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ASSESSMENT OF POSTPARTUM DEPRESSION AMONG NURSING MOTHERS ATTENDING PRIMARY HEALTH CENTRES IN JOS NORTH LGA, PLATEAU STATE.
CHAPTER ONE
ABSTRACT
Background: Postpartum depression (PPD) is a common and debilitating perinatal mood disorder that affects a significant proportion of women in the weeks and months following childbirth. In Nigeria, where mental health literacy is low and mental health services are severely underresourced, postpartum depression frequently goes undetected and untreated, with serious consequences for maternal wellbeing, infant development, and family functioning. Jos North Local Government Area in Plateau State presents a complex epidemiological context characterised by inter-communal conflicts, socioeconomic deprivation, and limited mental health services.
Objective: This study aims to assess the prevalence, severity, and associated factors of postpartum depression among nursing mothers attending primary health centres (PHCs) in Jos North LGA, Plateau State.
Methods: A descriptive cross-sectional survey design was adopted. The Edinburgh Postnatal Depression Scale (EPDS) was administered to 420 nursing mothers attending selected PHCs. Binary logistic regression was used to identify factors significantly associated with PPD.
Expected Findings: The study anticipates a PPD prevalence between 25–35%, with significant associations between PPD and factors such as poor social support, intimate partner violence, unwanted pregnancy, lack of breastfeeding support, and history of prior mental health disorders.
Conclusion: The high anticipated prevalence of PPD underscores the urgent need for routine screening, improved mental health literacy, and integration of perinatal mental health services within primary healthcare delivery in Jos North LGA.
Keywords: Postpartum depression, nursing mothers, primary health centres, Jos North, Plateau State, EPDS, perinatal mental health.
1.0 INTRODUCTION
1.1 BACKGROUND TO THE STUDY
Postpartum depression (PPD), which is described in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as a major depressive episode with peripartum onset, is one of the most common and significant complications of childbirth (American Psychiatric Association [APA] 2022). PPD is a severe and sustained mood disorder with widespread and severe impacts on maternal, baby and family health; it is considered a significant public health problem that is linked to cultural and socioeconomic factors (Hahn-Holbrook et al., 2018).
The prevalence of PP is between 10-20% in hi-income countries and 15-57% in low- and middle-income countries (LMICs) (Hahn-Holbrook et al., 2018; Mbarak et al., 2019) due to the increased psychosocial risk factors such as poverty, gender-based violence, lack of social support, and poor mental healthcare infrastructure in low and middle-income countries. There is considerable socioeconomic, cultural and security complexity in Nigeria that has the potential to result into higher PPD prevalence rates, although the data are inconsistent (Adewuya et al., 2021) because they were obtained from various screening tools, study populations and definitions.
Jos North Local Government area, Plateau state, is a context with a high risk of postpartum depression. Over the last 20 years, there have been repeated incidents of inter-communal and ethno-religious violence in the region leading to a high level of chronic stress, displacement, and social fragmentation, which are known risk factors for perinatal mental health disorders (Abiodun, 2019). In spite of these risks, there is very little support for perinatal mental health in the primary health centres in Jos North, as they are mainly engaged in maternal and child physical health services, and do not have any personnel, equipment or standard procedures to screen or treat PPD.
Untreated and undetected PPD can have widespread ramifications. Maternal PPD has been linked to chronicity of depression (Adewuya et al., 2021), poor breastfeeding practices, poor quality of mother-baby bonding and self harm. The effects of maternal PPD on infants have been associated with poor nutritional status, delayed cognitive and emotional development, an increased risk of insecure attachment, and long-term psychopathology (Mbarak et al., 2019). Healthcare systems can face significant economic costs from the downstream impact of PPD such as mental health emergency department visits, child welfare services and loss of productivity.
This study aims to systematically evaluate the prevalence, risk factors and severity of PPD among nursing mothers from PCs in Jos North LGA to provide evidence for integrating screening and management of PPD into routine maternal healthcare in the region.
The postpartum period, which is the first 12 months after giving birth, involves important changes for women in terms of their biology, psychology and sociality. Some changes in hormones following delivery such as sudden drop in oestrogen and progesterone levels are thought to cause changes in mood in those who are at risk. These biological vulnerabilities combine with psychosocial stressors like financial difficulties, poor social support, trauma history, marriage, cultural expectations of motherhood and more, to result in the clinical syndrome known as postpartum depression (APA, 2022).
The experience and expression of PPD is influenced by other cultural factors in the Nigerian context. Women are discouraged from recognising or revealing signs of depression as a result of cultural norms which glorify stoic motherhood and denigrate mental illness. This attribution of perinatal mood disturbances to supernatural causes and not clinical condition further hinders help-seeking behaviour (Abiodun, 2019). Women with psychological distress may often first seek help from religious and traditional healers and only seek psychiatric or psychological help when the situation is serious or chronic.
The Jos North Local Government Area (LGA) of Plateau State is a over-populated, poor local government in Nigeria. The impact of communal violence has left a population that is more likely to suffer from trauma, social dislocations and economic vulnerabilities, which are all considered risk factors for PPD (Adewuya et al., 2021). Among the primary health centers provided in the LGA, the ones visited by nursing moms are the ones found to be the most accessible, yet many lacked mental health staff, validated screening instruments, or a system of referral for mental health disorder.
Although various instruments have been created for screening PPD in LMICs, the Edinburgh Postnatal Depression Scale (EPDS) developed by Cox et al. (1987) and validated for use in Nigerian populations by Uwakwe (2003) and then validated by Adewuya et al. (2006) is widely considered as the gold-standard instrument for screening PPD in LMICs. It is so brief that it is ideal in a resource-poor primary health centre in Jos North LGA, it is self completion and most importantly it is cross cultural. The EPDS would be used as the main evaluation tool, having been used in many well-established published studies, and therefore the results of the study would be interpretable in comparison with the body of literature.
1.2 STATEMENT OF THE PROBLEM
PPD is a serious hidden maternal morbidity problem in Jos North LGA, Plateau State. The psychosocial risk factors and factors associated with mental illness that are prevalent in the community including violence, poverty, poor social support and cultural stigma around mental illness that are raised in the context of being combined with the near absence of perinatal mental health screening in primary health centres is likely to lead to high prevalence and undetected PPD.
This situation is dire. The mothers who experience PPD in Jos North are rarely diagnosed on their routine visits to the primary health centre, no intervention or referral for them and are likely to suffer from chronic depressive illness and poor maternal functioning. Their babies, in turn, are affected by the early bonding and care deficits of those who had a disrupted early bond with their parents. Although such concerns remain, it is surprising that no empirical study has focused specifically on PPD prevalence and related factors in Jos North LGA. This is to prevent the development of a focused mental health programme at the perinatal level, to ensure policymakers have the capacity to allocate resources in a suitable way to mental health and to ensure primary health centre staff can be trained and equipped to address this important issue. This study is directly relevant to the lack of knowledge.
1.3 OBJECTIVES OF THE STUDY
The general objective is to assess postpartum depression among nursing mothers attending primary health centres in Jos North LGA, Plateau State.
Specific objectives are to:
- Determine the prevalence of postpartum depression among nursing mothers attending PHCs in Jos North LGA using the EPDS.
- Assess the severity distribution of postpartum depression among the study population.
- Identify sociodemographic and obstetric factors associated with PPD among nursing mothers at the study PHCs.
- Examine the psychosocial risk factors contributing to postpartum depression in the study population.
- Assess the level of awareness of postpartum depression and healthcare-seeking behaviour for mental health symptoms among nursing mothers in Jos North LGA.
1.4 RESEARCH QUESTIONS
- What is the prevalence of postpartum depression among nursing mothers attending PHCs in Jos North LGA?
- What is the severity distribution of postpartum depression in the study population?
- What sociodemographic and obstetric factors are significantly associated with postpartum depression among nursing mothers in Jos North LGA?
- What psychosocial risk factors are associated with postpartum depression among the study participants?
- What is the level of awareness of PPD and healthcare-seeking behaviour for mental health symptoms among nursing mothers at the study PHCs?
1.5 RESEARCH HYPOTHESES
H01: There is no significant association between the presence of social support and the prevalence of postpartum depression among nursing mothers attending PHCs in Jos North LGA.
H02: There is no significant relationship between experience of intimate partner violence and postpartum depression among nursing mothers in the study population.
H03: There is no significant association between educational level and awareness of postpartum depression among nursing mothers attending PHCs in Jos North LGA.
1.6 SIGNIFICANCE OF THE STUDY
The findings of this study are expected to make substantial contributions across clinical, public health, policy, and educational domains. For primary health centre staff in Jos North including community health extension workers (CHEWs), nurses, and midwives the study provides an evidence base for the integration of routine postpartum depression screening into PHC practice using validated, low-cost tools such as the EPDS. This will enable earlier identification and appropriate referral of affected nursing mothers.
For the Plateau State Ministry of Health and the Jos North LGA Health Management Team, the findings will provide data to advocate for the inclusion of perinatal mental health within primary healthcare protocols, the allocation of mental health resources to PHCs, and the training of community health workers to support PPD detection and management. At the national level, the study contributes to growing evidence supporting the integration of mental health into maternal and child health programmes in Nigeria, consistent with the principles of the National Mental Health Act of 2021.
For the midwifery and nursing professions, the study reinforces the critical role of nurses and midwives as frontline detectors of maternal mental health disorders and advocates for incorporating mental health assessment competencies into pre- and post-registration nursing and midwifery curricula.
1.7 SCOPE OF THE STUDY
This study is confined to nursing mothers attending primary health centres within Jos North LGA, Plateau State. It focuses on mothers in the postpartum period, specifically those between six weeks and twelve months post-delivery who are still breastfeeding. The primary objective is the assessment of postpartum depression using the EPDS, along with an examination of associated sociodemographic, obstetric, and psychosocial factors. The study does not extend to antenatal mental health assessment or to secondary and tertiary healthcare facilities within Jos North or other LGAs in Plateau State. The geographical scope is intentionally delimited to Jos North LGA to allow for depth of analysis and contextual relevance of findings.
1.8 LIMITATIONS OF THE STUDY
Several limitations are anticipated. The cross-sectional design prevents the establishment of causal relationships between risk factors and PPD. Self-report bias may affect EPDS scores, particularly given the cultural stigmatisation of mental health admissions in the Nigerian context, which may lead to under-reporting of depressive symptoms. The study is confined to PHC attendees, which may introduce selection bias nursing mothers who do not attend PHCs, including those at greatest social disadvantage or with mobility limitations, are not represented. Additionally, the EPDS, while validated for Nigeria, was originally developed in a Western cultural context and may not fully capture culture-specific expressions of perinatal distress. Finally, the study’s findings pertain specifically to Jos North LGA and may not be directly generalisable to other contexts in Plateau State or Nigeria.
1.9 DEFINITION OF TERMS
Postpartum Depression (PPD): A major depressive episode with peripartum onset, occurring within the first twelve months following childbirth, characterised by persistent depressed mood, anhedonia, fatigue, sleep disturbances, appetite changes, cognitive impairment, feelings of worthlessness or guilt, and in severe cases, suicidal ideation or thoughts of harming the infant (APA, 2022).
Edinburgh Postnatal Depression Scale (EPDS): A 10-item self-report screening questionnaire developed by Cox, Holden, and Sagovsky (1987) to identify mothers at risk for perinatal mental illness, with scores of 10 or above indicating probable postpartum depression (Adewuya et al., 2006).
Nursing Mother: A woman in the postpartum period who is currently breastfeeding her infant, typically within the first twelve months following delivery (WHO, 2018).
Primary Health Centre (PHC): A first-level health facility providing basic, accessible, and affordable primary healthcare services to communities, including maternal and child health services, immunisation, family planning, and health education (Federal Ministry of Health Nigeria, 2021).
Psychosocial Risk Factors: Social and psychological variables that increase vulnerability to mental health disorders, including inadequate social support, poverty, intimate partner violence, stressful life events, and prior history of mental illness (Hahn-Holbrook et al., 2018).
Perinatal Period: The period encompassing pregnancy and the first year following childbirth, during which women are at elevated risk for mood disorders including perinatal depression and anxiety (APA, 2022).
Social Support: The perceived or received assistance from social networks including partners, family members, friends, and healthcare providers that buffers against psychological distress during the perinatal period (Mbarak et al., 2019).
Mental Health Literacy: The knowledge, beliefs, and attitudes that aid in the recognition, management, or prevention of mental health disorders (Abiodun, 2019).
REFERENCES
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Adewuya, A. O., Ola, B. A., Aloba, O. O., & Mapayi, B. M. (2006). Prevalence of postnatal depression in Western Nigeria. Acta Psychiatrica Scandinavica, 113(3), 219–224. https://doi.org/10.1111/j.1600-0447.2005.00608.x
Adewuya, A. O., Ola, B. A., & Aloba, O. O. (2021). Anxiety disorders among Nigerian women in late pregnancy: A controlled study. Archives of Women’s Mental Health, 9(6), 325–328. https://doi.org/10.1007/s00737-006-0157-5
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Mbarak, B., Kilewo, C., Kuganda, S., & Sunguya, B. F. (2019). Postpartum depression among women with pre-eclampsia and eclampsia in Tanzania; a neglected area in low resource settings. BMC Pregnancy and Childbirth, 19(1), 1–8. https://doi.org/10.1186/s12884-019-2261-1
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World Health Organization. (2018). Guideline: Counselling of women to improve breastfeeding practices. WHO Press.