Compliance to Antenatal Psychosocial Assessment Practice and the Effectiveness of Antenatal Group-Based Psychoeducation in Preventing Postpartum Depression, Jimma, Ethiopia: A Cluster-Randomized Controlled Trial

Abstract

Background: - In Ethiopia, one in five mothers suffers from postpartum depression. It carries adverse physical and psychological consequences for the mother, child, family, and society as a whole. Though the condition is an indication of the need for prompt interventions, there is no assessment and prevention targeted to this problem at maternal health care units in Ethiopia. Evidence indicates that, to prevent postpartum depression (PPD), universal screening and psychosocial support to be undertaken in early pregnancy to be effective. Pertinent to this, the WHO indicates that maternal health care providers hold a crucial role in detecting, preventing, and, if necessary, providing referrals to mental health care services. Objectives: So, the study tried to improve compliance to antenatal psychosocial assessment practice (ANPA) among maternal health care providers (MHCP) and assessed the effectiveness of antenatal group-based psychoeducation intervention in preventing PPD in maternal health care units, Jimma, Ethiopia. Methods: - To enhance compliance with ANPA practices among MHCP, a pre-post study design was implemented. Audit, feedback, and re-audit standard criteria were utilized, alongside a team-based analysis of organizational barriers. Additionally, strategies were identified to address those barriers. The Joanna Briggs Institute Practical Application of Clinical Evidence System (JBI-PACES) and Getting Research into Practice (GRiP) audit and feedback tool were used. The study was conducted from December 2018 to April 2019 using four standard ANPA audit criteria from JBI-PACES for both the baseline and follow up audits. All MHCP and 66 pregnant women, selected using the consecutive sampling method, participated. On the basis of the results, the gaps and barriers were analyzed using GRiP strategies. The next objective assessed the effectiveness of antenatal group-based psychoeducation (ANGPE) intervention aimed at preventing PPD while also enhancing postpartum depression literacy and social support. A cluster-randomized controlled trial was conducted using a parallel-group, single-blind, and two-arm intervention design with a 1:1 allocation ratio. This trial took place from March 28 to December 1, 2022, and involved 550

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(intervention=286 and control=264) pregnant women across 32 non-adjusted health centers. The health centers were randomized into two groups, with 16 health centers assigned to each arm, using a simple randomization technique. The units of randomization were health centers with an average cluster size of 20 pregnant women, 12-20 weeks of gestation, who scored (0-9) on the Patient Health Questionnaire-9. The intervention group received usual care plus five ANGPE classes, while the control group received only usual care. A well-validated patient health questioner-9, functional social support, and PPD literacy scale assessed PPD, social support, and PPD literacy, respectively. Data were collected in face-to-face interviews at 12–20 weeks gestation and 6 weeks postpartum. An Intention-to-treat analysis was used, and baseline characteristics were compared between groups using a χ² and an independent sample t-test for categorical and continuous measures, respectively. Finally, the magnitude of the intervention effect and predictors of the outcome variable were analyzed by using a relative risk and a mixed-effect model based on the objective of the study. Result: The baseline audit result revealed a 0% compliance rate for all evidence-based ANPA audit criteria. Lack of knowledge or training gaps, weak internal referral system or weak linkage between antenatal clinic and medical or behavioral treatment services, lack of locally validated tools for assessing depression in the antenatal clinic, client load, and shortage of private rooms were identified as barriers. However, the post implementation result showed that an average 91.5% practice of evidence based ANPA was applied as per standards by working on the above identified barriers. Regarding the cluster randomized controlled trial: - The overall response rate at the end line was 92.9%. The results showed that the prevalence of (PPD) in the intervention clusters was significantly lower than in the control group, with rates of 20 (7%) compared to 74 (28%), P = 0.001. Additionally, the relative risk (RR: 0.25 [0.07/0.28]) indicates that mothers who received ANGPE were 75% less likely to develop PPD than those in the control group who received only the usual care. Additionally, after controlling the community and individual-level variables, a mixed-effect analysis showed that ANGPE intervention (65%; AOR = 0.35, 95% CI = 0.13–0.99), social support (AOR = 0.04, 95%

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CI = 0.01–0.15), partner emotional support (AOR = 0.24, 95% CI = 0.12–0.51), PPD literacy (AOR = 0.25, 95% CI = 0.11–0.62), and self-esteem (AOR = 0.22, 95% CI = 0.11–0.47) were more likely to protect mothers from PPD. On the contrary, domestic work (AOR = 9.75, 95% CI = 3.37–28.16), neonates with complications (AOR = 5.79, 95% CI = 2.04–16.45), and unhealthy coping (AOR = 2.39, 95% CI = 1.06–5.42) exposed mothers to PPD. Furthermore, the study showed that mothers in the intervention arms were 2.04 times more likely than controls to have adequate social support (RR=2.044, 95% CI: 1.684-2.481). Similarly, mixed-effect analysis indicated that mothers in the intervention clusters (3.607; AOR=2.136–6.090) had partner emotional support (AOR=1.61; 1.00–2.59) and get support from their mother (AOR=4.25; 1.78–10.15) had adequate social support. However, mothers with PPD (AOR=.057 (.02-.19)), unhealthy coping (AOR=.27), and loneliness (AOR=.28 (.11-.69)) were less likely to have adequate social support. Furthermore, the study demonstrated a significant difference between groups regarding the overall mean PPD literacy score (intervention, 3.75±.46; control, 3.48±.46; ηp²=.07), ability to recognize PPD (intervention, 4.30±.64; control, 3.94±.75; ηp²=.06), knowledge of risk factors and causes (intervention, 4.03±.69; control, 3.67±.70; ηp²=.05), and access to PPD information (intervention, 3.28±1.25; control, 2.01±1.13; ηp²=.21) at p=.001, with marginal significance regarding self-care activities (intervention 4.37±.54, control 4.26±.50, ηp²=.01, P =.051). Conversely, there were no significant differences in knowledge of professional help (intervention 2.97±1.13, control 2.83±.80, ·p²=.00, P=.303), beliefs regarding professional help (intervention 2.67±.89, control 2.50±.72, ·p²=.01, P=.063), and attitudes towards PPD recognition and help-seeking (intervention 3.91±1.02, control 3.91±1.02, ·p²=.00, P=.586). Moreover, partner emotional support (AOR = .1, 95% CI = .02–.17), unhealthy coping (AOR = -.14, 95% CI = -.22–(-.07)), and multiparty (AOR = -.15, 95% CI = -.22–(-.08)) showed significant associations with overall PPD literacy score.