First phase (Piloting phase)
The piloting phase engaged the women and made them to actively participate in decision making regarding their further assessment and subsequent follow-up treatment (Appendix 1) and asked the following questions:
1. How do we get more mothers to consent to intervention services?
2. How do we communicate screening outcome to mothers in a way not to confer a feeling of being stigmatized?
3. Where would the women screened positive for PPD prefer for further assessment and possible follow-up for interventions?
Two hundred and seventeen (217) women were screened for post-partum depression in the piloting phase of the study.
1. 57 (26.3%) of the 217 mothers screened had a cut-off point of 7 and above on EPDS and therefore screened positive for PPD and were administered the Appointment Booking Form (Appendix 1).
2. Majority of the women screened positive for PPD, 47 (82.5%) of 57 opted for further assessment and possible follow-up treatment at NPI clinics as against the option of Home visit intervention.
3. Many of the women, 54 (94.7%) of 57 opted for option of group therapy if they are going to be involved in further interventional follow-up.
Second phase (Prototyping phase)
The outcome in piloting phase of the study provided the template for full launch into second phase of the study, where further assessment and interventional follow-up focused largely on NPI clinics, following the baseline screening with EPDS. The location of the study was further extended to Enugu State in South-Eastern Nigeria during this phase.
In addition to the women screened at piloting phase, a total of 3,686 women were screened at the selected NPI clinics, 958 (26%) had a score of 7 and above on EPDS and were involved in further follow-up assessment. On further follow-up assessment using both clinical judgment and depressive module of MINI, 674 women (18%) met diagnostic criteria for post-partum depression.
The age range of the mothers with diagnosis of postpartum depression was between 22 and 35 years, with a mean age of 29.0 ± 3.8 years. The age range of their infants was between 0.5 and 3.5 months, with a mean age of 2.55 ± 0.91 months. The sex distribution of the infants were 405 females (60.1%) and 269 males (39.9%). The mean EPDS score at baseline was 11.2 ± 5.5.
Interpretation of Results
Maternal Postpartum depression (PPD) was diagnosed in the mothers screened, when their infants were average age of about three months (3 Months) {Table 1}. Growth parameters in the infants deteriorated over the following 3 months at initiation of interventions for the mothers’ depressive symptoms, when the infants were at about average age of six months (6 Months) {Table 2}. Following further interventions, the growth parameters of the infants had peaked over the subsequent 6 months, when the average age of the children was about nine months (9 Months) and the peak had been sustained {Table 3}. The fourth follow-up impact assessment, nine months after the baseline showed closer correlations with the standard WHO growth charts, the average age of the children at this stage was about twelve months (12 Months) {Table 4}.
With each follow-up impact assessment, few of the mothers were being lost to follow up, which may necessitate the need for remote interface for the purpose of assessment and interventions in future study design.
From the foregoing, a total of 95.2% of the mothers diagnosed with post-partum depression in this study accessed interventions until the fourth and last impact assessment follow-up period, when the average age of their infants was about 12 months. This result is an improvement over the observation made in our previous report, where only 33.7% of the women diagnosed with post-partum depression showed up for further assessment and interventions following referral to a mental health facility.
Main Findings
The present study showed an improvement in the percentage of women willing to seek intervention, if the intervention is taking to primary care level at immunization clinics, as against referral to mental healthcare facility, where the mothers may have perceived stigma visiting.
More women were likely to consent to treatment and intervention if they are engaged and made to be part of the decision making in their own treatment. Follow-up assessment and interventions for the mothers showed a positive impact on the growth parameters of the infants over time.
Immunization clinics and intervention for maternal PPD
Immunization clinics at the primary healthcare centers had been earlier noted to constitute major clinical source of convergence for mothers and their infants and might provide a good forum for screening for depression in the mothers and developmental concerns in the children and may also provide a right forum for providing interventions. It is along this assumption that the idea behind the present study was tested.
Human centred design and interventional follow-up
Human centred design is defined as a creative approach to interactive systems development that aims to make systems usable and useful by focusing on the users, designing around their needs and requirements at all stages, and by applying human factors/ergonomics, usability knowledge, and techniques. This approach enhances effectiveness and efficiency, improves human well-being, user satisfaction, accessibility and sustainability; and counteracts possible adverse effects of use on human health, safety and performance.
The principle of human centred design was employed in the piloting and prototyping phase of this study by engaging the women and making them to actively participate in determining the course of their own interventions and treatment. This principle probably went a long way in promoting the willingness of the women to seek interventions, which also in turn served the ultimate benefit of promoting the growth and development of their infants as reflected by the findings of this study.
Maternal PPD and infant growth
Previous studieshad documented association between maternal depressive symptoms and child stunting. Observation in this study showed that the interventional follow-up of the mothers produced improvement in growth parameters of their infants followed up in this study.