Rajiv Gandhi University of Health Sciences, Karnataka
Bangalore.
Annexure- II
Proforma For Registration Of Subjects For Dissertation
1. / Name of the Candidate and Address
(in block letters) / Dr. PRAJNA SHARMA.
Post Graduate Student,
Department Of Community Medicine,
SDM College Of Medical Sciences And Hospital, Dharwad – 580009
2. / Name of the Institution / Sri Dharmasthala Manjunatheshwara College OF Medical Sciences And Hospital,
Manjushree Nagar, Sattur,
Dharwad – 580009
3. / Course of Study and Subject / M.D., (COMMUNITYMEDICINE)
4. / Date of Admission to the Course / 05-06-2013
5. / Title of the Topic / DEPRESSION AMONG WOMEN DURING POSTPARTUM PERIOD.
6. / Brief resume of the intended work:
6.1 NEED FOR STUDY:
Postpartumperiod starts about an hour after the delivery of the placenta and includes the following six weeks1,during which dramatic hormonal changes occur, leading to depression among women.2Postpartumdepression(PPD)often also called as postnatal depression is defined as “a non psychotic depressive episode of mild to moderate severity beginning in or extending into the first postnatal year”and is often missed by primary care physician.3
Depression accounts for the greatest burden of disease among all the mental health problems, and is expected to become the second-highest among all general health problems by 2020. PPD is an major public health problem and important category of depression in its own right with a peak incidence at around 4-6 weeks leading to a substantial impact on the mother and her partner, the family, mother-baby interactions and the longer-term emotional and cognitive development of the baby.4
Globally, PPD has been reported affecting 10-27% women in westernsocieties, 15.8% in Arab women, 16% inZimbabwean women, 34.7% in South Africanwomen, 11.2% in Chinese women, 7% in Japanesewomenand 18% in Pakistani women.In India, PPDreports approximately 23% womenin hospital-based dataand prevalence varies from11% to 26%in community-based studies.5
PPD does not usually have a single cause, but it may be the result of a combination of factors.6Uniquefactors leading to PPD are such as sex of the child, protective influence of the various traditional rituals, financial insecurity, marital violence and lack of social support have emerged as risk factors for PPD in low and medium income countries like India, Pakistan, Turkey and Nigeria.7
Considering the consequences of postpartum depression, one cannot doubt the fact that, even though it affects a smaller percentage of women, its consequences equals to a major public health problem especially in developing countries, where access to health care and emphasis on mental health is minimal. Therefore postpartum depression could be one of the silent contributors to the poor maternal and child health indices in developing countries8 and most of the maternal health programs have done little to reduce the burden of this consequentmorbidity.9
Thus, routine use of screening scales for the purpose of identifying symptoms of depression is an effective, simple andeconomical way to identify women at risk.10
There are very few studies on postpartum depression and associated factors in India and no data is available in our local setting. The objective of this study is to estimate the prevalence and to know factors leading to postpartum depression among women residing in urban slums.
6.2 REVIEW OF LITERATURE:
Various studies on postpartum depression done in the past have the following conclusions:
1.A study conducted at public health clinics, district hospital and MCH centrein Udupi, Karnataka, India in 2011 to know the prevalence and factors leading to postpartum depression among women using Edinburgh Postnatal Depression Scale (EPDS) and Mini International Neuropsychiatric Interview (MINIPlus). It was found that prevalence of postpartum depression was 11.3% in the first week and maximum 15.8% were suffering at six weeks. On multivariate analysis, postpartum depression was significantly associated with multiparity (OR=0.16, 95% CI:0.03–0.75, p=0.021), poor social support (OR=10.18, 95% CI:1.68–61.66, p=0.012), and stressful life events in the preceding one year (OR=1.05, 95% CI:1.03–1.68, p=0.005).On univariate analysis, postpartum depression was also significantly associated with lower socioeconomic status, multiparity, delivering a female infant and disappointment with the sex of the baby.7
2.A study conducted at immunization clinics at rural health training centre, Nandagudi in rural Bangalore, India in 2012to know the prevalence and factors leading to postnatal depression among postnatal women using EPDS,it was found that 11.47% had postnatal depression.Partner non-participation in baby care was an important risk factor among 20(71.42%) cases, spousal disappointment with sex was seen among 16 (57.14%) cases. Other risk factors were excessive crying of the infant (46.42%), marital dissatisfaction (28.57%), breast feeding problems (28.57%), less sleep for the mother (25%) and low social support (14.28%) were also noted.11
3.A study conducted at collaborative obstetrics and midwifery practice in Albuquerque, New Mexico, USA in 2007 to know the prevalence of postpartum depression among women using Postpartum Depression Screening Scale (PDSS). The prevalence of a positive screen for major PPD was 16%, and an additional 20% of women had potentialsymptoms of PPD. Women who had a positive screen at 6 weeks after birth were more likely to have not completed high school education, unpartnered, exclusively bottle feeding and have a history of depression. Two variables were statistically significant predictors of screening positively with the PDSS following logistic regression: history of depression (risk ratio, 4.8; 95% confidence interval, 4.4 - 5.2) and exclusive bottle feeding (risk ratio, 2.0; 95% confidence interval, 1.6 - 2.4).12
4.A study conducted by School of Nursing, Deakin University, Geelong, Victoria, Australia in 2004 to evaluate the clinical application of three screening instruments,Postpartum Depression Prediction Inventory (PDPI), PDSS and EPDSfor the early recognition of postpartum depression. It was found that 17% of the women scored significant symptoms of post-partum depression and 10–15% had a positive screen for major postnatal depression. There was a statistically significant correlation between the total score on the Postpartum Depression Screening Scale and the Edinburgh Postnatal Depression Scale. Of those eight women identified as being at risk, seven had received anticipatory guidance and five had received counselling by the nurses. The Postpartum Depression Prediction Inventory enabled nurses to identify women at risk of post-partum depression and offer interventions.13
5.A study conducted by School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA in 2008to compare the effectiveness of three screening instruments-EPDS, Patient Health Questionnaire-9 (PHQ-9) and PDSS for identifying women with PPD.123 (91%) were screened out of which EPDS at a cutoff point of > or =10 identified 8 (62%), the PHQ-9 at a cutoff point of > or =10 identified 4 (31%) and the PDSS 7-item Short Form (PDSS_SF) at a cutoff point of > or =14 identified 12 (92%). The EPDS was significantly more accurate (p = 0.01) than the PDSS_SF and PHQ-9 with the cutoff points used. After correcting for verification bias, it was also found that EPDS and the PDSS_SF were significantly more accurate than the PHQ-9 (p < 0.03).14
6.A study conducted by Olmsted Medical Center, Rochester, U.S. State of Minnesotain 2008compared the EPDSand PHQ-9 as screening tools for assessing postpartum depression. Out of 481 women,138 had elevated EPDS scores and 132 had elevatedPHQ-9 scores. Concordance of the EPDS and PHQ-9 was present in 399 (83%) women. 326 (67.8%) had “normal” score on both, and 73 (15.2%) had elevated scores for both. Discordantscores in 82 women included, 17 with elevated PHQ-9 scores but normal EPDS scores and 65 withelevated EPDS scores and PHQ-9 scores <10. It was concluded that postpartum depression screening is feasible in primary care practices, and for mostwomen the EPDS and PHQ-9 scores were concordant.15
6.3 OBJECTIVES OF THE STUDY:
  1. To know the prevalence of depression among women during postpartum period.
  2. To know factors leading to depression during postpartum period.
  3. Torecommend preventive measures to avoid further depression during the postpartum period.

7. / Materials and Methods:
7.1 SOURCE OF DATA:
  • Study subjects: The study population consists of postpartum women in the agegroup of 18 - 40 years and in the postpartum period (2-6weeks) in urban field practice area,
Department of Community Medicine, SDMCMS&H, Dharwad.
Inclusion Criteria: 1)Postpartum womenaged more than18 yearsand less than 40years.
2) Postpartum women two weeks and six weeks after delivery.
3)Postpartum women who have beenresiding in the study area for
more than one year.
4) Postpartum women willing to participate on voluntary basis
after giving a written consent.
5) Postpartum women who has delivered a live healthy baby.
Exclusion Criteria: 1)Postpartum women less than 18 yrs and more than 40 yrs of age.
2) Postpartum women two weeks and six weeks after delivery.
3) Postpartum mother who belong to the families who have not
beenresiding in the study areafor more than one year.
4) Women with previously known psychiatric disorder.
5) Postpartum women not willing to give consent.
6) Women who have delivered a stillborn or baby with congenital
anomalies.
  • Study area: Urban field practice area, Department of Community
Medicine, SDMCMSH, Dharwad.
  • Study period: One year. From November 2013 to October 2014
7.2 METHODS OF COLLECTION OF DATA:
  • Study design: Community based, cross-sectional study.
  • Sample size: The prevalence of postpartum depression in India is26%.[5]
Based on the formula 4pq/L2, where p is the prevalence (26%),
q = 1- p (74%) and L the permissible error, taken as20%, the
sample sizeworked out to be 284 at 5% alphaerror.
  • Sampling procedure:A house to house survey with systematic random sampling
will be done (every 5thhouse will be considered)
  • Study instrument: A pre-designed and pre-tested proforma, Edinburgh postnatal depression scale (EPDS)16, Postpartum depression screening scale (PDSS)17 and Patient health questionnaire-9 (PHQ-9)18 will be used. Weighingmachine,measuring tape, sphygmomanometerandstethoscope will be used for clinicalexamination.
  • Data collection: During the study period, postpartum women willing to participate on voluntary basis with prior written consent will be interviewed and data will be recorded in a pre-designed and pre-testedproforma, EPDS, PDSS andPHQ-9 to know the level of depression and factors leading to it in thepostpartum period. Information regarding demographic profile, environmental and sanitary conditions will also be collected. Generalphysicalexamination along with height and weight willalso betaken.
  • Study analysis: Descriptive statistics will be calculated (means, std.deviation, frequencies and percentages). Further,Chi-square test will be applied to find out association between two attributes. Multivariate analysis will be performed and results will be presented as odds ratio with 95% confidence intervals. Statistical significance will be set at 0.05% level of significance (p < 0.05)
7.3 Does the study require any investigations or interventions to be conducted on patients or other humans or animals? (If so, please describe briefly)
NO.
7.4 Has ethical clearance been obtained from ethical committee of your institution in case of
7.3?
Ethical clearancehas been obtained from the Institutional Ethics committee of SDM College of MedicalSciences and Hospital, Dharwad (Ref: SDMIEC: 87:2013, Dated: 6/11/2013).
8. / List of References:
  1. World Health Organization. Defining the postpartum period. In: Department of Reproductive Health and Research, World Health Organization. Postpartum care of
the mother and newborn: a practical guide. 1998. Accessed online November 5,2013,
  1. Priya Paul CM, StanlyAMS, Archanalakshmi PA. A study on the prevalence of depression among women in the reproductive age group(15-49years) in a rural population. Indian Journal of Research 2013;2(9):169-72.
  2. NimishaDD , Ritambhara YM, JaishreeG. Study of prevalence and risk factors of postpartum depression. Natl J Med Res 2012;2(2):194-98
  3. HewittCE, et al.Methods to identify postnatal depressionin primary care: an integrated evidencesynthesis and value of informationanalysis. Health Technol Assess2009;13(36):1-3
  4. Mina S, Balhara YPS, VermaR, MathurS. Anxiety and depression amongst the urban females of Delhi in ante-partum and post-partum period. Delhi psychiatry journal. 2012;15(2):347-51.
  5. Khatri S, Kubavat KB. Basic Body Awareness in Postnatal Depression-A Case study. Ibnosina J Med BS2013;5(1):45-6.
  6. HegdeS, LathaKS, BhatSM, SharmaPSVN, KamathA, ShettyA. Postpartum Depression: Prevalence and Associated Factors among Women in India. J Womens Health, Issues Care 2012;1(1):1-7
  1. KakyoTA, MuliiraJK, MbalindaSN, KizzaIB, MuliiraRS. Factors associated with depressive symptoms among postpartum mother in a rural district in Uganda. Midwifery2012;28(3):374-79.
  2. IyengarK, YadavR, SenS. Consequences of maternal complications in women’s lives in the first postpartum year: aprospective cohort study. J Health Popul Nutr 2012;30(2):226-40.
  3. ZubaranC, SchumacherM, RoxoMR, ForestiK. Screening tools for postpartum depression: validity and cultural dimensions. Afr J Psychiatry 2010;13(5):357-65.
  4. Sudeepa D, Madhukumar S, GaikwadV. A Study on Postnatal Depression of Women in Rural Bangalore. Int J Health SciRes2013;3(1):1-6.
  5. Mancini F, CarlsonC, AlbersL. Use of the Postpartum Depression Screening Scale in a Collaborative Obstetric Practice. J Midwifery Womens Health. 2007;52(5):429–34.
  6. HannaB,Jarman H, SavageS. The clinical application of three screening tools for recognizing post-partum depression. IntJ Nurs Pract2004;10(2):72–9.
  7. Hanusa BH, Scholle SH, Haskett RF, Spadaro K, Wisner KL.Screening for depression in the postpartum period: a comparison of three instruments. J Womens Health (Larchmt). 2008;17(4):585-96.
  8. Yawn BP, et al.Concordance of Edinburgh Postnatal Depression Scale (EPDS) and Patient Health Questionnaire(PHQ-9) to assess Increased Risk of Depressionamong Postpartum Women.J Am Board Fam Med 2009;22(5):483– 91.
  9. CoxJL, Holden JM, Sagovsky R. Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987;150:782-86.
  10. Beck CT, Gable RK. Postpartum Depression Screening Scale:Development and Psychometric Testing. Nurs Res 2000;49(5):272-82.
  11. Gjerdingen D, Crow S, McGovernP, MinerM, CenterB. Postpartum depression screening at well child visits:validity of a 2 question screen and the PHQ-9. Ann Fam Med2009;7(1):63-70.

9. / Signature of the candidate
10. / Remarks of the guide / No study has been undertaken on this topic in the department. So it is worthwhile to study depression among women during postpartum period, which is neglected major mental health problem in India using different types of screening methods.
11. / Name and Designation
11.1 Guide / DR. Mayur S Sherkhane
m.d (community medicine), mph, mba (hm)
associate PROFESSOR,
DEPARTMENT OF COMMUNITY MEDICINE,
sdmcmsh, dharwad.
11.2 Signature
11.3 Co-Guide / ------
11.4 Signature / ------
11.5 Head of the Department / DR. G.N. PRABHAKARA
M.D.
PROFESSOR AND HEAD
DEPARTMENT OF COMMUNITY MEDICINE,
sdm COLLEGE OF MEDICAL SCIENCES AND HOSPITAL, DHARWAD.
11.6 Signature
12. / 12.1 Remarks of the Principal and Chairman
12.2 Signature

CONSENT FORM

I ______daughter/wife of ______aged ______years resident of ______do here by give consent, to be included in the study titled “DEPRESSION AMONG WOMEN DURING POSTPARTUM PERIOD”, being conducted by ______.

My queries about the study have been answered satisfactorily. I have signed this consent voluntarily, out of my free will, without any pressure and in my full senses as this study does not involve any investigations and interventions and also for publishing this study in any scientific journal, I accept myself to be as a study participant.

Name and Signature of the Study Participant

Name and Signature of the Witness

Name and Signature of the Investigator

Place:

Date :

DEPRESSION AMONG WOMEN DURING POSTPARTUM PERIOD

PROFORMA

PART-1

PERSONAL/IDENTIFICATION DATA

  1. Sl.No:
  2. Age:
  3. Address:
  4. Occupation: Agriculturist/ Labourer/ Housewife/ Businessman/ Student/ Govt.employee/ Pvt.employee/ Others / Not applicable.
  5. Marital status: Unmarried/Married/ Widowed/Divorced/Separate

A)Age at marriage

B)Consanguineous marriage:

C)Duration of marriage:

6. Education history: Illiterate/ Primary/ Highschool/ PUC/ Graduate/ Post graduate

7. Religion: Hindu/ Muslim/ Christian/ Others

Family Details

1.Number of members in the family:

2.Type of family: Nuclear/ Joint/ Three generation

3.Total number of earning members in the family (per capita income): …………………

4.Socio-Economic status (As per modified B G Prasad’s Classification) a) Class I b) Class II c) Class III d) Class IV e) Class V

5.Family composition:

Sl.No / Name / Age / Sex / Education / Occupation / Income / Relation with head of family

Environmental Data

  1. Site:
  2. Type of house: Kuccha/ Pucca Set Back: Present/Absent
  3. Floor: Dampness- Present/ Absent
  4. Walls: Plastered/ Not plastered
  5. Roof: RCC slab/ Thatched
  6. Number of Rooms: Overcrowding: Present/Absent
  7. Floor area:
  8. Cross ventilation: Present/Absent
  9. Lighting: Adequate/ Inadequate
  10. Kitchen: Separate/ Not separate Fuel used: Smokeless/ Wood/ LPG gas Smoke Vent: Present/Absent
  11. Privy: Sanitary/ Open Air
  12. Garbage and Refuse Disposal: Indiscriminate/ Municipality Dustbins
  13. Water Supply: Municipality/ Bore Well

HISTORY

Antepartum history

  1. LMP:
  2. EDD:
  3. Parity:
  4. Planning of pregnancy: Planned/ Unplanned/ Treated infertility
  5. First trimester: UPT test done: yes/no

Folic acid: yes/no

Vomiting: Mild/ Moderate/ Severe (hospitalized)

Scan done: yes/no

Any warning signs: yes/no If yes, specify:

Number of hospital visits: 1/2/3

  1. Second trimester: TT : First dose/ Second dose/ None

Iron, folic acid and calcium given: yes/no

Any warning signs: yes/no If yes specify:

Scan done: yes/no

Elevated BP: yes/no

GCT/OGTT done: yes (normal / elevated)/ no

Other medical complications:

Number of hospital visits:

  1. Third trimester: Any warning signs: yes/no If yes specify:

Any medical complications:

Number of hospital visits:

Intrapartum history

  1. Date of delivery:
  2. Gestational age at delivery: Preterm/ Term/ Post term
  3. Place of delivery: Home/ Hospital/ PHC
  4. Mode of delivery: Normal/ LSCS/ Instrumental
  5. Length of delivery:
  6. Blood transfusion done: yes/no
  7. Cry of baby at birth: Immediately/ Delayed
  8. NICU admission: yes/ no

Postpartum history

  1. Hospital stay(no of days): 1-3days/ 3-5days/ 5-7days/ >7days
  2. Breast feeding: a) yes- initiation: immediately/delayed

b) Prelacteal feeds given: yes/ no

  1. Exclusive breast feeding till: <4 months/ 4-6 months/ >6 months
  2. Family planning method used: OCPs/IUCDs/ barrier method/none/others
  3. Baby: Weight: LBW/ Normal Sex: Male/Female
  4. Trouble breast feeding/sucking: yes/no
  5. Birth injury: yes/no
  6. Excess cry:
  7. Any other complaints:
  8. If hospitalized baby anytime: yes/no

PAST HISTORY

  1. Any abortion/ miscarriages/ stillbirths: yes/no
  2. Previous caesarian: yes/no
  3. Past psychiatric illness: yes/no
  4. PPD in previous pregnancy: yes/no
  5. Any complications during previous pregnancy: yes/no

PERSONAL HISTORY

  1. Age at menarche:
  2. Premenstrual tensions: yes/no
  3. Menstrual cycles: Regular/ Irregular
  4. Age at first child birth:
  5. Number of children:
  6. Habits: Alcohol/ Smoking/ Tobacco chewing/ Others

FAMILY HISTORY