assessed disorder with a weighted mean prevalence of 11.3% (95% CI 9.5%–13.1%) during pregnancy and 18.3% (95% CI 17.6%–19.1%) after birth. Only a small number of studies assessed other psychological disorders. Prevalence rates of pre- and postnatal anxiety were 14.8% (95% CI 12.3%–17.4%) and 14.0% (95% CI 12.9%–15.2%), respectively; and one study reported the prevalence of PTSD as 5.9% (95% CI 4.4%–7.4%) following childbirth. Lack of support and marital/family conflict were associated with poorer mental health. Evidence relating sociodemographic and obstetric variables to mental health was inconclusive.

Limitations

Most studies included in this review were cross-sectional and measures of mental health varied considerably.

Conclusions

This paper demonstrates that maternal mental health disorders are prevalent in African women, and highlights the importance of maternal mental health care being integrated into future maternal and infant health policies in African countries.

Introduction

There is growing international recognition that maternal mental health is a major public health concern (Oates et al., 2004). The World Health Organisation (WHO) identified maternal mental health as an integral component of improving global maternal health in their Millennium Development Goals (WHO, 2005) and in the UK, the Department of Health's (2008) recent strategy for global health emphasised the need for better and fairer health care in reproductive and maternal health (Health is Global: a UK Government Strategy 2008–2013).

Postnatal mood disorders can vary in severity from mild to psychotic (Brockington, 2004). Postnatal depression (PND) is the most frequently recognised disorder after birth and generally begins within four to six weeks after childbirth (Robertson et al., 2004). Symptoms include low mood, tiredness, insomnia, lack of energy, forgetfulness, irritability, and poor functioning. In Western countries the prevalence of PND is between 10 and 15% (Beck, 2001, O'Hara and Swain, 1996). Postnatal anxiety disorders are increasingly recognised (Brockington et al., 2006, Wenzel et al., 2005). For example, Wenzel et al. (2003) carried out clinical interviews with women eight weeks after birth and found 16% of them met diagnostic criteria for an anxiety disorder, including generalised anxiety disorder, panic, phobias, and obsessive–compulsive disorder. In recent years converging evidence suggests that 1 to 2% of women develop post-traumatic stress disorder (PTSD) following childbirth (e.g. Ayers and Pickering, 2001, Wijma et al., 1997).

Antenatal mental health is also associated with psychological disorders but this has been less widely researched. A meta-analysis found that the point prevalence of depression ranged from 8.5% (95% CI 6.6%–10.9%) to 11% (7.6%–15.8%) at different times during pregnancy (Gaynes et al., 2005), indicating that the prevalence of depression during pregnancy might be similar to postnatal levels. In addition, a recent review paper suggested that clinically significant anxiety disorders may be twice as common as depression during pregnancy (Brockington et al., 2006). Poorer mental health during pregnancy has been identified as a significant risk factor for postnatal mental disorders (Josefsson et al., 2001, Robertson et al., 2004).

There is a global literature on maternal mental health, but most research has focused on Western, developed countries, primarily Europe and North America. Prevalence rates of maternal mental health disorders show considerable variation between countries (Halbreich and Karkun, 2006, Leahy-Warren and McCarthy, 2007). For example a review of PND in 40 countries worldwide found that prevalence rates ranged widely from almost 0% to 73.5% (Halbreich and Karkun, 2006). One contributor to these disparate prevalence rates might be the inherent difficulties of conducting cross-cultural research. For example, many of the studies used measures based on Western diagnostic classification systems of depression, which may not be generalisable to non-Western cultures. The most common measure of PND in the review was the Edinburgh Postnatal Depression Scale (EPDS). Although this scale has been validated across a range of cultural settings, it does not include a somatic subscale, which could be disadvantageous in developing parts of the world where somatic symptoms are considered manifestations of depression (Halbreich et al., 2007). Despite these methodological limitations reviews of cross-cultural research are useful in identifying where the gaps are in the current research, especially when very little is known about the area.

Of all the regions of the world Africa has the highest proportion of people living in extreme poverty (Department for International Development, 2008). The World Health Organisation (WHO) estimates that women in sub-Saharan Africa have a one in 16 lifetime risk of dying during pregnancy and childbirth, compared with one in 2800 in developed regions (World Health Organization, 2004a, World Health Organization, 2004b). Maternal morbidity is also high. A recent paper reported that between 3% and 9% of pregnant women in West Africa experienced severe morbidity directly attributable to obstetric causes, of which the main causes were haemorrhage, obstructed labour, hypertensive disorders and sepsis (Prual et al., 2000). Higher morbidity and mortality is due in part to the different availability of health services. High numbers of births are at home and mission houses, which are often overseen by traditional birth attendants (Adewuya et al., 2005b, Ejembi et al., 2004). Understandably, in developing countries the focus of health care is on women's medical and obstetrical problems and on the baby's wellbeing. The psychological needs of pregnant and postnatal women are rarely addressed (Chaaya et al., 2002).

Psychological disorders associated with pregnancy and the birth of a child should not be ignored because of the potential adverse consequences on the mother's health, the early mother–infant relationship, the child's health and development (Hadley et al., 2008, Halbreich and Karkun, 2006, Leiferman, 2002). Evidence from developing countries suggests that poor maternal mental health may be associated with malnutrition and poor physical health in their infants (Harpham et al., 2005, Patel et al., 2004). For example a longitudinal case controlled study of 242 women found that infants of depressed mothers in Nigeria had significantly poorer growth than infants of non-depressed mothers three (weight OR 3.41, 95% CI 1.30–8.52; length OR 3.28, 95% CI 1.03–10.47) and six months (weight OR 4.21, 95% CI 1.36–13.20; length OR 3.34, 95% CI 1.18–9.52) following childbirth (Adewuya et al., 2008).

To date, only one paper has reviewed studies of maternal mental health in Africa. This was part of a worldwide review, which focused exclusively on PND (Halbreich and Karkun, 2006). To assess the full extent of the burden of psychological disorders it is essential to look at the entire range of psychological disorders that present both during pregnancy and after childbirth (Global Forum for Health Research, 2000). Moreover, key risk factors that may predispose pregnant or postpartum African women to mental health problems were not assessed. The identification of vulnerable populations, particularly in developing countries, is a key factor in the organisation and adequacy of health services and the planning of health programs (Tannous et al., 2008). This deficit of information about key factors that predispose women to mental health disorders in developing countries needs to be addressed urgently. Reviews of studies conducted in Western developed countries identify poor marital relationship, past history of psychopathology, psychological disorders during pregnancy, poor social support and stressful life events as the primary risk factors for pre- and postnatal disorders (Beck, 2001, O'Hara and Swain, 1996, Lusskin et al., 2007) but little is known about risk factors in African countries.

This paper therefore systematically examines the prevalence of psychological disorders during pregnancy and after childbirth in African women; and identifies factors associated with psychological disorders during pregnancy and after childbirth.

Section snippets

Search strategy

A systematic search was conducted to identify studies of prenatal and postnatal mental health in African women. The following computerised databases were searched up to January 2009: Medline, PsychInfo, Psycharticles PubMed, Web of Science, Scopus, and African Index Medicus. Broad search terms were used to ensure as many articles as possible would be identified as it is known that studies conducted in developing parts of the world are difficult to locate through electronic searching (Betrán et

Results

Thirty-five studies were included in the review, with a total of 10,880 participants. Sample sizes ranged from 27 to 1723 (M = 284.74, mdn = 172, mode = 47). Studies were conducted between 1972 and 2009, with the majority taking place between 2003 and 2009. Most studies recruited women from antenatal and postnatal health clinics (n = 27), six studies recruited women from the community, and one study was conducted in both settings. Nineteen studies were cross-sectional, 11 were longitudinal, and five

Discussion

This is the first systematic attempt to review the literature on maternal mental health disorders in pregnant and postnatal African women. Although studies were conducted in many countries within Africa and caution should be taken when generalising the findings between cultures, this paper provides a useful overview of the current state of knowledge in this area. This review suggests that depression is the most commonly identified psychological complication of the prenatal and postnatal period

Role of funding source

No funding was provided for this study.

Conflict of interest

No authors have any conflict of interest.

Acknowledgement

There are no acknowledgements for this research.

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