Postpartum Depression Among Mothers Who Gave Birth and Attended Public Health

Facilities of East Shewa Zone, Ethiopia.

Asnake Tesfaye

A Dissertation to be Submitted to the School of Graduate Studies of Addis Ababa University

for the Fulfillment of the Requirements for the Degree of Doctor of Philosophy (Ph.D) in
Social Work and Social Development

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 Postpartum Depressions among Mothers who Gave Birth and Attending Public Health
Facilities ofEastern Shewa Zone, Ethiopia

By

Asnake Tesfaye (MSW, Ph.DCandidate)

Advisor: Dr.Margaret E. Adamek (Professor and Director, Ph. D, Program)

Co-advisor: Dr. Yania Seid-mekiye (AAU Community Service Director)

A PHD Dissertation to be Submitted to the School of Graduate Studies of Addis Ababa

University for the Fulfillment of the Requirements for the Degree of Doctor of Philosophy
(PHD) in Social Work and Social Development

March 2020,

Addis Ababa University, Ethiopia

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 Addis Ababa University
School of Social Work
Name of Ph.D Candidate Asnake Tesfaye (MSW & Ph.D Candidate)

ID. No: GSR/1171/08

Name of Advisor Margaret E. Adamek, PhD

Professor and Director, PhD Program

Indiana University
Editor, Advances in Social Work

Name of Co-Advisor Yania Seid-Mekiye, Ph.D.

Head, School of Social Work
College of Social Sciences, AAU

Full title of PhD Project Postpartum Depression among Mothers Who Gave Birth and
Attended Public Health Facilities of East Shewa Zone, Ethiopia

Fully PhD Project life 2016- 2020

Study Area East Shewa Zone, Ethiopia

Total cost of the Project 102, 160 Ethiopian Birr($4442)

Address of Investigator (PI) Email: [email protected]

(Email, Tel and P O Box) Mobile: +251-911-315-444

P. O. Box , AAU 1176- Ethiopia

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 DEACLARATION
I, under signed, declare that this dissertation entitled: Postpartum Depressions among

Mothers who Gave Birth and Attending Public Health Facilities of East Shewa Zone,

Ethiopia, 2019: A Mixed Method Study is my original work, has not been presented for any

degree in any other university, and that all sources of materials used for it are duly

acknowledged.

Student‘s name: Asnake Tesfaye Signature: ________ Date:_______

CONFIRMATION AND APPROVAL

This dissertation has been submitted for examination with my approval as supervisors:

Name: Margaret E. Adamek (PhD): Signature: ____________ Date:______

Name: Yania Seid-Mekiye (PhD): Signature: ____________ Date: ________

SIGNED AND APPROVED BY THE BOARD OF EXAMINATION:

_______________ _____________ _____________

Supervisor Signature Date
_______________ ______________ _____________
Internal Examiner Signature Date
_______________ _______________ _____________
External Examiner Signature Dat

i
ACKNOWLEDGEMENT

I would like to express my heartfelt thanks to my Major Supervisor Professor

Margaret Adamek (Ph.D) for her guiding inputs and constructive comments with broader

insight on scientific concepts and methodological approaches while developing this

dissertation from the inception up to current stage. I am also thankful to my Co-Supervisor

Dr. Yanya Seid (Ph.D) for her productive and valuable comments while working on this

research. I would also like to acknowledge AAU School of Social Work for providing us this

wonderful opportunity for doing Ph.D within the School. I am also indepted to thank all the

ressearch participants, Adama Hospital leaders and midwives, Modjo Hospital Leaders and

midwives, Batu Hospital leaders and Midwives and last but not least Bishoftu Hospital

leaders and midwives for thier kind cooperation in all the process of data collection.

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ACRONYMS AND ABBREVIATIONS iii

ANC Antenatal Care

DHS Demographic and Health Survey

EDHS Ethiopia Demographic and Health Survey

IDI In-depth Interview

LAMICs Low- and middle-income countries

MMR Mixed Method Research

PHSW Public Health Social Work

PPD Postpartum Depression

PNC Postnatal Care

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TABLE OF CONTENTS

Contents
Deaclaration of Approval Form .................................................................................................. i
Acknowledgement .....................................................................................................................ii
Acronyms and Abbreviations .................................................................................................. iii
Table of Contents ...................................................................................................................... iv
Tables and Figures ................................................................................................................. viii
Abstract ..................................................................................................................................... ix
CHAPTER ONE: BACKGROUND ....................................................................................... 1
1.1. Background of the study ..................................................................................................... 1
1.2. Statement of the Problem .................................................................................................... 3
1.3. Objective of the stud ........................................................................................................... 6
General objective ................................................................................................................ 6
Specific objectives for Quantitative Study ......................................................................... 6
Objectives of qualitative study ........................................................................................... 6
1.4. Research questions .............................................................................................................. 7
1.5.Rationale for the study.........................................................................................................7

1.6. Significance of the Study ...................................................................................................9

1.7. Scope of the Study ...........................................................................................................11

1.8. Operational Definitions ...................................................................................................13

1.9. Organization of the proposal ............................................................................................14

CHAPTER TWO: LITERATURE REVIEW ..................................................................... 16

2.1. Postpartum Depression and Relevance to Social Work .................................................... 16
2.2. Major symptoms of postpartum depression ...................................................................... 18
2.3. Causes of Postpartum Depression ..................................................................................... 20
2.4. Socio demographic factors ................................................................................................ 20
2.5. Social Supports ................................................................................................................. 21
2.6. Prevalence of Postpartum depression ... ...........................................................................23
2.7. Prevalence and Contributing factors of PPD in Ethiopia .……………………………...24
2.9. Treatment for postpartum depression ................................................... ..........................26
2.10. Coping mechanisms with PPD .......................................................................................27

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2.11. Midwives‘ views and Perceptions about Postpartum Depression .................................. 29
2.12. Theories of Postpartum depression ................................................................................ 29
2.13. Conceptual framework .................................................................................................... 35
CHAPTER THREE: METHODOLOGY...........................................................................36

3.1. Description of Study Area and Study period .................................................................... 36

3.2. Research Paradigm............................................................................................................ 39
3.3. Research Approach ........................................................................................................... 39
3.4. Research Designe ............................................................................................................ 39

3.5. Quantitative Study ............................................................................................................ 41

3.5.1. The source population ...................................................................................................41

3.5.2. Study Population ............................................................................................................ 41

3.5.3. Inclusion and Exclusion Criteria.................................................................................... 41
3.5.4. Sampling ....................................................................................................................... 41
3.6. Study Period .....................................................................................................................44

3.7. Instrument..........................................................................................................................44

3.8. Reliability and Validity Testing ........................................................................................ 46

3.9. Variables of the study ....................................................................................................... 48
3.10. Quantitative Data Analysis ............................................................................................. 47
3.11. Qualitative Study ............................................................................................................ 49
3.12. Selection of Study Participants ....................................................................................... 48
3.13. Criteria within the target groups ..................................................................................... 49
3.14. Sampling for qualitative part ......................................................................................... 49
3.15. Qualitative Data Analysis ............................................................................................... 50
3.16. Data Quality Control for-Qualitative Study.................................................................... 52
3.17. Integrating Quantitative and Qualitative Data ................................................................ 53
3.18. Limitations of the study .................................................................................................54
3.19. Ethical Considerations ....................................................................................................57

CHAPTER FOUR: RESULTSvariate ................................................................................. 58

4.1. Overview of Results …………………………………………………………………….58

4.2. Socio-demographic and economic characteristics of the participants ..............................58

4.3. Obstetric Characteristics of study participant ……..………………………………..…..60

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4.4. Previous history of depression, substance abuse and social support ………………...…62

Intimate partner violence …………………………………………………………….63

Social support …………….…………….…….……………………….……………..64

4.5. Factors related to family ……..…………….……….…………………………………..64

4.6.Prevalence of postpartum depression..…………….……………………………………..65

4.7. Predictors of Postpartum depression …………………….……………………………..65

4.7.1. Postpartum depression by Socio-demographic variables ……………………….……65

4.7.2. Postpartum Depression by obstetric characteristics …………………….…………...66

4.7.3. Postpartum Depression by previous history, substance abuse and Social Support.….67

4.7.4. Postpartum Depression by Family-Related Factors ………………………………….68

4.7.5. Multivariable logistic regression analysis Model predicting Postpartum Depression..68

4.8. Qualitative Study ……………………….…………………………………………….72

4.9. Experience of postpartum depression among mothers in East Shewa Zone ..................74

4.10. Mothers‘Experienceof Emotional Distress ……………………………………………75

4.11. Related to the newborn ………………..………………………………………………79

4.12. Domestic Violence ……………………………………………………………………81

4.13. Socio- economic status …………………….………………………………………….84

4.14. Economic instability in the country / continuous inflation/ living cost ………..……..85

4.15. Mothers‘ Experience of Social support ……………………………………………… 86

4.16. Mothers experience in the Hospital .............................................................................89

4.2. Part two of the qualitative study ……………………………………………………….90

4.2.1. Characteristics of the seven Professional Midwives ………………………….…… 90

4.2.2. General views about their professional life as Midwives …………………………….91

4.2.3. Midwives on their views of Postpartum depression ………………………..………..96

CHAPTER FIVE: DISCUSSION....................................................................................... 101

5.1. Magnitude of postpartum depression ………………………….………………………101

5.2. Factors Associated with PPD ………………………………………………………….103

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5.3. PPD and violence against women ……………………………………………………..105

5.4. Social support …………………………………….……………………………………106

5.5. In relation to the hospital …………………………………..…………………………109

CHAPTER SIX: CONCLUSION, RECOMMENDATIOS AND IMPLICATIONS ..112

6.1. Conclusion ....................................................................................................................112

6.2. Implications for Social workers ....................................................................................114

6.3. Implications for social work Education .........................................................................115

6.4. Implications for health professionals .............................................................................116

6.5. Implications for local policy development .....................................................................118

6.6. Implications for future research .................................................................................... 120

6.7. Recommendations ………..……………………………………………………………122

REFERENCES ..................................................................................................................... 127

Annnexes................................................................................................................................ 140
Annex I: Consent form........................................................................................................... 140
Information sheet ................................................................................................................... 141
Annex II: Questionnaires ....................................................................................................... 142
Structured Questionnaire English Version............................................................................. 142
Structured Questionnaire Amharic Version ........................................................................... 161
Structured Questionnaire Afaan Oromo Version……….………..…………...……….……183
Assurance of PhD. Candidate (Principal investigator) ..........................................................206

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 List of Tables and Figures
Tables
Table 1. Characterstics of postpartum depression and Baby blues…………………..…...19
Table 2: Parameters used to determine the sample size for the second study objective… 42
Table 3. In-Depth Interview Sample for PPD mothers .....................................................49
Table 4: Summary of the Mixed Method Study Procedure ..............................................56
Table 5: SD characteristics of study participants (n=500) ………………………………58
Table 6: Factors related to pregnancy among depressed mothers ………………………. 60
Table 7: Factors related to delivery ………………………………………………………61
Table 8: Factors related to previous history of depression ………………………………61
Table 9: Family related factor for PPD..……………………………………………...... 63
Table 10. Multivariable logistic regression model predicting PPD ……………………. 69
Table 11: displays the participants‘ profile for the qualitative study................................72
Table 12: Themes and sub-themes from PPD IDPs……………………………………. 74
Table 13: Characteristics of Midwives who participated in the qualitative part ….…….90

Table 14: Themes and sub-themes from Midwives IDPs………………….…………….91

I. Figures
Figure 1: Conceptual frame work …..……………………..………………………...........35
Figure 2: map of the stud area ..........…………………………………………………….37
Figure 3: Pragmatism with its corresponding research designs, strategies and methods...40
Figure 4: Sampling Technique............................................................................................43

Figure 5: Qualitative and Quantitative Integration diagram ..............................................52

Figure 6: Diagrammatic presentation of sampling system ....................................................53
Figure 7: Intimate partner violence.....................................................................................62

Figure 8: Social support ....................................................................................................62

Figure 9: Prevalence of PPD ...............................................................................................64

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Abstract

Postpartum depression (PPD) is a pervasive disease in the big picture of reproductive

health. The World Health Organization declared there is no health if the issues of mental

health are ignored. Postpartum depression is a serious mental health disability characterized

by a prolonged period of emotional disturbance, occurring at a time of major life change and

increased responsibilities in the care of a newborn infant. PPD impacts a mother's thinking,

feeling or mood and may affect her ability to relate to others and function on a daily basis.

Postpartum Depression (PPD) is a serious public health problem that leads to high maternal

morbidity and mortality, enormously affecting the infant, family, and society. Thus, the aim

of this study was to determine the prevalence and associated factors of PPD. This study also

aims to explain mothers‘ experience of emotional distress in their first postnatal year. A

facility-based cross-sectional mixed method approach was employed. Approximately 550

postnatal mothers who gave birth within the past one year had participated in the quantitative

part of the study, with 10% non-response rate i.e. 500 participant and 17 research participants

were involved in the qualitative part of the study, out of which 10 are postpartum mothers

and seven of them are professional midwives. For the quantitative data, a simple random

sampling (SRS) technique was used to identify the sampling units from the public health

facilities based on their pre-determined patient flow rate. An SRS technique was used to

identify study participants using a lottery method. The data were cleaned accordingly and

then exported to SPSS Windows version 20.0 for further analysis. The magnitude of

postpartum depression among the study population was 23.2%. Postpartum depression is

higher among mothers with age below 28 years. domestic violence, unplanned pregnancy,

baby with sleeping problems, health of the baby, lack of social support and partner‘s

substance use has significant association with postpartum depression. The magnitude of

postpartum depression in East Shewa zone, East Ethiopia was high. This underline the

ix
necessity of giving attention to PPD by policy makers, health professionals and social care

planners for integrating of screening strategies for depression following childbirth.

Keywords: East Shewa Zone, Ethiopia, Emotional distress, Postpartum depression (PPD)

and Social support.

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 CHAPTER ONE

1.1 Background of the study

Globally, maternal mental health problems like depression and anxiety are very

common in the course of the postnatal period. Maternal mental health issues are a major

health and social challenges that is necessary to be considered. Appropriate prevention and

treatment is important to reduce a devastating impact on mothers, newborns, families, and

societies. Maternal mental illnesses are one of the causes of maternal death during pregnancy

and after childbirth (Howard, Piot & Stein, 2014). In high-income countries, about one in

ten mothers have mental health problems while in low and middle-income countries one in

three to one in five mothers have a mental health problem during pregnancy and after

childbirth. For example, African countries such as Ethiopia, Nigeria, Senegal, South Africa

and Uganda have high rates of maternal mental health problems during pregnancy (World

Health Organization WHO, 2008). Poor perinatal mental health has an undesirable impact on

women in raising their child and on the growth and development of the child. The

consequence of perinatal mental health problems is severe in children and associated with a

range of adverse outcomes such as childhood depression, nutritional problems, issues with

breastfeeding, cognitive and motor delays, behavioural problems, and low academic

achievement (Husain, Cruickshank, Tomenson, Khan & Rahman, 2012). In low income

countries, it is estimated that approximately 16% of pregnant mothers and 20% of postpartum

mothers are affected by a common perinatal mental disorder such as anxiety and depression

(Fisher et al., 2012).

According to Hanlon (2012), one of the major common mental health conditions to

affect mothers globally is depression. Depression is one of the major health problems that is

twice as common in women of childbearing age than in men, and is estimated to become the

1
second most prevalent of all general health problems globally by 2020 (Norhayati, Hazlina,

Asrenee & Emilin, 2015). These maternal depressive conditions include antenatal depression,

postpartum depression, and postpartum psychosis. Depression during pregnancy and after

childbirth increase the suffering and disability of the mother and reduce the mother‘s

response to newborn needs. Studies showed that early diagnosis and intervention with

mothers leads to improved raising and development of the child and reduces the occurrence

of diharia and malnutrition (Rahman, Bunn, Lovel & Creed, 2007). Maternal mental health

problems could be alleviated by giving appropriate advice and social support during antenatal

care visits to new mothers and mothers at risk of perinatal depression (Rahman, Malik,

Sikander, Roberts & Creed, 2008)

The sustainable development goal 3(SDG3, target 3.4) indicated that by 2030 the

target goal is to reduce by one-third premature mortality from non-communicable diseases

through prevention and treatment and promote mental health and well-being in prevention

methods of common mental health problems (WHO, 2016). This goal shows a strong focus

on preventing and reducing mortality related to common mental health problems. Evidence

indicating that some low-income countries have started offering integrated maternal mental

health services for the prevention of maternal mental health problems. Low cost interventions

that involve primary health care providers influence not only the health of the mothers but

also the growth and development of children (Shrivastava, Ramasamy&Shrivastava, 2015)

Women of childbearing age are susceptible to antenatal and postnatal depression and

anxiety. Early identification and management of depression during antenatal visits is essential

for the health of women, their newborn and family, and as well as for the community as a

whole. There are simple and reliable tools and cost-effective interventions to recognize

maternal mental health problems during pregnancy and after childbirth at a primary health

care level. For instance, health care workers working at maternal and child health care

2
services can be trained to identify the symptoms and signs of mental health problems and

counsel women about their anxiety and stress and about coping methods. Hence, maternal

mental health approaches are simple to integrate into ongoing maternal health care services

and require strengthening of basic health-care systems (Howard, et al, 2014).

As per the researcher‘s knowledge in this specific study area, maternal mental health

has suffered from a lack of research as evidenced by the search conducted via electronics on

the current status of postpartum depression and communication with zonal health offices. The

study seeks to explore mothers‘ experience of emotional distress in their first postnatal year,

the type of social support used to prevent or minimize PPD on East Shewa Zone and also

aimed to determine the risk factors for PPD among mothers attending public health facilities

in East Shewa zone. This is important as base line data to inform social work practice and to

assist stakeholders in improving the health care of women using antenatal care services in

health facilities.

1.2. Statement of the Problem

Postpartum depression (PPD) is a global problem that demands a worldwide response.

Depression is reported as second after HIV/AIDS in its total disability for women in the

reproductive age group (WHO, 2001, 2017). PPD is also associated with the transition to

parenthood as a stressful time wherein parents are presented with a range of new challenges

(Doss, Cicila, Hsueh, Morrison & Carhart, 2014). Kessler (2003) asserted that depression is a

prominent source of disease among mothers with an occurrence twofold greater than in men.

Postpartum depression can have serious mental health consequences for populations that are

of concern to social workers. These populations include financially vulnerable women,

adolescent girls, and single mothers (Abrams & Curran, 2007).

3
 The postpartum stage is usually recognized as an amplified season of risk for the

occurrence of severe mood disorders. Postpartum depression can have adverse long-term

effects. For the mother, the episode can be the precursor of chronic recurrent depression. For

her children, a mother‘s ongoing depression can contribute to emotional, behavioral,

cognitive, and interpersonal problems in later life (Jacobsen, 1999). Postpartum depression

affects the quality of life of mothers, has negative consequences for the emotional,

behavioral, and cognitive functioning of their infants, and threatens the healthy functioning of

the entire family (Sobey, 2002).

Several contemporary research articles are reporting depression as one of the crucial

public health problems. (Andersson, Sundstrom-Poromaa, Wulff, Astrom & Bixo, 2004;

Dayan, Creveuil, Herlicoviez, Herbel, Baranger, Savoye, et al. 2002). Postpartum depression

attacks mothers by disabling her normal life and daily functions. (Senturk, Hanlon, Medihin,

Dewey, Araya, Alem, Prince & Stewart, 2012). The severity of the problem of postpartum

depression is; it will not end with limiting the daily life. But also come up with manners of

less self-care, such behaviors are considered as a health risk behavior that has long term

consequences on the mothers. (Katon, Russo, Gavin, Melville &Katon, 2011). From this we

can infer that PPD is a challenge for not only mothers but affects family and community in

general.

Moreover, several literatures are witnessing the adversative bearings of postpartum

depression on the babies as well, in this sense, we can say PPD is a serious problem that

affect the future generation (Grote, Bridge, Gavin, Melville, Iyengar & Katon, 2010). PPD is

affecting one mothers out of four, affecting mothers will affect the children in a numerous

way, and hence, we are seeing PPD has great implication in impacting the generations to

come as well.

4
 As Illechukwu (1991), depicted postpartum depression is a substantial public health

problem that throw hostile impact on mothers‘ daily activity and her self-care and also the

impact arrays child health and development including family cohesion. PPD is a problem

which brings unsafe condition to a family. Once mothers are with PPD they totally loss their

motivation and interest with daily life and become careless. (Carney, Freedlanda, Millerb &

Jaffec, 2002)

Furthermore, mothers with emotional distress exhibits trouble of attachment and

interacting with her newborn; which implies developmental problems of her child. (Lusskin

et al., 2007). On the other hand, we are seeing some literatures who are suggesting long-

lasting postpartum depression which can result with deprived language skills among children.

Postpartum depression, if left untreated, negatively impacts the mothers‘ ability for proper

maternal responsibility. Hence, PPD negatively affects her self-esteem while putting the child

at unnecessary risks in both psychologically and physically (Perfetti, et al., 2004).

Some mothers disguise the real symptoms of PPD and this makes the diagnosis

process difficult. Midwives and mothers might not always distinguish indirect symptoms of

postpartum depression (Chaudron et al., 2005). Mothers who are unable to recognize or

identify depression often cannot articulate their feelings, thus postpartum depression persists

untreated. Therefore, such research is important in creating awareness to start a proper

screening for postpartum (Howell et al., 2005). Underestimating symptoms of PPD or lacking

of knowledge towards PPD will have a devastating impact as evidenced by the literatures

from all over the world.

The Ethiopian demographic and health survey report of 2016 revealed that; mothers

and their babies are most defenseless during postnatal period. Many other long-term

5
conditions also disable women who survive delivery-related complications including

depression (EDHS, 2016).

The magnitude of PPD is quite alarming in both developed and developing nations

(WHO, 2008). The problem in developing countries like Ethiopia is widespread and

associated with socioeconomic status and other factors. As to the researcher‘s knowledge,

despite the wide scope of the problem, there are insufficient social work studies which

describe the mothers‘ experience with PPD in the study area and disclose the severity of PPD.

Therefore, we need to study the problem of postpartum depression as it has multiple impacts.

The impact is not only on mothers but the children‘s, the future generations, family,

community and the nation at large. The researcher of this study believed that, there are no

research in the current study area; hence conducting such study will help to have a better

understanding of the problem of PPD in the study area. Henceforth, this study aimed to

explore on the magnitude and the associated factors of postpartum depression in East Shewa

Zone of Ethiopia.

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1.3. Aim and Objective of the study

General objective

To Investigate Postpartum Depression Among Mothers Who Gave Birth and Attended

Public Health Facilities of East Shewa Zone, Ethiopia, 2019.

Specific objectives for Quantitative Study

 To determine the magnitude of postpartum depression among mothers who gave birth

and attended public health facilities in East Shewa Zone.

 To assess factors associated with PPD in relation to obestatric characterstics, previous

history of depression, substance abuse, social support and family among mothers who

gave birth and attended public health facilities of East Shewa Zone

Objectives of qualitative study

 To explore the experience of postpartum depression among mothers in East Shewa

Zone

 To explore the type of social support mothers received during the postpartum period in

East Shewa Zone.

 To explore the views and experiences of midwives‘ about postpartum depression among

mothers in East Shewa Zone.

1.4. Research questions

 What is the current magnitude of postpartum depression among mothers in East

Shewa Zone?

 What are the factors associated with postpartum depression among mothers in East

Shewa Zone?

7
  How do women experience the postpartum depression within their first postnatal year

in East Shewa Zone?

 How do mothers veiw their experiences of social support during the postpartum

period in the East Shewa Zone?

 How do profesional midwives view postpartum depression among mothers in East

Shewa Zone?

1.5. Rationale for the Study

From my experience, I learned about PPD when I was Master of Social Work (MSW)

student in India. As a second year MSW trainee in 2011, I have joined Government hospital

named Krishna Teaching Hospital Department of Psychiatry, Mysore, India for one year.

Thereby, I worked with health professionals who specialized in mental health. Within the

psychiatric inpatient and outpatient departments there were mothers with postpartum

depression and postpartum psychosis. I had an opportunity to work with health workers and

other professionals as a team member in the psychiatry department. At that time such

exposure gave me great insight into the role of a social worker in mental health settings.

Though I joined as a course requirement, I developed an interest since then. In addition, I had

taken the course Preventive Medicine and Medical Social Work and also psychiatric social

work with four credit hours. Such classroom and hospital level engagement spurred an

interest in me and inspired me to contribute at this level.

On the other hand, the literature review in the area of PPD in Ethiopia revealed that

PPD is a pervasive disease across the country. The World Health Organization report also

gave emphasis as PPD is a serious mental health disability characterized by a prolonged

period of emotional disturbance, occurring at a time of major life change and increased

responsibilities in the care of a newborn infant. PPD impacts a mother's thinking, feelings

8
 or mood, and may affect her ability to relate to others and function on a daily basis.

Postpartum Depression (PPD) is a serious public health problem that leads to high

maternal morbidity and mortality, enormously affecting the infant, family, and society.

These issues in the literature convinced me to do more research to confirm the prevalence

and factors associated with PPD.

Furthermore, my background as a social worker also accentuates the need to

consider the vulnerable and neglected groups of the society in our research and practice.

As a social work student, the present and emerging social problems and health problems

such as negative effects of globalization, unemployed youth, drag addiction, vulnerable

mothers, and disasters are affecting us in complex ways. These have brought questions

regarding the adequacy of Social workers to work with public health professionals. I also

share the views that claim Social work and public health share a social justice mission to

improve, defend, and enhance well-being, working together to ameliorate social health

problems (Keefe & Jurkowski, 2013). In Ethiopia it is necessary to open the platform for

PHSW. Therefore, I believe it is necessary to conduct research that are linked with both

Social work‘s and Public Health‘s concern, and the combination of the two as an emerging

branch of Social Work i.e. Public Health Social Work (PHSW).

Generally, the three points, i.e. The review literature on the ground, My academic

background of social work and my expirience with public health setting practical

attachment contributed to the emergence of this study. Hence, I would like to give voice

and make contribution in doing research in PPD among postpartum mothers.

1.6. Significance of the Study

A study conducted in Melbourne, Australia on PPD pointed to a need for a broader

assessment of distress in the PPD with a view to prevention and early intervention (Miller,

Pallant & Negri, 2006). Therefore, to mention some of the significance of the current study

9
includes to the postpartum mothers, to health care practitioners, social work professionals,

knowledge production and policy makers as well. Below discussed each of the significances

shortly.

Significance for postpartum mothers: The results of the current study may come up

with vital benefits for postpartum mothers in many aspects. Exploring the associated factors

of postpartum depression that has practically affecting mothers can be exposed through the

available means to reach mothers. This could be exposed by local government who requested

the researcher to bring the dissertation in hard and soft copy up on the approval of data

collection. Hence, the result will help mothers to be aware about the impact of postpartum

depression and they can easily manage with necessary consultations once they know PPD

symptoms in their own.

Significance for health care practitioners: Our study finding portrays on the current

status and activities of midwife by provide insight to inform the impact of PPD. This research

also can help health care providers to design appropriate intervention strategies that

appreciate postpartum mothers screening and proper actions for those who are with PPD.

Furthermore, our research findings will help health care practitioners to raise up to date

awareness on PPD and can develop a working screening tools, once they know the

prevalence of PPD.

Significance for Social Work Professionals: Traditionally, Social Work has been a

field of study concerned with helping the needy to help themselves. This kind of help was

similar to the informal help provided by the given community. But, currently the field of

Social Work practice is developed and professionalized with emprically-based knowledge. In

spite of the trend that social workers have an established history of delivering services to

mothers and children, there is limited research published in social work journals to inform

10
social workers in their work with mothers with PPD (Keefe, Brownstein-Evans, Lane, Carter,

& Rouland Polmanteer, 2015). The effects of postnatal depression (PPD) on mothers, their

marital relationship, and their children make it an important condition to diagnose, treat, and

prevent (Robinson & Stewart, 2001).

Social Workers primarily strive to bring about social welfare of the disadvantage.

Therefore, as a social worker our commission is attaining the leading goal of the profession,

that is enhancing the overall well-being of all people by responding to the needs of vulnerable

members of a society and people living in abject poverty (Rubin, & Babbie, 2012). Such

kinds of study will inform the social worker for zooming in to an important focal point to do

the needful in the health settings, especially issues related to postpartum depression. Besides,

the current finding will help to intensify the social work profession‘s responsibility with

settings such as maternal health. The result we obtain from this study can be important one to

activate facility benefactors such as government, non-governmental, and voluntary

community-based associations to design appropriate interventions to address the identified

magnitude and associated factors of PPD that the current East Shewa dweller mothers are

facing during their seasons following delivery.

Significance for knowledge production: According to the researcher‘s knowledge,

there is no study conducted in the current study area. By considering the limited study with

the subject of postpartum depression in the current study area, our research could be one of

the first study conducted within East Shewa Zone on PPD. This will help as a baseline for

many studies to come. With this research we have conducted both qualitative and quantitative

data and explored both statistical and thematical analysis on PPD.

Significance for policy and further research development: In the Ethiopian

context, the researcher has communicated with higher officials and observed annual reports

11
from Oromia Health bureau. According to the report, there is no scientific research on PPD in

this specific study area. Hence, studying PPD will bring usable findings that are important

for stakeholders in their efforts to overcome such health challenges. This paper may be useful

for raising community awareness by disseminating the findings. In addition, the present study

will be published in reputable journals and be disseminated to other research groups and the

academic community in general. Further, the database generated from the study will be made

available to other users for more in-depth analysis. In addition, since this research findings

came up with valuable information, it can be valuable for policy advocates and policy makers

to design timely and relevant policy for combating PPD.

1.7. Scope of the Study

The current research aimed to study postpartum depression among mothers who gave

birth and attended public health facilities of East Shewa Zone, Ethiopia. Within this study

magnitude of PPD, factors associated with PPD, social support, and midwives‘ and mothers‘

view towards PPD were covered. An institution-based cross-sectional study with a concurrent

mixed method design was employed. The study sample for the quantitative study is 500

postpartum mothers who gave birth and attended public health facilities of East Shewa Zone

within one year after delivery. The sample size for the qualitative study was 17,i.e.,

qualitative data were collected from 10 postpartum mothers with diverse sociodemographic

characteristics and 7 professional midwives. The data collection period was from August 1-

2019 up to August 30-2019.

12
1.8. Operational definitions

 Postpartum Depression (PPD): is a condition that impacts thinking, feeling or

mood and may affect one‘s ability to relate to others and function on a daily

basis. PPD is also an affective mood disorder with symptoms of a major decrease

or increase in appetite, moderate to severe anxiety, headaches, and chest

pains.The onset is generally within four weeks after delivery up to one year.

 Postpartum period: is defined as one hour following the delivery of the

placenta through the first six weeks of an infant‘s life and up to one year (WHO,

1998).

 Social support: operationalized as a well-intentioned action that is given

willingly to postpartum mothers. The support can be either in the form of

personal help in doing needed activities, instrumental and financial assistance, or

emotional empathy and understanding offered to mothers during the postpartum

period. The source of social support may include intimate relationships,

friendships, relatives and neighbourhood or community contacts.

 Emotional support: referred to postpartum women‘s access to provision of

empathy, caring, love, and trust. Emotional support also included receiving

encouragement, approval, and feeling of togetherness with others during the

postpartum period.

 Appraisal support: drawn from the encouragement and advice given to

postpartum period by other mothers who had been in a similar situation.

 Physical activity: referred to postpartum women‘s engagement in daily routines

and formal exercises to maintain the balance of their body‘s weight and increase

13
 strength. Physical activities included any type of activity (e.g., occupational,

recreational, child care, indoor and outdoor household activity).

 Coping: referred to postpartum women‘s strategies to respond or cope with

stressful life events as a result of the demands of self-care needs, child-care, and

parenting roles.

 Public Health Social Work: is defined as social work practice that uses an

epidemiologic approach to preventing, addressing, and solving social health

problems. By emphasizing prevention and health promotion, PHSW is

multimethod and transdisciplinary, making it especially relevant to contemporary

practice

1.9. Organization of the Dissertation

As this dissertation is for the preparation of Ph.D. dissertation it has the full

protocol of dissertation with six chapters including all the preliminary pages. Hence, the

paper is organized into six chapters. Chapter One describes the background of the study,

including the problem statement, study objectives, rationale for the study, significance of

the study, scope of the study, and operational definition of terms.

Chapter Two contains the literature review and it contains both emperical and

theoretical evidence on postpartum depression. Therefore, as an emperical evidence we

highlited postpartum depression and its relevance to social work, major symptoms of

postpartum depression, causes of postpartum depression, socio demographic factors, social

supports, prevalence of postpartum depression, prevalence and contributing factors of PPD

in Ethiopia, treatment for postpartum depression, The perception and views of midwives‘

about postpartum depression. From the theoretical evidence we have pricisely highlited

the Psychosocial theory, the biological theory and the behavioral theory.

14
 Chapter Three contains a brief discussion of the research methods. Accordingly,

it involves a description of the study area and population, philosophical stance, research

approach including the research design, sample size determination and sampling,

participant selection criteria, instruments, data collection procedures, data analysis, ethical

clearance and issues of confidentiality in protecting the research participant.

Chapter Four presents the result of the study. Within this part of the dissertation,

the study; the results are portrayed with five different parts. The first part deals with the

socio-demographic characteristics of the study participants of the quantitative part. The

second part deals with the prevalence of the PPD. The third part displays the contributing

factors associated with PPD, the fourth part deals with the socio-demographic

characteristics of the qualitative part and the fifth part deals with the results found from

PPD mothers and midwives from the in-depth interviews.

Chapter Five contains the discussion part of the study. This part of the study

elaborates our findings by various views and findings from previous studies in different

settings and countries. In here, alike and opposing research reports are acknowledged from

prior studies and discussed in comparison with the current results.

Chapter Six summarizes the conclusion and study implications. At last, references

cited inside the dissertation and appendices (questionnaires, interview guide, Ethical

clearance, consent form and other supporting documents) are included.

15
 CHAPTER TWO: LITERATURE REVIEW

Introduction

In this chapter, the researcher conducted review of literatures on various aspects of

postpartum depression (PPD). The chapter encompasses discussing about PPD and its

relevance to social work, major symptoms of postpartum depression, causes of postpartum

depression, socio demographic factors, social support, prevalence of postpartum depression,

prevalence and Contributing factors of PPD in Ethiopia, treatment for postpartum depression,

coping mechanisms with PPD, midwives‘ views and perceptions about postpartum

depression, theories of postpartum depression and conceptual framework.

2.1. Postpartum Depression and Relevance to Social Work

Postpartum depression (PPD) is a pervasive disease in the big picture of reproductive

health (Robertson, Grace, Wallington, &Stewart, 2004). The World Health Organization

(WHO, 2005) declared there is no health if the issues of mental health are ignored. The

American Psychological Association (APA, 2015) describes postpartum depression as a

serious mental health disability characterized by a prolonged period of emotional disturbance,

occurring at a time of major life change and increased responsibilities in the care of a

newborn infant. In addition, the National Alliance on Mental Illness (NAMI,2015) defined

PPD as a condition that impacts a person's thinking, feeling or mood and may affect her

ability to relate to others and function on a daily basis.

The period after delivery is regarded as a high time for the occurrence of serious

mood disorders. The association between the postpartum period and mood disturbances has

been noted since the time of Hippocrates (Miller, 2002). There are three common forms of

postpartum affective illness: the blues (baby blues, maternity blues), postpartum (or

postnatal) depression, and puerperal (postpartum or postnatal) psychosis. Each has different

16
manifestation in its occurrence, onset, duration, and treatment. Postpartum depression (PPD)

is a significant public health problem which affects approximately 10-15% of women within

a year of childbirth, and as such represents a considerable public health problem affecting

women and their families (Stewart, Robertson, Dennis, Grace & Wallington, 2003).

Maternal depression is one type of depression that disturbs mothers before or after the

birth of their baby. Postpartum depression is a serious disorder with potentially devastating

personal and familial consequences (Greenberg & Witztum, 2008). As Sobey (2002)

depicted, PPD affects the healthy functioning of the entire family including the quality of life

of mothers with negative consequences for the emotional, behavioral, and cognitive

functioning of their infants.

Social workers are involved with mothers in a variety of settings (Gruen, 1990). One

of the concerns of Social Work is to address personal and family level difficulties. Hence,

dealing with such problems is a priority area of Social Work especially in health and mental

healthcare settings. Lessons from several western countries indicate that Social workers are

employed in health and mental healthcare settings (Abrams & Curran, 2007). In this setting

Social Work is very important, because many of the PPD cases are directly linked with the

very concern of Social Work,i.e.,individuals, families, and communities. Social Workers

have an appreciation and understanding of the postpartum context for mothers and their

families (Walther, 1997). This puts them in a position to offer proper interventions for

postpartum depression including prevention, education, intervention, and referrals, as needed,

to other professionals.

Social workers can also develop community awareness of postpartum depression by

educating professionals and community leaders (Gruen, 1990). This can promote the

professionalism of social workers, as well as treatment rates. Education is important also in

17
light of the fact that many women experience relief when they are in therapy with a social

worker who is knowledgeable about postpartum depression (Walther, 1997).

Another beneficial contribution social workers make in the community is through

social support groups for women with postpartum depression. Social support provides an

accepting, supportive environment in which participants can share their experiences and

assist each other in coping with their depression (Fairchild, 1995). Social workers should also

be aware of the low rates of utilizing services and hence promote the importance of social

support in a given community.

On the other hand, there is an emerging branch of Social Work, such as Psychiatric

Social Work and Public Health Social Work. Both are timely branches of Social Work that

we need to build on such researches. Currently there are many emerging social problems and

health problems such as the impacts of globalization, unemployed youth, drag addiction,

vulnerable mothers, and disasters are affecting us in complex ways. These have brought the

importance of working through integration i.e. Social workers to work with public health

professionals. Social work and public health share a social justice mission to improve,

defend, and enhance well-being, working together to ameliorate social health problems

(American Public Health Association, Social work Section Newsletter, 2006). Therefore,

studying postpartum depression could be one of the parts and parcel of public health social

work in this context.

2.2. Major symptoms of postpartum depression

Many women experience some affective symptoms during the postpartum period, 4 to

6 weeks following delivery. Women may develop the baby blues, a transient mood

disturbance characterized by mood lability, sadness, dysphoria, subjective confusion, and

tearfulness (Sadock & Sadock, 2007). These feelings, which may last days, have been

18
ascribed to rapid changes in women's hormonal levels, the stress of childbirth, and the

awareness of the increased responsibility that motherhood brings. For the baby blues no

medical treatment is required but only education and support for the new mother during their

few days after delivery. If the symptoms persist longer than 2 weeks, evaluation is indicated

for postpartum depression (Stewart,et al, 2003).

Postpartum depression is characterized by a depressed mood, excessive anxiety,

insomnia, and change in weight. The onset is generally within 12 weeks after delivery. No

conclusive evidence indicates that baby blues will lead to a subsequent episode of depression.

Several studies do indicate that an episode of postpartum depression increases the risk of

lifetime episodes of major depression (Sadock & Sadock, 2007). According to the

Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) (APA, 2013),

Postpartum depression is a depressive episode with moderate to severe severity that begins

four weeks after delivery. Patel et al.(2012) indicated some of the major quantifiable

manifestations of postpartum depression include: lack of sleeping or sleeping too much,

mood swings, change in appetite, fear of harming, extreme concern and worry about the

baby, sadness or excessive crying, feelings of doubt, guilt and helplessness, difficulty

concentrating and remembering, loss of interest in hobbies and usual activities, and recurrent

thoughts of death, which may include suicidal ideation. Table 1 is adapted from Sadock and

Sadock (2007) to throw light on postpartum depression and baby blues.

19
Table 1.Characteristics of Postpartum Depression and Baby blues

Characteristic Baby blues Postpartum depression

Incidence 30% to 75% of women who 10% to 15% of women who

give birth give birth

Time of onset 3 to 5 days after delivery Within 3 to 6 months after

delivery

Duration Days to weeks Months to years, if untreated

Associated stressors No Yes, especially lack of

support
Sociocultural influence No; present in all cultures Strong association
and socioeconomic classes

History of mood disorder No association Strong association

Family history of mood No association Some association

disorder
Tearfulness Yes Yes

Mood lability Yes Often present, but

sometimes mood is
uniformly depressed
Anhedonia No Often
Sleep disturbance Sometimes Nearly always

Suicidal thoughts No Sometimes

Thoughts of harming the Rarely Often
baby

Feelings of guilt, inadequacy Absent or mild Often present and excessive

(Adopted from Sadock & Sadock 2007, p. 865)

2.3. Causes of Postpartum Depression

Studies have described contributing factors to PPD but the exact causes seem unclear

and no specific cause of PPD has came forward (Soares & Zitek, 2008). But, a number of

contributing factors have been proposed as contributing to the severity of the depression that

20
is experienced by the recently delivered mother, including the mother's health, the health of

the infant, and the number of additional stressful life events that occur during pregnancy and

the postpartum period (Cutrona, Beth & Troutman, 1986). In a cross-sectional study

conducted in Ethiopia, uunplanned pregnancy, experiencing the death of an infant, and

unstable marital conditions were found to have a significant association with postpartum

depression (Kerie, Menberu, &Niguse, 2018).

2.4. Socio demographic factors

Various studies have reported factors associated with PPD including demographic and

some socioeconomic factors such as maternal age, parity, maternal educational attainment,

place of residence as well as husband‘s educational attainment (Fiala, et al. 2017, Giri, et al.

, 2015; Muneer, et al. , 2009 & Patel, Rodrigues & DeSouza, 2002). A cross-sectional study

conducted on the prevalence and associated factors of postpartum depression in Southwest,

Ethiopia revealed that PPD is associated with socio- demographic factors such as age, marital

status, economic status, and educational level of both the postpartum mothers and their

spouses (Kerie, et al, 2018). Factors associated with anxiety during pregnancy, stressful

recent life events, poor social support, previous history of depression, early life abuse, abuse

by an intimate partner, maternal low educational attainment, low socioeconomic status at the

time of pregnancy, and a history of mental illness have also been associated with postpartum

depression (Gelaye, Rondon, Araya Ricardo, & Williams, 2016).

2.5. Social Supports

Most popularly, the accepted notion that a new baby brings happiness is observed in

many cultures. But, there can also be highly stressful times soon after birth (Miller & Sollie,

1980). One resource that has been shown effective in helping women cope with a range of

stressors following childbirth is social support (O'Hara,Neunaber & Zekoski, 1984).

Studies have documented associations between psychological distress and weak social
21
support. It is unclear, however, whether good social support can improve psychological

distress. Studies pointed that social support has an important impact on mental health. Lack

of social relationships, social isolation and social support, has been implicated as a risk factor

for depression. There are two alternative causal models which are common in explaining how

social support affects psychological distress, the direct effect model and the indirect (buffer)

effect model (Cohen & Wills, 1985). The direct effect implies that social relationships have a

beneficial effect on health, regardless of life situation, whereas the stress-buffering effect

implies that social relationships only have a beneficial effect for persons exposed to stressors,

such as negative life events and hardships over time. In this instance, social support is

thought to buffer the effects of stress by enhancing personal coping abilities such as self-

esteem and self-efficacy (Dalgard, 2009). Through a strengthening of the coping mechanism,

the negative emotional reaction to a stressful event will either be reduced, or the

physiological responses on health via the immune system were dampened (Dalgard, Bjork &

Tambs, 1995; Kawachi & Berkman, 2001).

In one of the studies mothers who had high levels of social support were able to

establish more secure attachments with their infants than were women with low levels of

social support (Crockenberg, 1981), suggesting that social support may be an important

resource for parents of new infants. Although good relationships with others, especially the

spouse, have been associated with adjustment and adaptive parenting in the postpartum

period, little is known about the mechanisms through which social support helps women cope

with the stress of childbearing. A lack of insight into the mechanisms of social support

characterizes the entire literature on stress and social support (Cohen & McKay, 1984; Gore,

1981; LaRocco, & Wortman, 1984).

A systematic review by Biaggi, Conroy, Pawlby, and Pariante (2015) suggested that

the lack of a partner or social support was associated with higher rates of antenatal depressive

22
and anxiety symptoms while Yim et al. (2015) found that low social support and poor quality

relationships with close others was a predictor for postpartum depression. Fisher et al. (2012)

conducted a systematic review into the determinants of depression in low income countries.

They found that difficulties in the relationship between the woman and her partner were

associated with depression (Fisher et al., 2012). These difficulties were varied and could

include a partner who was unsupportive, uninvolved, overcritical, or inflicting physical abuse

(Fisher et al., 2012). Adinew and Adamu (2018) conducted a study in Addis-Ababa and

found that 23% of study-participanst who were the victims of domestic violence had

symptoms of postpartum depression. Domestic violence was positively and significantly

associated with symptoms of postpartum depression.

In contrast, a cross-sectional study conducted in Mombasa, Kenya with 429 mothers

on social support and social stress, no association was found between depression and level of

social support (Husain et. al, 2016). Observing such a dichotomy, the researcher would like to

explain the Ethiopian current situation with the case of East Shewa zone.

2.6. Prevalence of postpartum depression

Postpartum depression has become a relatively common part of a new mother‘s life.

Becoming a mother is associated with emotional distress in about 30% of women (Bener,

Gerber& Sheikh, 2012). Mental and neurological conditions like postpartum depression

contribute to more than 12.3% disability adjusted life years (Lester, Turnley, Bloodgood, &

Bolino, 2002).

The prevalence of PPD is estimated to between 10% and 20%, with an average

prevalence of 13% (O‘Hara &Swain, 1996). This figure depends on the geographic location

and the socio-economic conditions. In western countries such as United States the prevalence

of PPD ranges from 7 to 20%, but most studies suggest rates between 10 to 15%. Lifetime

23
risk is 10 to 25%, risk at two months postpartum is 5.7%, and at six months postpartum it is

5.6% (Patel, et al. 2012). In sub-Saharan Africa, studies have reported a prevalence of 14.6%

in Nigeria, 34.7% in South Africa, and up to 50.8% in the Democratic Republic of

Congo,6.6% in Uganda, (Adewuya, Fatoye, Ola, Ijaodola. &Ibigbami, 2005; Cooper et al.

1999 & Imbula,Okitundu, & Mampunza, 2012,Nakku, Nakasi& Mirembe, 2006). In Pakistan

PPD ranges from 28%-57% (Kazi, Fatmi, &Kedir, 2006), and 35-50% in Latin America

(Wolf, Deandraca, &Lozoff, 2002).

Little is known about the prevalence rate of postpartum depression in Ethiopia (Kerie,

et al., 2017). A cross-sectional study conducted in Addis Ababa, Addis Ketema Sub City,

revealed that the prevalence of PPD was 19%. In rural Ethiopia Butajira the prevalence of

PPD was 17% (Hanlon, Araya, Tesfaye, &Wondimagegn, 2008).

According to the researcher‘s knowledge, there is no national level study in Ethiopia

which can inform us of the exact prevalence of postpartum depression. The Researcher also

observed the existing prevalence of PPD varies from one place to another within Ethiopia.

The need to know the prevalence of East Shewa comes to light here as fragmented studies

cannot inform us about the figure in the current study area. On the other hand, reliable

estimates of postpartum depression in these contexts are required for the development of

national and international health policies. Hence, one of the purposes of this study is to

determine the prevalence of postpartum depression to fill the gap.

2.7. Prevalence and contributing factors of PPD in Ethiopia

This part of the paper reviews PPD studies conducted in Ethiopia. The review

precisely highlights the findings of prevalence/magnitude and factors of PPD from studies

conducted in various parts of Ethiopia.

24
 PPD in South West Ethiopia was found to be high with a prevalence of 33%, (Kerrie

& et. a, 2018). Hanlon and colleagues (2017) reported that 28.7% of women had Postpartum

depression symptoms in rural Ethiopia around Butajira. In Bale Oromia Region, South East

Ethiopia, findings revealed a prevalence of 31.5% for PPD (Tefera et al. 2015). A study

conducted in Ethiopian capital city Addis Ababa revealed that nearly a quarter (23.3%) of

women had symptoms of postpartum depression (Addishiwet & Yohannes, 2018). Likewise,

another study in Addis Ababa found a similar result with a significant amount of PPD

(23.3%) among the study participants (Fantahun, Cherie & Deribe, 2016). Hanlon, et. al

(2018) found a prevalence of 12.2 % of new mothers with PPD symptoms in Soddo district in

South Ethiopia. A cross-sectional study conducted in Amhara region, northern Ethiopia came

up with a result of 32.8% of mothers having PPD symptoms (Joy, Angela, Yared & Dereje,

2014). In Bench Maji, South Ethiopia the magnitude of PPD among the study population was

22.4% (Tigistu, Fantaye & Anand, 2018).

Associated factors: Age of the participants, unplanned pregnancy, chronic illness,

death of infant and current marital problems were predictors of postpartum depression in

Southern Ethiopia (Kerrie et. a, 2018). Family history of mental illness, lack of social

support, history of child death, and husband smoking status were found as independent

predictors of perinatal depression at Bale Zone, Oromia region South East Ethiopia (Tefera et

al. 2015). Domestic violence was a significant factor for PPD in Addis Ababa (Addishiwet &

Yohannes, 2018). Grand multiparity, perinatal complications, a past history of abortion,

experiencing hunger in the preceding 1-month, lower perceived wealth, poor marital

relationship and social support were found to be associated with PPD (Hanlon et. al 2018).

Tigistu, Fantaye and Anand (2018) reported that unplanned pregnancy, child having sleep

problems, domestic violence, unsatisfactory marital relations, poor social support, and history

of previous depression were highly associated with PPD.

25
 Generally, there seems to be little attention to PPD particularly on early detection

(Kerrie & et. a, 2018). There is significant gap on maternal mental health service and

treatment (Hanlon & et. al, 2016). Further research on PPD is necessary to further confirm

these findings (Hanlon & et. al, 2017). There is a need to create public awareness about PPD

especially regarding its causes and consequences (Hanlon & et. al, 2016). Organizing

training on mental health for new mothers is important (Tefera et al., 2015).

There is a lack of evidence regarding the prevalence of PPD and treatment of women

with maternal mental disorders including very limited evidence on effective psychosocial

interventions (Baron, Hanlon, Sumaya, Simone, Breuer, et al, 2016). In addition, according to

the researcher‘s observation, there is a lack of research on PPD which can represent the

overall status of PPD in Ethiopia. Clear attention is not given to PPD in Ethiopia.

2.8. Effects of postpartum depression

Mothers spend the most time with their child during the postpartum period. She is the

one who mediates between social environments and their experience of the external world.

Children of PPD mothers showed less affective sharing and significantly less sociability with

strangers as well as chronic social difficulties in the areas of marriage, finances, or housing

(Stewart, et al, 2003).

Postnatal depression (PPD) is also an important health problem which influences

well-being, quality, and security of life. Depression occurring in the postnatal period may

cause more serious problems than major depression occurring in normal life periods and

displays similar symptoms. PPD has an adverse influence on self-esteem, skills, child care,

familial responsibilities, and roles of the mother. In this period, mothers may harm

themselves and their babies, influencing the relation of the mother and the baby unfavorably

(Stewart e. al, 2003).

26
2.9. Treatment for postpartum depression

Several public health studies and scholarly publications support the opinion that

postpartum depression is treatable using a variety of interventions. Where the causes of PPD

can be identified, treatment should be aimed at alleviating the root cause of the problem

(Patel, et al. 2012). Basic treatment can be either non-pharmacological or pharmacological.

There have been concerns about mothers with postpartum depression taking antidepressants

because of infant exposure to medication though breast milk or potential side effects

(Dennis,& Chung-Lee,2006). Psychotherapy is considered the mainstream therapy and many

postnatal mothers prefer psychological treatment (Pearlstein, Zlotnick, Battle, et al, 2006).

The two most commonly used psychotherapies that have been found to be beneficial are

interpersonal therapy (IPT) and cognitive behavioral therapy (CBT). For mild to moderate

postpartum depression individual or group psychotherapy is an effective treatment.

Psychotherapy also can be used as adjunct therapy with medication in moderate to severe

postpartum depression (Nonacs & Cohen, 1998).

27
 Both psychosocial and psychological interventions are effective in decreasing

depression and are viable treatment options for postpartum depression (Dennis & Hodnett,

2007). A study conducted with 120 women who recently gave birth showed that interpersonal

psychotherapy was effective for the relief of depressive symptoms and for improvement in

psychosocial function in treated women compared with control groups who were on the

waiting list for such therapy (Warner, Whitton, et al, 1997). Many physicians in the study

also encouraged the women to exercise, engage in acupuncture and massages, obtain

adequate exposure to morning light, and seek support from others as an adjunct to treatment

for postpartum depression.

Second-line therapy is pharmacotherapy. A selective serotonin reuptake inhibitor

should be tried initially as a first agent because it is associated with low risk of toxic effect in

patients taking an overdose, as well as with ease of administration (Turner, Sharp, Folkes, et

al, 2008). If the patient has previous positive responses to a specific drug, that agent should

be strongly considered as a first choice unless there is evidence of potential harm (Payne,

2007).

2.10. Coping mechanisms with PPD

After child birth, a mother deals with her baby in her own circumstances. Perhaps the

baby may lead the mother to encounter mental and physiological changes with new roles and

tasks. Any encounters that happen as a consequence from having new baby needs a coping

mechanism for adjusting with emotional & behavioral changes (Razurel, Bruchon-

Schweitzer, Dupanloup, Irion, & Epiney, 2011).

Varity of coping mechanisms are employed to combat postpartum depression. Some

advised doing physical activity. Others share their experience of prayer, listening songs and

28
some others used Yoga. Physical activity is important because childbearing years are

provisional periods that put women at higher risk for over weightness. Empirical evidence

has established the importance of regular exercise during the postpartum period that have

implication in reducing depression (Evenson, Aytur, & Borodulin, 2009).

Furthermore, mothers during the postpartum period required to build sense of balance

between her daily task and taking adequate rest. Such actions will help in order to have an

enhanced functioning as a mother and eventually advance the satisfaction of the postpartum

period (Rychnovsky & Hunter, 2009). Conducting physical exercise next to delivery will help

to have normal postpartum weight (Yeh, St John, & Venturato, et al., 2014), and also it will

reduce the occurrence of postpartum depression. Hence, we need to appreciate coping

mechanism for postpartum mothers that includes physical exercise. As doing activities that

makes mothers more relaxed will be necessary. As a result, mothers can easily cope and

balance their postpartum period by maximizing adaptability to the changes (Ha and Kim,

2013)

2.11. Midwives‟ views and perceptions about postpartum depression

According to Jones, Creedy and Gamble (2011), emotional care provided by

midwives may improve mothers‘ health and well-being; reduce stress, trauma, and depressive

symptoms; and enhance maternal outcomes in childbearing women. The provision of

antepartum and postpartum emotional care can be challenging and requires a good knowledge

base for the provider to screen and assist distressed women. This study examined East Shewa

Zone midwives' veiws and perceptions regarding postpartum depression.

PPD, since it jeopardizes life quality and safety, has been considered as anegative

effect influencing mother, baby and family members (Hanna, Jarman, Savage & Layton,

29
2004). Therefore, nurses and midwives are expected to conduct regular medical screening for

women in the postpartum period to detect depressive symptoms (Goodman, 2004).

Midwives are health care professionals who interact most with women during

pregnancy and postpartum periods (Longsdon, Wisner, Billings&Shanahan,2006). Also,

nurses who have frequent contact with women during the perinatal period are well-positioned

to provide screening and treatment for PPD (Segre, O‘Hara, Arndt& Beck, 2010). As they

meet with mothers for immunization, postpartum health controls and healthy baby checks

they may have a chance for PPD screening. During these interactions nurses/midwives can

detect risky women and patients with symptoms of PPD.

They may conduct medical screening by making use of appropriate tools and can

guide the woman to professional assistance if needed (Longsdon, Wisner& Pinto-Foltz ,

2006). According to Keng Malasian (2005), the biggest handicap of nurses/midwives is the

lack of sufficient training concerning diagnosing, consulting, and guiding risky patients in the

early diagnosis and management of PPD. If postpartum depression knowledge of nurses and

midwives is insufficient, that may mislead them in identifying symptoms and PPD (Keng

Malasian, 2005). To that end, the present research examined the PPD knowledge and

opinions of midwives employed in health care facilities of East Shewa Zone, Ethiopia.

2.12 Theories on postpartum depression

According to the Researcher knowledge there is no common agreement on the

theories regarding the nature of PPD. Below are a review on theoretical perspectives about

PPD. In this regard, neither the concept of one size fits all nor a single theory will help to

elucidate postpartum depression by being the only exponent. Hence, a mixture of theories

should be considered in our perspective with regard to mental health in general and

postpartum depression in particular.

30
Psychosocial Theories
The field of social work was traditionally concerned with helping the needy to help

themselves. This form of help no doubt resembled the informal help provided by the society.

However, the activities of Social Work practice are professionalized, evidence-based, and

delivered systematically. The knowledge of social work service involves the theoretical and

practical models for understanding of the dynamics of people and their environment.

There are approaches and models which were developed within the framework of

each one of the broader methods in Social work. These models reflect accumulated wisdom

and basic tenets of practice (Lyndsay, 2009). Social work practitioners who work with

various clienteles in various settings; often refer approaches out of which the prominent one

is psychosocial approaches. ―The term psychosocial has been used to refer to a number of

theories, which combine concern with psychological development and interaction between

the individual and the social environment‖ (Lindsay, 2009, p 10).

This psychosocial approach is historically connected with Mary Richmond (1917).

The approach was also known as the ‗Diagnostic or Organismic or differential model‘. The

term psychosocial was mostly preferred as it explains the nature and the purpose of the

model. The psychosocial approach is essentially a system theory in social work practice. This

model addresses to person -in –situation Gestalt or Configuration which state that the person

and their situation (environments) are inter-systemic, interdependent or interrelated. Thus, the

change in one part of this situation – person configuration, brings changes in other parts,

which in turn leads to another change. Hence, the model stresses that the person must be seen

in the context of their interactional transactions with the external world, which includes

family, social groups, work place, or any other system of which the person is a part. The

knowledge about this social environment is considered essential in understanding human

31
problems. Thus, the approach presumes that the current normal behaviors of the individual

are influenced by certain attitudes, reflexes and perceptions of the past (Lindsay, 2009).

Since the psychosocial theory in social work originated from psychodynamic theory,

it seems important to reflect on psychodynamic theory. Psychodynamic theory is primarily

concerned with the inner person – their thought and feelings- and considers external factors

only from the client‘s view. In this regard, the psychodynamic perspective declares the idea

that unfinished business in women‘s childhood or family may cause more psychological

difficulties after birth (Abdollahi, Lye & Zarghami, 2016). Many women have an inclination

to copy their own mother‘s role as soon as they become a mother after birth. Nevertheless, if

there is a denial in accepting the roles of their own mother, they might develop difficulties in

coping or adapting to their new role of motherhood (Kaplan & Sadock, 2010). In this case,

psychodynamic theory suggests characteristics of personality predispose new mothers to PPD

(Abdollahi, Lye &Zarghami, 2016).

The psychosocial approach borrows from both psychodynamic theory and ego

psychology but adds social, economic and practical considerations. Within social work a

purely psychodynamic approach is rare, however it forms the basis of psychosocial work and

is the starting place for a number of other interventions (Lindsay, 2009).

In this approach interpersonal struggles in an individual‘s life have significant

influences on mental health (Egele, 2008). Most individuals require affection which needs to

be fulfilled in the initial stage of a relationship. Uncertainties concerning a relationship may

result to disappointment and bring about depression and anxiety (Grupe & Nitschke, 2013). A

number of interpersonal factors play a role in women‘s distress, and sensitivity makes them

prone to develop postpartum disorders. These include insufficient social support and marital

conflicts (Hammen & Brennan, 2002).

32
 Psychosocial theorists propose the occurrence of stressful life events, such as the birth

of an infant, marital problems, lack of social support associated with the social and family

environment, loss of a loved one, marital or relationship difficulties, or serious financial or

housing difficulties may precipitate the onset of depression (Abdollahi, Lye &Zarghami,

2016). Some women who suffer from major PPD and with symptoms such as psychomotor

retardation, weight loss, loss of interest in activities, lack of concentration, and constant

suicidal thoughts may not seek social support. Moreover, actions that women take to reduce

these psychological problems may predispose her to PPD (Hegen, 1999).

Although the birth of a child is a stressful event requiring a great deal of adaptation

and readjustment, many new mothers do not become depressed (Egeline,2008). A recent

undesirable life event was the factor most strongly associated with the onset of this disorder.

The probability of becoming depressed after childbirth is about three times greater if a

significant stressful event had recently occurred, than if no such event had occurred

(Halbreich, 2005).

A growing number of studies support a psychosocial explanation of postpartum

depression. The above literature has demonstrated a relationship between a number of

psychosocial variables with postpartum depression. From a psychosocial perspective,

postpartum depression, unlike the "blues" and postpartum psychosis, is thought to result from

an interaction of psychological and social/environmental factors (Bina, 2008).

However, the causal nature of the psychosocial factors is not fully understood.

Research regarding the role of psychosocial factors in the etiology of postpartum depression

has produced contradictory results. Therefore, more studies on the psychosocial determinants

of postpartum depression are needed. As there is no single factor that is responsible for

33
precipitating postpartum depression, there may be a more complex causal pattern involved in

the factors associated with PPD.

Biological Theories

Biological theory pronounces with the mother‘s experience of illness and the medical

condition during the postpartum period. This could be because of hormonal change but

nothing to do with social or environmental circumstances (Beck, 2002). According to Soares

& Zitek (2008), hormones such as human chorionic gonadotrophin, progesterone and cortisol

increase and intensifies during pregnancy and significantly drop after birth, this biological

and natural encounter is considered as a contributing factor for postpartum depression.

Rapkin, Mikacich & Moatakef-Imani (2003) discussed that mothers are under huge impact of

biological factors during postpartum period that affects her mood. The biological theory

proposes the change that undergoes during birth experience will lead women to the

postpartum depression. It also suggests that it is biology not about social issues as it‘s linked

with hormonal changes. By means of natural happening not social is the primary argument of

the biological theory.

Behavioral theory

Behavioral theories advocate emotional distress incident might happen from major

life events which disturb a mother‘s normal life style. Challenges of life, for instance, family

separation and levels of emotional support are forecasters for the emotional distress

occurrence during postpartum period (Hammen& Brennan, 2002). On the other hand, the

experience of reinforcement positive/negative/ is considered as a factor for PPD (Davidson,

Rieckmann & Lespérance, 2004). From the Behavioral theories we can understand that

emotional distress or comfort can appear either by appraisal or forfeit for challenging

34
behavior. In this case, such measures are contributing factors for emotional distress during

the postpartum periods. (Davidson, Rieckmann & Lespérance, 2004).

Moreover, postpartum depression perceive childbirth as a major stressor that disrupts

the parent's usual living patterns, thereby forcing them to implement new behavior patterns.

These disruptions during the postpartum period increase the woman's vulnerability to

emotional disturbance (Abdollahi, Lye &Zarghami, 2016).

Evolutionary theory

In congruent with the psychosocial and behavioral theory; there are articles and

findings that strive to explain postpartum depression with Evolutionary theory. Here the

suggestion of the ideas of evolutionary theorists are the process of adaptive roles of mothers

have an implication for PPD. Many Researcher reported that, during postpartum period; quite

a lot of mothers habitually faces undesirable consequence their birth experiences. The effects

include emotional distress and gloomy due to problems related to her baby, partner, lack of

support that is directly implies with family and social environment. So, the evolutionary

theory in this regard suggests that, not being able to adapt with the new process of being

mom, newness and unable to quickly adjust to such change leads to emotional distress

(Hagen, 1999).

On the other hand, by contrasting the other view evolutionary theory says it‘s not a

problem to have PPD it‘s a normal process of being mom. The evolutionary perspective

assertively states that, postpartum depression might be the outcome of an adaptive function

that indicates a likely appropriateness charge to the mother. Thus, PPD is not a disability but

rather an adaptive process. Postpartum depression signifies a given mother who has suffered

to provide care to her baby. Hence, PPD is a common occurrence that happen in many

mothers in the globe (Nebraska, 2005)

35
 2.13. Conceptual framework

Socio- Demographic Factors-

Age of mother, religion,
ethnicity, occupation, education,
Household economy

Obstetric History: Parity, Postpartum Social Support

gravidity, birth interval, DepressionPPD Intimate partner support,
Number of live children social support from family
and friends

Midwives view & Mothers

perceptions of PPD

Figure 1 Conceptual framework developed by this author based on key areas of research
findings in the literature.

36
 CHAPTER THREE: RESEARCH METHODOLOGY

This chapter details the methodological approach employed in the study. The

researcher described the study site and setting, research design, sample size determination,

sampling technique, participant selection criteria, instrumentation, data collection procedures,

and data analysis process. In addition, ethical considerations and issues of keeping

confidentiality are described.

3.1. Description of Study Area and Study period

This study was conducted in East Shewa (In Afaan Oromo: Shawaa Bahaa) one of the

Zones of the Ethiopian Region of Oromia. This zone takes its name from the kingdom or

former province of Shewa. East Shewa is located in the middle of Oromia, connecting the

western regions to the East ones (See Figure 2). This zone is bordered on the south by the

West Arsi Zone, on the south west by the Southern Nations, Nationalities and Peoples

Region, on the west by South West Shewa and Oromia Special Zone surrounding Addis

Ababa, on the northwest by North Shewa, on the north by the Amhara Region, on the

northeast by the Afar Region, and on the southeast by Arsi. Its westernmost reach is defined

by the course of the Bilate River. Towns and cities in East Shewa include Adama, Bishoftu

(Debre Zeit), Meta hara, Modjo, Bote, Meki and Batu (Ziway). In East Shewa zone there are

7 hospitals.

Demographics

Based on the 2007 census conducted by the Central Statistical Agency of Ethiopia

(CSA, 2007), this zone has a total population of 1,356,342, of whom 696,350 are men and

659,992 women. With an area of 8,370.90 square kilometers, East Shewa has a population

density of 162.03. While 340,225 or 25.08% are urban inhabitants, a further 664 or 0.05% are

pastoralists. A total of 309,726 households were counted in this zone, which results in an

37
average of 4.38 persons to a household and 296,342 housing units. The three largest ethnic

groups reported were the Oromo (74.06%), the Amhara (15.39%) and Gurage (3.82%); all

other ethnic groups made up 6.73% of the population. Afaan Oromo is spoken as a first

language by 69.15%, Amharic was spoken by 24.29%, and Guragigna by 2.64% of the

population. The remaining 3.92% spoke all other primary languages reported. The majority

of the inhabitants professed Ethiopian Orthodox Christianity, with 69.33% of the population

having reported they practiced that belief, while 16.18% of the population were Muslim,

8.4% of the population professed Protestantism, and 5.08% practiced traditional beliefs.

Source: Map of study area (East Shewa) adapted from the annual report of the zonal office.

Figure 2:Map of the study area

38
3.2. Research Paradigm

As my guiding research philosophy, I prefer pragmatism. Pragmatism is a philosophy

with an eclectic world view. It is not committed to any one of the philosophies on reality and

knowledge and considers truth as one that works best to meet immediate needs. As a result,

pragmatism gives freedom to individual researcher to choose methods, techniques, and

procedures (Creswell, 2009) and initiates Researcher to emphasize the research problem.

That is, it is based on the intended consequences that pragmatists look to what and how to

research. The benefit of this philosophy is the flexibility on design and method and the

opportunity it gives to alleviate the weaknesses of one design, strategy, or method by the

strengths of the other (Roux & Barry, 2009). Since it is a problem-centered and

methodologically pluralistic, I align myself with the assumptions of the pragmatism

paradigm.

3.3. Research Approach

The current study was situated within a tradition of mixed methods research (MMR).

The discussion below aims to explain and justify the methodological and research design

choices made in this study.

By sharing a view that; careful combining of different data types and analysis

techniques can reveal contrasting dimensions of given social phenomena, thereby increasing

depth of understanding in such studies. This approach aims to obtain a deeper understanding

of the study problem. Creswell (2013) portrayed that a mixed- methods research approach

combines elements of both qualitative and quantitative methods during data collection,

analysis, and inference techniques. The researcher prefers mixed-method research (MMR)

approach because MMR provides a more elaborate understanding of the study problem by

offsetting methodological biases by taking advantage of the two methods.

39
 Researchers are expected to respond to the research context innovatively and use

whatever data types and analysis techniques that are necessary to answer their research

questions. The result has been a surge in demand from Researcher to be equipped with

appropriate skills to conduct any type of research. What is newer, however, is the explicit

and intentional combining of different data types and analysis techniques together as a

distinct methodological approach that can complement mono-method approaches to

research (Creswell & Plano Clark, 2007).

The greatest advantage of mixed methods research is its potential to overcome at

least some of the problems associated with conventional research methods (Creswell &

Plano Clark, 2007). These include quantitative methods dehumanizing the subject matter, or

qualitative ones failing to move from the specific to the general. By rejecting the

incompatibility of different data types and analysis techniques, Researchers are able to

exploit the entire available toolkit, rather than be restricted by (questionable) ontological or

epistemological boundaries (Creswell, 2003; Johnson & Onwuegbuzie, 2004; Tashakkori&

Teddlie, 1998). In the discussion that follows, the MMR designs and methods are

elaborated, along with the key elements of the research process.

3.4. Research design

―Research design refers to the way in which a research idea is transformed into a

research project or plan that can be carried out in practice by a researcher or research team‖

(Given, 2008, p. 761). Creswell (2009) identified three types of research designs: qualitative,

quantitative, and mixed methods and put them in a continuum with mixed methods in the

middle. There are two types of designs under the mixed method approach. These strategies

are sequential and concurrent mixed method designs (Creswell, 2014). The current study used

the concurrent mixed study design.

40
 ―The purpose of a convergent (or parallel or concurrent) mixed methods design is to

simultaneously collect both quantitative and qualitative data, merge the data, and use the

results to understand a research problem‖ (Creswell, 2012, p.540). That means both the

quantitative and qualitative data were gathered at the same time and then merging or

converging the two data sets by bringing them together.

Within this study, objectives which were not covered by the quantitative approach,

were addressed using a qualitative approach. Hence, the quantitative approach was used to

collect data regarding the prevalence of postpartum depression and factors associated with

postpartum depression. Qualitative data were collected to describe mothers‘ experience of

emotional distress in their first postnatal year and to explain midwives‘ perceptions of PPD.

Pragmatism

Mixed-Method Design

Parallel or Concurrent Mixed

Strategies(Explanatory)

Both Quantitative and Qualitative data

Figure 3. Pragmatism with its corresponding research designs, strategies, and methods

41
3.5. Quantitative Study

The quantitative phase was designed to determine the current prevalence of

postpartum depression and to identify the risk factors associated with postpartum

depression in East Shewa Zone Ethiopia.

3.5.1. The source population

All mothers who gave birth within one year in a health facility of East Shewa Zone

during the study period.

3.5.2. Study Population

Randomly selected mothers who gave birth within the last one year at the health

facilities of East Shewa Zone during the time of the study.

3.5.3. Inclusion and Exclusion Criteria

All mothers who came for postnatal care and vaccination service within one year after

delivery in selected health facilities during data collection period and consented to participate

in the study were included. Women who were seriously ill, unable to respond to the

questions, and those who refused to participate in the study were excluded.

3.5.4. Sampling

Sample size determination and sampling procedure

The sample frame for the study were all postpartum mothers who gave birth within

the last one year attending public health facilities in East Shewa Zone. For the first study

objective, we used single population proportion formula. Based on studies conducted in

Ethiopia; the proportion of 33.82% expected prevalence of PPD among mothers were

considered to calculate the sample size for prevalence studies (Kerie, et al, 2018). With the

marginal error of 5% (d=0.05) and standard score corresponding to 95% confidence

42
 (Zα/2=1.96) and we also added a 5% for non-response rate. Accordingly, the total desirable

sample size was determined to be 362.

n = (Z1-/2)2 * p(1-p)
d2
n = (1.96)2 * 0.3382(1-0.3382) = 344
(0.05)2

344 + 17.15= 362

Where,

n = the minimal sample required

d = the marginal error tolerated/degree of confidence = 5% = 0.05

p = population proportion= 33.82% = 0.3382

Z1-/2 = the standard normal variable at 95% confidence level= 1.96

For the second study objective, the sample size was calculated using stat Calc of

EpiInfo7 (Kerie, et al, 2018).

Table 2: Parameters used to determine the sample size for the second study objective.

Variables CI (%) Power Ratio % outcome Odds ratio Sample size

(%) (unexpose in
d: unexposed
exposed) grp
Unplanned 95 80 1 33 2 298
pregnancy
Experiencing death 95 80 1 13 2 500
of infant
Unstable marital 95 80 1 25 2 330
condition

Generally, the final sample size for this study were taking the maximum number i.e. 500 and

we further added 10% non-response rate which are a total of 550. We used a simple random

sampling (SRS) technique to reach the sampling units that was available at the public health

facilities based on their pre-determined patient flow rate in all designated hospitals. In East

Shewa zone, there are 7 hospitals available, 4 of which were included in this study; namely,

43
Adama Hospital, Bishoftu Hospital, Modjo Hospital and Batu Hospital. To allocate the study

subjects; first, the average numbers of clients who visited the MCH department was estimated

daily by referencing delivery registration books for two weeks prior to data collection. Then,

proportional allocation was made for each hospital based on the possible number of patients

expected during the study period. SRS was used to identify study participants by using a

lottery method. The below diagram displays the proportional allocation made for each

hospital.

Fig. 4 Sampling technique for prevalence and associated factors of post-partum depression
among Adama hospital, Bishoftu hospital, Modjo hospital and Batu hospital, Oromia
Ethiopia, 2019

44
3.6. Study Period

The study was conducted from August 1-2019 up to August 30-2019 among 500 study

participant mothers. For the qualitative part we had 17 participants, of which 10 of them are

PPD mothers and seven of them were midwives in the selected hospitals in the East Shewa

Zone, Ethiopia.

3.7. Instrument

PHQ-9

The magnitude of PPD was measured using the PHQ-9 (Patient Health

Questionnaire). PHQ-9 is locally validated both in Afaan Oromo and Amharic version

(Kroenke, Spitzer & Wiliams, 2001). In this research PHQ-9 was selected for its internal

consistency (Cronbach's alpha=0.81) and outstanding intra-class correlation of 0.92 in a study

of 926 outpatients in a major referral hospital in Addis Ababa, Ethiopia (Gelaye, Williams,

Lemma, Deyessa, Bahretibeb, Shibre, & et al. 2013). PHQ-9 also has a better sensitivity

(83.3) and specificity (74.7) when compared with the other instruments.

In a study conducted in Ghana the optimal cut-off to designate possible depression

was 5 and/or above (Weobong, Asbroek, Soremekun, Manu, Owusu-Agyei, Prince, & et al.,

2014). Hence, in the current research, Postpartum depressed: those postpartum mothers who

score >= 5 cut off point of PHQ-9. From 9 questions each of which has 4 options giving

maximum score of 27 and a minimumm 0. Normal postpartum mothers (not depressed): those

mothers who scored < 5 cut off point of PHQ-9 (Weobong, Asbroek, Soremekun, Manu,

Owusu-Agyei, Prince, & et al., 2014).

45
Women's Abuse Screening Test (WAST)

We used WAST to measure Domestic Violence/Intimate partner violence (IPV).

Women's Abuse Screening Test (WAST) is a five-item scale and employed and tested in

several countries and across many cultures (Rabin, Jennings, Campbell & Bair-Merritt, 2009

and Zink, Levin, Putnam & Backstrom. We considered WAST scale because of the language

use in Ethiopian context. WAST uses a more expressive language as compared to other scales

on IPV. The WAST was demonstrated to have a good specificity of 91.4% and predictive

validity of 92.4% compared to the Conflict Tactic scale version 2.0 in Ohio (Zink, Levin,

Putnam & Beckstrom, 2007) with a cutoff greater than one, at least for one of its items. Its

score ranges from 0-16 where a score greater than one indicates the presence of domestic

violence.

Social Support

Social support was assessed by using the three-item Oslo Social Support Scale

(OSSS-3), a three-item scale which asks about concern from others, ease of getting help, and

the number of supporting persons that participants can count on. Its score ranges from 3-14.

The scale was originally developed in the Netherlands and has been used widely, including in

Ethiopia. A study in Norway categorized the scores into three levels: 3–8 = poor social

support, 9–11 = intermediate social support and 12–14 = strong social support with a

Cronbach‘s alpha of 0.60 (Abiola, Udofia & Zakari, 2013).

Ethiopian Demographic Health Survey (EDHS)

An item from the Ethiopian Demographic Health Survey (EDHS) was used to assess

the participants‘ personal data and potential confounders. A semi-structured questionnaire

was adopted from standard tools, mainly EDHS. In addition to EDHS we also used WHO and

46
different literature for further analysis. The questionnaire initially was prepared in English

and translated into the local language and retranslated back into English by people who are

proficient in both languages to maintain the consistency of the questionnaires.

The questionnaires contained questions to explain socio-demographic

characteristics such-as-postpartum mothers‘ age, religion, marital status, educational

background, income source, family income level, employment status, family type, number

of pregnancies, nature of delivery, antenatal care, gravidity, postnatal care attendance, and

some health-related features of postpartum mothers. These variables were used to describe

the study population and to assess any significant association with PPD.

Potential confounders

In addition, based on the identified literature review, the aspects listed below were

also assessed as potential confounders. The association between dependent and independent

variables including intimate partner violence (IPV), family history of mental illness, and

whether the woman wanted to have baby (labeled as ―planned‖) or if she never wanted to

have a baby at all (labeled as ―unplanned‖) were assessed in order to statistically control for

potential confounding effects.

3.8. Reliability and Validity Testing

In Ethiopia, both the Afaan Oromo and the Amharic version of the PHQ-9 have

been validated as a screening tool to detect postnatal depression, and were found to have a

sensitivity of 78.9% and a specificity of 75.3%, at a cut-off score of 6/7 (Tesfaye, 2009).

Data Quality Control: To ensure the quality of the data, training was delivered for

data collectors and supervisors. According to Turner et al (2008), a pilot test is necessary to

check if there are flaws, limitations, or other weaknesses within the tools. Pilot-testing allows

47
the researcher to make necessary revisions prior to the implementation of the study. Hence,

pre-tests were conducted with a 5% sample to assess the study instruments‘ clarity, length,

completeness, and consistency. The questionnaires were translated into the local language to

facilitate understanding of the respondents. Questionnaires were checked daily for

completeness and to correct errors. The completeness and accuracy of data collection forms

were checked at the end of each day of data collection. Identified gaps were addressed with

the respective research assistants.

Data collection: Qualitative data were collected by four female BSc nurses/midwives. The

midwives were recruited from the study area. Training was given for one day about the study

objectives, relevance of the study, confidentiality of information, respondents‘ rights,

informed consent, techniques of interview, and how to guide study participants in completing

the questionnaire. Moreover, classroom practical demonstration of the interview was carried

out. All field questionnaires were reviewed each night and morning. Sessions were conducted

every morning with the data collectors to discuss any problems encountered. Participants who

were unable to read and write were supported by data collectors to fill out the questionnaire

through interviewing.

3.9. Study Variables

In this study the dependent variable was postpartum depression (PPD) and the

independent variables included: Socio-demographic factors age, religion, ethnicity,

educational status, occupation, household income, family size, pregnancy and labor related

factors, history of Cesarean section, perinatal complications, multiparty, unplanned

pregnancy, early experience of breast feeding, and social support.

48
3.10. Quantitative Data Analysis

To minimize errors, each completed questionnaire was coded on pre-arranged coding

sheets by the principal investigator (PI). Data were entered into a computer using Epi-info

window version 7.1 statistical programs. Ten percent of the responses were randomly

selected and checked for consistency of the data entry. Printed frequencies were then used to

check for outliers to clean the data. The data were cleaned accordingly and then exported to

SPSS Windows version 20.0 for further analysis. Descriptive analysis such as proportions,

percentages, frequency distributions, and measures of central tendency were used.

Binary logistic Regression analysis: Initially, bivariate analysis was performed

between the dependent variable and each of the independent variables, one at a time. Odds

ratios (OR) at 95% confidence intervals (CI) and p-values were obtained. The findings at this

stage helped to identify important associations.

Multivariable analysis: All variables found to be significant at the bivariable level (at

p-value<0.05) were entered into a multivariable analysis using the logistic regression model

to test the significance of the associations.

3.11. Qualitative Study

This part of the method discusses the qualitative inquiry. The qualitative inquiry was

designed to understand the experience of mother‘s emotional distress, mothers‘ view of

PPD, and midwives ‗perception and view of PPD. Understanding and defining mothers‘

experience of emotional distress and perceptions of midwives of PPD is necessary to get

further insight about postpartum depression.

49
3.12. Selection of Study Participants

According to Creswell (2013), there are many types of sampling strategies such as

critical case sampling or criterion-based sampling in order to obtain competent candidates

that will provide the most reliable data for the study. In addition, issues of honesty and

willingness are also important to the quality of the information to be acquired from the

study participants.

Hence, purposive sampling strategies were employed to deliberately select

postpartum mothers who were willing and had experiences in PPD and social support in

their postpartum period. Below is a list of the study criteria used for purposive selection of

participants consistent with the objectives of the study. This criterion helped to indicate

the target group for the qualitative phase.

3.13. Criteria within the target groups

 Postpartum mothers who had given birth in the study area within one year prior to the

data collection date.

 Participants who had given birth and attended PNC service in the selected health

facilities of East Shewa Zone.

 Mothers who experienced emotional distress in the first postnatal year.

 Midwives by profession with at least 2 years of practice.

 Participants who were willing and interested to share their experiences

3.14. Sampling for qualitative part

This study used a qualitative approach with in-depth interviews (IDIs). A total of

sixteen (16) PPD mothers were selected purposely for the IDPs. But we have only

considered ten (10) postpartum mothers.

50
Table 3. In-Depth Interview Sample for PPD mothers and Midwives

Hospital PPD Mothers Midwives

Adama Hospital 3 3
Bishoftu Hospital 3 2

Batu Hospital 2 1
Modjo Hospital 2 1
Total= 17

Primarily, we approached about 16 mothers and six of them were discarded for their

withdrawal and quality-related issues of the interview. The actual participants were 10 for

mothers and on the other hand we have recruited seven (7) professional midwives for the

third qualitative questions. The sample size of the qualitative study was decided based on

the information saturation theory.

3.15. Qualitative Data Analysis

In the qualitative part there were three aims, i.e., aim three, four and five as listed in

the objectives. Aim three is to understand mothers‘ experience of emotional distress in their

postnatal period. Aim four focused on their perceptions of social support during PPD and

the fifth one aimed to see the views of midwives on PPD. For the above three objectives the

main data collection tool were in-depth interviews.

Within this qualitative data analysis part, we used the content-driven themes and

interrelated steps proposed by Padgett (2016) as a guiding principle to analyze the

qualitative data. Padgett provided a qualitative method in Social Work Research on how-to

instruction for carrying out rigorous qualitative research. The five steps included: 1)

preparing and transcribing the raw data; 2) coding; 3) memoing; 4) creating

themes/categories; and 5) interpretation. Each step was implemented consecutively.

51
 Hence, each IDI session was convened at a venue where there is unlikely to be

interruption or excessive noise interference and that was convenient to participants.

Interviews commenced with introductions and clarifications about the purpose and

procedures of the IDI. The IDIs were facilitated with a guide that contained questions on a

range of topics. IDIs were conducted in the local language as agreed upon between the

facilitator and participants.

The IDI conductor introduced and guided the IDI sessions. Each interview was tape-

recorded. Following the interviews, participants were thanked for their contribution.

Immediately after each session of qualitative data collection, word by word transcription of

tape records commenced. Progress of the works and key issues of qualitative data collection

were discussed during the daily debriefing meeting held with the PI and data collectors.

Taped records verbatim from each sessions of IDI were transcribed into Microsoft

Word. Transcriptions of IDI had headings that include: Description of participant/s; name of

facilitator; date of interview; number and demographic characteristics of participant (s).

Using content-driven themes and interrelated steps approaches of Padgett (2016) as a guiding

principle, the outcome report was synthesized. Findings from the qualitative study were

drawn to precisely answer the study objectives with recommendations.

3.16. Data Quality Control for the Qualitative Study

Careful measures were taken to increase the credibility and validity of the study by

developing and using hand interview guide. Next, a pilot test of the qualitative in-depth

interview was conducted with 2 postpartum women. Peer scrutiny was used with two

midwives who were willing to comment on the interview-guide before the actual

administration to mothers. The researcher conducted this pretest to check and refine the

52
interview guide and to determine the appropriateness of language use and the cultural

appropriateness of the guiding questions.

In the analysis process, we followed standard procedures. Complete transcription

and analysis of data was presented to provide meaningful results. To maintain the balance

of the interpretation, the researcher used negative case analysis to obtain an alternative

explanation by searching for evidence that did not fit with the majority responses and

interpretations. Searching for evidence that contradicts the dominant explanation increases

the credibility of the data interpretation (Shenton, 2004). The researcher checked for

consistency and disagreements of findings with previous studies, and the applicability of

the findings to study participants and to a wider scope.

3.17. Integrating Quantitative and Qualitative Data

As outlined in the above section, quantitative and qualitative data were the sources

for this study. In order to come up with unified integrated data we used interrelated

processes to ensure interpretive uniformity. At the beginning we analyzed and presented

the quantitative and qualitative data separately within the findings section. Then, by

combining the quantitative and qualitative data we created and transformed data to a

single-and coherent format.

Figure 5: Quantitative and Qualitative Data Integration Diagram

53
 The below figure outlines the summary of the sampling system with a diagrammatic

presentation implemented in the study.

Figure 6: Diagrammatic presentation of sampling system.

All postpartum mothers who delivered in the

past one year and living in East Shewa Zone

Quantitative samples Qualitative Samples

Postpartum Mothers living in Postpartum Mothers living in

East Shewa Zone East Shewa Zone & Midwives
in East Shewa zone hospitals

Four Hospitals randomly Sample size allocated 10 + 7

selected from ESZ.

Sample size calculated

Study of selected PPD mothers
& midwives

Study of selected mothers

Allocated sample size for

Calculated sample size Qualitative study
for quantitative study Postpartum Mothers = 10
500 Midwives = 7

Total= 517

54
3.18. Limitations of the Study

In a common paralance Researcher says all studies have limitations. Hence, there are

limitations to this study as well. With the common view of limitation, the current study

has issues related to methods and scope. The anticipated limitation with regard to methods

are due to the integration of both qualitative and quantitative methods. A research studies

employing a mixed-methods design encompass the limitations commonly associated with

both methods. Hence, we focus our attention to the ―Fundamental Principle of Mixed

Methods,‖ which declare that, all methods have strengths and weaknesses and that the

strengths are complementary and the weaknesses do not overlap (Tashakkori & Teddlie,

2010). As an example, the qualitative findings cannot be generalized because of a

relatively small number of participants and use of non probability sampling. Another

limitation involves the restrictions of quantitative data analysis including lack of depth and

breadth.

On the other hand, the scope is limmtted in East Shewa Zone; where as Ethiopia is a

country with more than 86 languages and diversified cultures with several ethnic groups.

Such diversity definitely increases the peculiarities in the social and cultural settings and

meanings for any social phenomenon. Since the research on prevalence, associated factors,

exploring mothers and midwives expirience was conducted in one of the zones from

Oromia Region, Ethiopia, it may not be representative of all areas in Ethiopia.

I am also aware of the sensetiveness of the subject as we deal with person‘s

personal expiriance. Hence, worked my level best by being careful on the trustworthiness

of the qualitative data, researcher bias, respondents‘ bias, and reactivity. On the other hand

potential threats to reliability and validity of the quantitative data are another limitation

issues but, I have tried my best to establishe rigorous verification processes to ensure a

55
greater degree of reliability, validity, and trustworthiness of the data with the standard

procedures and formality.

56
 Table 4: Summary of the Mixed Method Study Procedure

Phase The implemented Procedure Achieved Result

Quantitative Institution-based cross-sectional Numeric data
data collection survey (N=500) (PHQ-9) Oslo-3,
IPV(WAST) and SDC

Quantitative -Data screening (Binary LR,  Descriptive statistics,

data analysis multivariable) bivariate analysis, Binary
-SPSS 20.0 software) logistic regression

Individual In-depth Interview with Narrative data (Interview

Qualitative data 17participants (until data transcript)
collection saturation) (purposive selection)

Qualitative data Coding and thematic analysis  Codes and themes

analysis  Similar and different
themes and categories

Integration of Interpretation and explanation of  Single and coherent data

qualitative and the quantitative and qualitative (Discussion, Implications,
quantitative results Recommendations)
results

3.19. Ethical Considerations

Ethical clearance and permission were obtained from the appropriate Research

Review Committee. Permission was secured from each hospital through a formal letter.

Medical directors and directresses were briefed on the relevance and objectives of the study.

The purpose of the study was explained to the participants and written informed consent was

obtained from each participant. Confidentiality of information was maintained by omitting

any personal identifier from the questionnaire. Mothers were informed of their full right to

skip or ignore any question or withdraw their participation at any stage.

57
 CHAPTER FOUR: RESULTS

4.1. Overview of Results

This part of the study delivers the findings on postpartum depression. Accordingly,

the results are reflected in four parts. First, the socio-demographic characteristicsof the

research participants for both the quantitative and qualitative parts are presented. Then the

binary LR and multivariable analysesare presented followed by descriptions of the

prevalence of PPD, social support, and IPV scales using computed percentages, ranges,

mean, and standard deviations. Next, factors related to postpartum depression are

explained using multivariable logistic regression analysis. A p-value of 0.05 was

considered to be statistically significant. Independent variables with p<0.2 on bivariate

tests were entered into the binary logistic regression model. Finally, the mothers‘

emotional experience of depression and their social support practice is discussed well.

Data were collected from 500 postpartum mothers. The SD variables of the study

participants included 14 variables: age, religion, ethnicity, marital status, occupation,

husband‘s occupation, educational background, husband‘s educational background,

household economy, having radio, having TV, having Mobile phone, family size and place

of residence.

4.2. Socio-demographic and economic characteristics of the participants

About 550 mothers were invited to participate in the quantitative study. Out of 550

mothers 50 questionnaires were discarded for incompleteness and withdrawal during data

collection. Hence, 500 mothers were included in the quantitative study with an overall

response rate of 10%. The majority of the participants (65.5%) were less than 29 years old.

Regarding ethnicity, religion, and marital status, the majority of the participants were Oromo

(70.4%), about half (49.2%) of the respondents were Orthodox and married (88.2%),

58
respectively. Seventy-two percent lived in urban areas and 42.6% attended primary

education. Many women (80.8%) do not engage in the formal job sector. Regarding the

economic condition of participants, many (61.8%) earn less than 2000ETB per month. Most

mothers (94.6%) had a mobile phone and 73% had a television (Table 5).

Table 5 Socio–demographic characteristics of study participants in East Shewa Zone of

Ethiopia (n = 500).

Variable Response category Frequency Percent

Age in years < 29 328 65.5
29 and above 172 34.4

Ethnicity Oromo 352 70.4

Amhara 56 11.2
Gurage 35 7.0
Others* 57 11.4

Religion Orthodox 246 49.2

Muslim 156 31.2
Protestant 67 13.4
Catholic 16 3.2
Others** 15 3.0

Marital status Single 27 5.4

Married 441 88.2
Widowed 9 1.8
Divorced 23 4.6

Place of residence Rural 140 28

Urban 360 72

Educational status No formal education 7 1.4

Read and write 133 26.6
Primary education 213 42.6
Secondary education 80 16
College diploma and 67 13.4
above

Occupational status Employed 30 6

Daily laborer 50 10
Housewife 404 80.8
Merchant 8 1.6
Student 8 1.6

59
Husband education Read and write 3 0.6
Primary education 251 50.2
Secondary education 164 32.8
College diploma and 82 16.4
above

Household income Less than 2000 309 61.8

2000 and above 191 38.2

Has a mobile phone Yes 473 94.6

No 27 5.4

Has a radio Yes 1 0.2

No 499 99.8

Has a TV Yes 135 27

No 365 73

* Wolayita, Kambata, Mekan, Mareko, ** traditional religion

4.3. Obstetric Characterstics of study participant

Pregnancy-related factors, obstetric-related, and other psychosocial factors. A

descriptive report of these factors is presented below. Table 2 shows different factors of PPD

which could occur during pregnancy. About 34% had been pregnant before the current

condition and the majority (94.4%) became pregnant after the age of 18 years. About 12%

had abortion experience and 5.4% had a stillbirth experience. About 8% had an unplanned

pregnancy (Table 6).

60
Table 6: Factors related to pregnancy among depression mothers in the Hospitals of East
Shewa Zone

Factors related to pregnancy Frequency Percentage

(n=500) (100%)
Previous history of No 332 66.4
pregnancy Yes 168 33.6

Age at first pregnancy 18 and less 28 5.6

Above 18 472 94.4

Abortion No 442 88.4

Once 58 11.6
Stillbirth No 473 94.6
Once 27 5.4

Pregnancy status Planned 459 91.8

Unplanned 41 8.2

Gestational age less than 38 209 41.8

38 and above 291 58.2

About 99% of the women had a vaginal delivery, and 31%experienced different types

of complications during and post-delivery. The complications include hypertension, loss of

consciousness, severe headache, pain during urination, severe weakness, severe bleeding,

blurred vision, high fever, vaginal discharge, difficulty breathing, and severe abdominal pain.

Eleven percent of the participants reported dissatisfaction by the maternal service they got

from the health centers and only 11% were aware of PPD (Table 7).

61
 Table 7: Factors related to delivery
Factors related to delivery Frequency Percentage
(n=500) (100%)
Mode of delivery Vaginal 494 98.8
Caesarean section 6 1.2

Obstetrics complications No 345 69

Hypertension 16 3.2
Loss of consciousness 18 3.6
Severe headache 16 3.2
Pain during urination 14 2.8
Sever weakness 18 3.6
Others signs & symptoms 22 4.4
Satisfaction with the service yes 445 89
No 55 11

PPD awareness yes 55 11

No 445 89

4.4. Previous history of depression, substance abuse and social support

Almost none of the participants reported substance use and history of well-known

mental illness, but 12% had a spouse who used alcohol. (Table 8).

Variable Frequency (n=500) Percentage

(100%)
Previous history of mental No 499 99.8
illness Yes 1 0.2

Substance use yes 0 0

No 500 100

Partner substance use No 437 87.4

Khat 4 0.8
Alcohol 59 11.8

Social support Poor 84 16.8

Moderate 53 10.6
Strong 363 72.6

Intimate partner violence No 80.4 80.4

Yes 98.6 19.6
Table 8: Previous history of depression, substance abuse and social support among the
PPD mothers in ESZ

62
Intimate partner violence
The study also indicated that the prevalence of intimate partner violence was 19.6%.
This shows significant number of mothers are facing challenges of intimate partners violence.

Figure 7: Intimate partner violence

Social support

Regarding social support, about 16.8% were categorized under poor social support,

10.6 % were moderate social support and 72.6 had Strong level of social support using the 3-

item Oslo Social Support Scale.

63
4.5. Factors related to family
Table 9 presents family-related factors. These factors include the need for more

children, decision-maker on having more children, number of live children, family size, sex

of preference for the new baby, history of infant illness, and infant death. About 5% and 11%

reported infant death and infant illness, respectively. About 54% of the participants preferred

a male baby many participants (58%) had 3 or fewer family members in the household and

92% of the participants reported having 2 or fewer children. Many participants (91.6%)

intend to have more children (Table 9).

Table 9: Family-related Factors for PPD

Frequency (n=500) Percentage (100%)
Intend to have more children Yes 458 91.6
No 42 8.4

Decision maker on having more Husband 10 2

children upon agreement 490 98

No. of live children 2 and less 459 91.8

above 2 41 8.2

Family size 3 and less 290 58

more than 3 210 42

Sex of the baby Male 241 48.2

Female 259 51.8

Baby sex preference Male 269 53.8

female 231 46.2

History of infant illness No 447 89.4

Yes 53 10.6

History of baby death for the last one No 474 94.8

year Yes 26 5.2

64
4.7. Prevalence of postpartum depression

The prevalence of postpartum depression was 23.2% with 95%CI of 20 - 27. Mean

score of 4.4, (SD+ 1.62). Depression symptom scores and standard deviation were 1.62

and ± 4.4 respectively. The minimum depression total score was 0 and the maximum was

21 (Figure 9).

Prevalence of PPD using the PHQ-9 score (Depressed 23.2 and non-depressed 76.8%)

Figure 9: Prevalence of PPD

4.7. Predictors of Postpartum depression

4.7.1. Postpartum depression by Socio-demographic variables

A bi-variable logistic regression analysis of postpartum depression (PPD) by socio-

demographic economic characteristics indicated that maternal age, residency, level of

education, husband occupation, and monthly income were significantly associated with

postpartum depression (PPD). The odds of having PPD were three times higher in mothers

older than 28 years compared to younger mothers (COR = 3.21, 95% CI (2.09 – 4.95), p-

value < 0.001). Whereas, mothers who were rural residents were 60% less likely to have PPD

compared to mothers who were urban in residence (COR = 0.40, 95% CI (0.23 – 0.69), p-

value = 0.001). Mothers who were only able to read and write had a 90% less probability of

PPD compared to mothers who completed primary school (COR = 0.10, 95% CI (0.43 –

65
0.24), p-value < 0.001). The odds of developing PPD was 2.2 and 2.5 times higher in mothers

who have a government employee and merchant husbands, respectively, compared to wives‘

daily laborer (COR = 2.21, 95% CI (1.28 – 3.81), p-value = 0.004; COR = 2.49, 95% CI

(1.16 – 5.34), p-value = 0.019 respectively). Finally, the odds of mothers who reported a

monthly income of 2000 and above to exhibit PPD were 1.8 times higher compared to

mothers who reported a monthly income of less than 2000 ETB (1 USD = 30ETB, during the

data collection period) (COR = 1.84, 95% CI (1.21 – 2.81), p-value = 0.005) (Table 10).

4.7.2. Postpartum Depression by obstetric characteristics

A history of pregnancy, history of abortion, history of stillbirth, and pregnancy status

were significantly associated with having PPD. The odds of mothers with previous history of

pregnancy were to have PDD were five times higher compared to mothers with no previous

history of pregnancy (COR = 5.31, 95% CI (3.40 - 8.28), p-value < 0.001). Similarly,

previous history of having an abortion and stillbirth were found to be significantly associated

with current PPD. The odds of mothers who had a previous history of abortion to develop

current PPD were 6.9 times higher compared to those who have no previous history of

abortion (COR = 6.88, 95% CI (3.86 – 12.29), p-value < 0.001). Similarly, mothers who had

a previous history of stillbirth were found to have 18 times higher odds of developing PPD

compared to mothers who had no previous history of PPD (COR = 17.98, 95% CI (6.63 –

48.73), p-value < 0.001). Finally, the odds of mothers whose pregnancy was unplanned to

have PPD were 3.6 times higher compared to those mothers for whom the current pregnancy

was planned (COR = 3.65, 95% CI (1.90 – 7.01), p-value < 0.001) (see Table 10).

Obstetrics complications, satisfaction with the service, and PPD awareness were

found to be significantly associated with PPD. We found that the odds of mothers who

reported obstetrics complications to have PPD were 9.1 times higher compared to mothers

66
who reported no obstetrics complications (COR = 9.10, 95% CI (4.70 – 17.62), p-value <

0.001). Similarly, the odds of mothers who were not satisfied by the service to develop PPD

were 3.3 times higher compared to mothers who were satisfied with the service provided

(COR = 3.29, 95% CI (1.84 – 5.86), p-value < 0.001). Finally, the odds of mothers with

awareness of PPD to be cases of PPD were 1.9 times higher compared to those who were not

aware of PPD (COR = 1.92, 95% CI (1.05 – 3.50), p-value = 0.033) (see Table 10).

4.7.3. Postpartum Depression by previous history, substance abuse and Social Support

In terms of psycho-social factors, substance use history of partner, social support, and

intimate partner violence were found to have a significant association with PPD. The odds of

mothers who have a substance user husband to have PPD were 3.3 times higher compared to

mothers whose partner did not use substances (COR = 3.32, 95% CI (1.91 – 5.77), p-value <

0.001). In the same way social support was found to be significantly associated with PPD.

The odds of mothers with poor and moderate social support to have PPD were 1.7 and 2.1

time higher, respectively, compared to mothers with good social support ( (COR = 1.71, 95%

CI (1.00 – 2.92), p-value = 0.048; COR = 2.08, 95% CI (1.11 – 3.88), p-value = 0.022,

respectively). Finally, the odds of mothers who reported intimate-partner violence to have

PPD were 1.9 times higher compared to mothers who did not report intimate-partner violence

(COR = 1.98, 95% CI (1.22 – 3.22), p-value = 0.006) (see Table 10).

4.7.4. Postpartum Depression by Family-Related Factors

From family related factors more children need, decision maker on number of

children, family size, and baby sex preference were significantly associated with PPD on bi-

variable analysis. On which the odds of mothers who do not want more children to have PPD

were 2.2 times higher compared to mothers who want more children (COR = 2.23, 95% CI

67
(1.15 – 4.32), p-value = 0.017). Similarly, the odds of having PPD on mothers were 8.2 times

higher in families were the husband were the decision maker on the number of children

compared to those families on which the decision on the number of children is made based on

mutual agreement (COR = 8.25, 95% CI (2.10 – 32.45), p-value = 0.003). The other variable

found to be associated with PPD was family size, on which the odds of the mothers to have

PPD was three times higher in families with more than three members compared to families

with less than or equal to three members (COR = 3.00, 95% CI (1.95 – 4.61), p-value <

0.001). Similarly, the odds of having PPD were 1.6 times higher in mothers who prefer to

have female baby compared to mothers who prefer baby boy (COR = 1.64, 95% CI (1.08 –

2.49), p-value = 0.021). In the same way, the odds of having PPD was found to be two times

higher in mothers who reported a history of infant illness compared to mothers who reported

no history of infant illness (COR = 2.04, 95% CI (1.12 – 3.74), p-value = 0.021) (Table,10).

4.7.5. Multivariable logistic regression analysis Model predicting Postpartum

Depression

On the final model, which is described below in Table 10, variables with p-values of

less than 0.25 in the binary LR analysis were included to control for potential confounders.

Variables found to have a statistically significant association with PPD in the multi-variable

analysis with PPD were maternal age, husband occupation, history of abortion, history of still

birth, obstetrics complications, partner substance use, and baby sex preference.

This study showed that the odds of mothers who were 29 years old and greater were 2.9 times

higher than younger mothers to develop PPD (AOR = 2.88, 95% CI (1.50 – 5.53), p = 0.021).

Being a student hold 7.94 times higher odds of having PPD compared to mothers who were

housewife‘s (AOR = 7.94, 95% CI (1.10 – 57.16), p = 0.040). Similarly, having a history of

abortion was reported to have 12 times higher odds of developing PPD than those with no

68
history of abortion (AOR = 12.08, 95% CI (5.28 – 27.64), p < 0.001). Likewise, mothers with

a history of stillbirth had 16 times more odds of developing PPD than those who had no

history of stillbirth (AOR = 16.20, 95% CI (4.24 - 61.90), p < 0.01).

In other analyses, experiencing obstetric complications was reported to have 12.3

times higher odds of developing PPD compared to those who had no experience of obstetrics

complications (AOR = 12.27, 95% CI (4.83 – 31.22), p < 0.001). Likewise, the odds of

having PPD were 7.9 times higher in mothers who had a partner who used substances

compared to mothers whose partner did not use substances (AOR = 7.94, 95% CI (3.40 –

18.54), p < 0.001). Finally, mothers who preferred a female baby had increased odds of

having PPD. The odds of mothers who prefer a female baby in developing PPD were 2.6

times higher than mothers who preferred a boy (AOR = 2.65, 95% CI (1.10 – 6.41), p =

0.030) (Table 10).

69
 Table 10. Multivariable logistic regression model predicting postpartum depression
among mothers in Hospitals of East Shewa Zone, East Ethiopia
Variable Category COR (95% CI) P value AOR (95% CI) P value

Age < 29 years R R

3.21 (2.09 - 4.95) 0.0001** 2.88 (1.50 – 5.53) 0.001*
>= 29 years
Residence Urban R R
Rural 0.40 (0.23 - 0.69) 0.001* 0.73 (0.32 - 1.64) 0.444

Educational Level Illiterate 1.63 (0.36 – 7.51) 0.528 5.23 (0.71 – 38.52) 0.105
Read and write 0.10 (0.04 - 0.24) 0.0001** 0.38 (0.11 - 1.38) 0.141
Primary education 1.00 1.00
Secondary 0.68 (0.38 - 1.22) 0.198 0.69 (0.31 – 1.53) 0.363
education
College diploma 0.93 (0.51 - 1.69) 0.805 1.34 (0.54 - 3.32) 0.534
and above

Occupation Government 0.63 (0.24 - 1.70) 0.364 0.31 (0.08 - 1.23) 0.096
employee
Daily laborer 0.70 (0.33 - 1.48) 0.346 0.72 (0.25 - 2.04) 0.537
House wife R R
Merchant 0.45 (0.06 - 3.72) 0.460 0.15 (0.01 - 2.59) 0.191
Student 1.90 (0.45 - 8.09) 0.386 7.94 (1.10 - 57.16) 0.040*

Husband Government 2.21 (1.28 - 3.81) 0.004* 0 .91 (0.37 - 2.24) 0.842
Occupation employee
Daily laborer R R
Private work 0.94 (0.56 - 1.60) 0.831 1.24 (0.48 - 3.23) 0.657
Merchant 2.49 (1.16 - 5.34) 0.019* 2.20 (0.59 - 8.21) 0.243

Monthly Income < 2000 ETB R R

>= 2000 ETB 1.84 (1.21 - 2.81) 0.005* 0.50 (0.20 - 1.27) 0.147

Owning mobile Yes R R

No 0.40 (0.12 - 1.36) 0.144 1.52 (0.26 - 8.98) 0.647
Owning TV Yes 1.54 (0.98 - 2.42) 0.058 1.26 (0.56 - 2.87) 0.576
No R R

Previous hx of Yes 6.89 (3.86 - 12.29) 0.0001** 12.08 (5.28 - 27.64) < 0.001**
Abortion No R R

Previous hx of Still Yes 17.98 (6.63 - 48.73) 0.0001** 16.20 (4.24 - 61.90) < 0.001**
birth No R R

70
Pregnancy status Planned R R
Unplanned 3.65 (1.90 - 7.01) 0.0001** 1.460 (0.57 - 3.72) 0.428

Mode of delivery Vaginal R R

Caesarean Section 3.41 (0.68 - 17.13) 0.136 0.69 (0.09 - 5.34) 0.721

Experiencing Yes 9.10 (4.70 - 17.62) 0.0001** 12.27 (4.83 - 31.22) < 0.001**
obstetrics No R R
complications

Satisfaction with Satisfied R R

the service Not satisfied 3.29 (1.84, 5.86) 0.0001** 1.58 (0.66 - 3.81) 0.309

PPD awareness Aware of PPD 1.92 (1.05, 3.50) 0.033* 0.78 (0.33 - 1.87) 0.584
Not aware of PPD R R

Partner substance Yes 3.32 (1.91 - 5.77) 0.0001** 7.94 (3.40 - 18.54) < 0.001**
use history No R R

Social support Poor 1.71 (1.00 - 2.92) 0.048* 0.20 (0.03 - 1.43) 0.110
Moderate 2.08 (1.11 - 3.88) 0.022* 1.65 (0.60 - 4.53) 0.335
Strong R R

Intimate partner Presence 1.98 (1.22 - 3.22) 0.006* 3.56 (0.63 - 20.01) 0.149
violence Absent R R

Intend to have Yes R R

more children No 2.23 (1.15 - 4.32) 0.017* 1.77 (0.73 - 4.31) 0.207

Decision maker on Husbanded 8.25 (2.10 - 32.45) 0.003* 1.02 (0.142 - 7.26) 0.986
number of children Mutual R R

No of children <= 2 R R
>2 1.62 (0.81 - 3.25) 0.170 1.26 (0.46 - 3.46) 0.659

Baby Sex Male 0.75 (0.49 - 1.14) 0.172 1.60 (0.67 - 3.86) 0.291
Female R R

Sex preference Male R R

Female 1.64 (1.08 - 2.49) 0.021* 2.65 (1.10 - 6.41) 0.030*

History of infant Yes 2.04 (1.12 - 3.74) 0.021* 2.20 (0.96 - 5.00) 0.061
illness No R R

History of < one- Yes 2.20 (0.97 - 4.98) 0.060 1.10 (0.33 - 3.65) 0.875
year baby death No R R

71
* for variables significantly associated with PPD at p-value of < 0.5; ** for variables
significantly associated with PPD at p = 0.0001

4.8. Qualitative Study

Participants‟ profile for the qualitative inquiry

The qualitative part of the study employed in-depth interviews (IDPs). The IDPs

were conducted in an environment that was suitable to conduct the IDP sessions.

Morethan 20 mothers were invited to participate in the qualitative part of the study.

Sixteen postpartum mothers were selected voluntarily and deliberately to be participants in

this part of the study. Before the indepth interviews we screened mothers‘ level of PPD by

using the PHQ-9 (See Table 11 for the PHQ-9 scores). Ten mothers finished the interview

successfully. The age of study participants varied from 18 to 40 years old with a mean age

of 28.

72
 Five mothers were Orthodox Christian followers, three were Muslims, and two were

protestant Christian followers. Seven of the study participantswere married, two were

separated, and one was divorced. The study participants‘ family size ranged from 2 to 7.

Cases Age Religion Marital Family No of Education Employment Nature of PPD

status size delivery delivery score

Regarding their educational background, one study participant was a University

student; two participants hold their first degree. One participant had a Masters Degree.

Two of the study participants were educated to 10th grade and another three studied up to

9th Grade. One participant completed 8th grade.

Six of the 10 study participants were house wives. Two study participants were

involved in small businesses in the informal sector, one participant was employed in an

NGO (non-governmental organization), and another participant was employed in a

Government organization. Five of the study participants gave birth to their first child where

as another three study participants gave birth to their second child. Two mothers who were

interviewed gave birth to their fourth and sixth child, respectively. Seven study participants

had labor delivery and three had a C-section. In our screening their level of PPD ranged

from 8 to 17. All names shown in Table 7are pseudonyms based on the confidentiality

agreements. The below table displays the participants‘ profile for the qualitative study.

73
Beshatu 24 Orthodox Married 3 1nd University Small Labor 12
Christian (with student business/
husband) traditional
cloth shop
Etenesh 29 Orthodox Married 4 2nd 9th Grade Housewife C-section 14
Christian (with
husband)
Hortu 25 Orthodox Married 3 1st 1st Degree Housewife Labor 16
Christian (with
husband)
Hibo 35 Muslim Divorced 5 4th 9th grade House wife C-Section/ 12
(lives Twins
alone)
Medrek 30 Orthodox Separated 3 1st 9th grade House wife Labor 10
Christian (with
husband)

Alamitu 19 Muslim Separated 2 1st 10th grade Small Labor 17

(lives business/traditi
alone) onal coffee

Sara 18 Orthodox Married 3 1st 10th Grade House wife C- Section 13

Christian (with
husband)

Baftu 26 Protestant Married 4 2nd Master‘s Government Labor 8

Christian (with Degree Employee
husband)

Zeinab 40 Muslim Married 7 6th 8th Grade House wife Labor 15

(with
husband)
Lelisa 36 Protestant Married 4 2nd 1st Degree Working in Labor 8
Christian (with NGO
husband)

Table 11: The profile of qualitative study participant

4.9. Experience of postpartum depression among mothers in East Shewa Zone

Within the qualitative part of the study the third research aim was to explore the

experience of postpartum depression among mothers in the East Shewa Zone. Mothers

expressed their experience in various ways. The in-depth interviews (IDIs) revealed a new

74
dimension of the reality mothers are facing. Some of the reflections match the quantitative

result, but there are new issues and experiences that were not revealed by the quantitative

analyses. The new perspectives and thematic areas uncovered in the qualitative study include:

mothers‘ own experience, violence using social media, living costs (inflation of the current

Ethiopian economy), expectation vs reality, lack of experience/ newness to the situation, and

mothers‘ experiences of coping. Some of the qualitative findings aligned with the

quantitative analyses such as mothers‘ health status, issues related to the newborn, feeding

habits, behavior of the new baby, health of the baby, sleeping pattern of the baby, alcoholic

husband, socio- economic status, and work status/joblessness The narrative data were

categorized into seven major themes:

 Emotional Distress

 Related to the newborn

 Violence against women

 Socio- demographic factors

 Social support

 Coping Mechanism

 Related to the hospitals and midwives

Within the above seven major themes, we also come up with emerging and subordinate sub-

themes.

Table 12 displays the themes and sub-themes identified from the interviews of the ten

participants.

Themes and subthemes PPD Mothers who raised the

theme

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 N=10 (100%)

Emotional distress 100% (10)

 Lack of experience/ Newness to the situation  50 % (5)
 Mothers own health related  30 % (3)
 Mothers expectation  10 % (1)

Related to the newborn 100% (10)

 Feeding habit/breastfeeding  40 % (4)
 Behavior of the new baby  50 % (5)
 The health of the baby  20 % (2)
 Sleeping pattern of the baby  40% (4)
Violence against women 100% (10)
 Violence  20% (2)
 Alcoholic husband  30 % (3)
Socio- economic status 100% (10)
 Work status/Joblessness  40 % (4)
 Economic instability in the country /  50% (5)
continuous inflation/ living cost/
Social support 100% (10)
 Emotional support  60 % (6)
 Financial support  50 % (5)
 Support related to cleaning &washing clothes  70 % (7)
 Appraisal support  60 % (6)

Coping with PPD  100% (10)

 Prayer  60 % (6)
 Spiritual song  50% (5)
 Holy water  30% (3)
 Walking /physical activity  50(5)
 Listening modern Music  60% (6)
 Taking to family member  30% (3)
 Watching movies  30% (3)
 Reading Bible  40% (4)
 Asking for help  20% (2)
 Crying
Related to the Hospital & services  100% (10)
 Happy with the services  70% (7)
 Not happy with the service  30% (3)
Table 12: Themes and sub-themes identified from the interviews

4.10. Mothers‟ Experience of Emotional Distress

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 Mothers shared about their own positive and negative experiences of emotional

distress in different ways. Biftu, a mother from Batu expressed her positive experience of her

postpartum period by saying:

My experience after being mom and before differs. Before, I was using all my time

in my shop, working my job on my own. But, after I get my son, I have to give time.

Sometimes, I even shut down my shop, until I get somebody to help me. This

directly affected my income but it‘s nothing if I compare the blessing, I have to have

baby. Actually, should not be compared. But still I like it the way it is. Yes, no

problem for that. In my family I used to cook myself, my husband works in

government office. With my baby as a new member of our family everything is

changed. Including volume of TV, electric light and I have to be awake when he

needs breastfeeding, changing diapers, washing and cleaning every stuff of my baby.

Generally, the feeling is different sometimes tiresome. But, when I see my son, I get

source of inspiration. It is totally new experience of both excitement and new life

style. I am enjoying it.

Some of the mothers expressed negative experiences in their time of PPD. One study

participant described her experiences as a challenging and bad one in terms of her socio-

economic status: Alamitu said

I passed through stressful experience; I was not able to do what I wanted to do. My heart

thinks big but practically doing nothing this makes me feel so sad. I cry several times

when, by the way when I cry; I get relief. Since my situation was not good, I was not

comfortable to talk to anyone when I compare before and after; now I am passing new

way of life new challenging experience.

Lack of Experience/ Newness

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The issues of lack of experience and newness of being a mom is reflected as another negative

experience of mothers during the postpartum period. There are mothers who enjoyed their

postpartum period and mothers who suffered and self-blamed for not having enough

experience on how to handle the new baby. Sara complained:

She is my first born and now is the third month, I sometimes feel I might not fit to

be a good mother. I say this because, I don‘t have any experience of holding and

washing baby. Specially I am worried to give her bath, I mean it I don‘t have

experience and it‘s scary to give her bath.

Lelisa explained her fear on how to handle the newborn.

Soon I get birth, the first two weeks were scary, as I didn‘t have experience of

handling my baby. I fear just because I might not be good mom, I felt sleepy and tired

almost every day in the first two weeks.

In contrast, some mothers who had good experiences in handling newborns and no

complaint of emotional distress as Beshatu shared:.―Regarding my experience, since I was

mother and gaurdian to other childrens I have no problem on handling newborn‖ The

experiences differ from mother to mother as reported in our findings. The current finding is

also in congruent with the evolutionary perspective which assertively states that, postpartum

depression might be the outcome of an adaptive function that indicates a likely

appropriateness charge to the mother. The issues of newness and adaptive problem is

identified as a factor to PPD (Nebraska, 2005).

Mothers‟ Health Status and PPD

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 Mothers‘ health is taken as one of the factors in the quantitative study. We also have

observed mother‘s health as one of the factors in their experience of emotional distress in the

review of literature. Some mothers complained that their source of distress is their own health

status. Lelisa said: ―I have been to hospital several times. I am sick and I have continuous

bleeding. My own health situation makes me worry, what will happen if I die? This is the

question in my mind‖.

Zeinab, another mother from Adamah, reported her health status makes her feel

distressed as a result of the surgery and its aftermath.

Since I gave birth with CS, I have the pain still and actually there was some infection

after the surgery. That infection has affected me and now am taking medication. The

medication, the doctor said no problem on your child it‘s mild medicine for

breastfeeding mothers. Though I have to breastfeed the doctors advised to take

medicine. No option I have to do it. So, I worried and feel distressed, when I take the

medication. As I do not want to hurt my baby as we heard breastfeeding mothers

should not take medicine.

Mothers‟ expectations

The qualitative research revealed additional, insights from mothers on their

perspectives and expectations to be a mother. As they describe their reality is often different

from their expectations. Some mothers expressed their dissatisfaction with the reality as

opposed to expectations. Biftu said:

I expected a lot to my situation, I thought its easy, but in reality, being a mom is not

easy. It‘s takes a lot, it takes time, it takes discipline, it takes money, it takes passion

and it also takes a lot.

Bushatu reported that even though she is happy to be a mom she expressed distress

about the mismatch between reality and her expectations.

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 To be honest being mom is something that I loved to be. I feel like I am glad to be a

mom. But sometimes I feel distress when I think of the reality and my expectation.

Being mom is not just funny, it‘s not funny. But it has lots of fun with pleasant stay

with my baby. The expectation starts from the real day-to-day activity to raise my

baby, and goes to my interactions with the whole family and neighbors. Before I gave

birth, since I love children and I have experience of showing love to kids. But when I

give birth seems like nobody cares about my baby, people live their life. And every

corner my expectation is different from the reality on the ground.

4.11. Related to the newborn

Feeding habit/ breastfeeding

PPD mothers reflected their source of distress is directly related to the health, feeding

habits, and general condition of their newborn. Medrek was desiring and dreaming to do

breastfeeding but it was not possible and she had dificulty in feeding her baby with

breastfeeding.

Soon after my delivery, I heard my baby crying out loud, the people in hospital said

it‘s normal, then the issues of breastfeeding started then itself. I tried it didn‘t have

milk. He continues to cry and I was sick. And the situation was sorrowful. Here my

pain then he cries. I was totally confused with the phenomena. My husband was with

me, I told him to call my mom, He said I will call her once everything is done. Told

him to call now, just now. Then she comes the same day in the evening. She was

happy but am crying. She said what happened. The baby is taking formula milk just in

day one. My mom said, ―No worries it‘s will come in a couple of days. Then its third

month my baby is taking formula milk. I am really distressed about this.

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The baby‘s behavior is also one of the sub-themes identified in the IDIs. Some mothers

reported challenging behaviors of a newborn such as abnormal crying and needing all the

time to be in the hands of the mother. Biftu said:

When my Babyboy cries and behaves in a strange way, I feel sad as he will

continuously makes me stressed. You know he wants to be always in my hand. I am

human being; I need to rest but he wants to remain in my hand and take breastfeeding

the moment I keep him on the bed he starts shouting. Oh really, I am suffering and

already distressed with this experience.

Another reported case of child related issue is the health of the baby. As mothers are

emotionally, biologically attached with her baby she critically follows her baby‘s health

status. In our qualitative study Horenus said:

I just do not want to take my baby to hospital at this age, she is too small. Whenever

she is not feeling good she cries. Her health situation really makes me feel distress.

But, I have taken her to pediatricians three times. What to do? Sometimes it seems

kind of luck. I don‘t understand; my prayer is for my babygirl to be healthy. That‘s

why I am here. You know I cry when she cries.

The health of the baby

In our sample three mothers stated that the health of the baby contributed to their

emotional distress. Zeinab said:

When my baby is sick, I felt terrible, most of the time specially whenever she got

fever, she faints, It‘s really scary. I am consulting pediatricians. I am worried about

this thing. Actually, the Doctor told me to take out her clothes and do bathing or

sponging her with lukewarm water. That helped us to bring down her fever.

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 Whenever she has fever, I am doing that first, if no change I am taking her hospital.

This is the bad experience I am facing she has frequent fever.

Sleeping pattern of the baby

The fourth sub-theme with the child-related case is the sleeping pattern of a baby. Sleeping

pattern was raised as a stressful experience by the majority of the participants. Horenus said:

For example, now he is sleeping and let me put him to the place. Then he wakes up.

And slowly again I tried my level best yet, he is not sleeping. It really disturbing

situation, specially during the time you really need rest. The baby‘s sleeping pattern is

really decisive part that needs solution. So that as a mother we can get time to rest.

Hibo said:

My son does have sleeping problem, we have to carry him before he sleeps. He does

not need any voice. Any voice can make him disturbed. My house set up itself might

be a problem that cause him to wake up as a noise pollution are too much around our

sub-city.

A mother from Bishoftu town, Alamitu, reported if she does not carry her baby he will not

sleep:

If I do not carry him, he will never sleep. I think we have done wrong in handling my

baby boy. As my mother keeps him in the mattress let him sleep by himself,

then we continued to carry, now he learned, I think this may be why he is not

sleeping when we put him in his bed.

Mothers reported the sleeping pattern of a child is a challenge and makes them feel

distressed. From the above respondents we can infer that; sleeping pattern of a baby leads

postpartum mothers to feel distressed.

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4.12. Domestic Violence

Domestic violence is one of the factors contributing to mothers‘ emotional distress.

One of the research participants named Etenesh repeatedly mentioned the violence she faces

from her intimate partner:

I don‘t have anyone to call even my partner was not around he left the house for

almost two months. When he came in the fourth week after my delivery, for one week

he was behaving (at least by not smoking in the house and not asking me money) but

after one week he continued his daily life style. He started to disturb me, insult me. I

don‘t have someone here to help me. He does not care about me. He even wants me

to give him money irrespective of my situation, he never worries about his own

daughter. He even smokes at home, several times he drank and beat me he also

come home in the mid-night its really difficult. Since he came, I feel distressed. In

his absence I was managing on my own.

One of the partners told us her experience of violence from her former boyfriend. In

her current experience of being a mom the source of depression is the threatening behavior

from her ex-boyfriend using social media platform. Alemitu explained her current situtaion

and experience:.

Before my marriage, I had another boyfriend. We broke up 3 years ago. Now I came

to modjo, I have a husband. My ex-boyfriend used to scare me by some personal and

very private picture and that he threatened to post on social media. Another person got

some personal picture from him and he asked me some money and want to do sex

with me, he warned otherwise he will post it to the wider public, including my

husband. At this period of PPD, my husband and I only know each other for one year

as a friend and we came to marry. I told him I had a boyfriend. But some of the

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 pictures are taken without my knowledge and I was shocked when I saw it. This is an

offense against me via social media. They came to know that as I am married from

social media page of my husband. Now they are threatening me saying we will share

this pic! They are repeatedly threatening to share on my husband page. Now I am

worried.

These kinds of issues were not mentioned in our quantitative studies, but emerged

through the indepth interviews of the PPD mothers. Violence against women is one of the

factors we found contributing to the distress of new mothers.

Alcoholic partners

Two participants reported that their partner is alcoholic. One reported that her

husband does not harm her, but the other participant, Etenesh, reported her husband abuses

her when he gets drunk:

My husband is a drinker almost daily. He does not beat me or do anything. By the

time he drinks, he is just comic and becomes sleepy. But I am worried by his

behavior. As for me, my daily life is packed with walk of responsibility for my baby

and myself. I have a lot of things to consider. Earlier it is normal to be with my

partner even if he is drunker; I don‘t care. I was not that much committed to our

relationship. Our relationship was started like being good friend. By then he used to

be very funny, but after getting together and living together he is not as I used to

know him. He is just typical drunker. He get drunk always he had no clue why he is

doing it he just drunk. He never hurted me or abuses when he got drunk. But I feel sad

for him to be like the way he is. He works but, he finishes his money by drinking. So

sad about this expierience of mine.

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 In contrast, Lelise reported about her husband‘s abusive behaviour. According to her,

her husband is very naughty when he get drunk. Her sources of distress is his habitual life

style of getting drunk: ―When my husband gets drunk, he thinks he is the creator of

everything. He acts mad and bossy. I am sick and tired of his behavior when he gets drunk.‖

4.13. Socio- economic status

Three participants reflected the issues related to socio-economic status. This sub-

theme reflects mothers‘ accounts of the emotional effects of their difficult life experiences

related to their socioeconomic status. Some mothers indicated that their emotional distress

was a result of current economic instability in the country. They used expressions like, When

I think of our economic status, I feel ―sad,‖ ‗stressed‘, ‗afraid‘ and ‗desperate‘.

One participant Alemitu said:

I was new to the place where I live and the place is rental house in the outskirt of

Adama. My neighbors are daily laborers, so I spend day time at home alone, it was

really difficult to get help. Like I told you the first two weeks, a woman whom I know

by my coffee place, she supported me. After that, I passed through a lot of challenge,

I even worried and cried several days. Being poor and as the same time alone is not

good. As you know in this town, when you have money you will have a lot of social

connections. But if you don‘t have enough money and if you are poor nobody

wants to associate with poor.

As illustrated in the above statement, socio-economic status was identified by mothers

as one of the factors contributing to PPD.

Work status/Joblessness

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 There are mothers who struggle to survive, and there are also mothers striving to be

involved in bread winning activities. Mothers’ work status or joblessness emerged as a

pervasive contributing factor to depression, specifically when it comes to food, shelter, and

constant income. The below quote illustrates how this experience affects Lelisa: ―I do not

have job. I am housewife, even though I get what I need from my husband. But still I feel bad

for not working. I do not have job.‖ In addition, another study participant also complained

about the issues of joblessness as a source of emotional distress:

“I am a House wife, my partner works in government and living cost is too high and

we are not managing and I feel stressed when I think of not being capable of

providing what my baby needs. If I get a good job I will support, my baby, mother

and my siblings to live a better life. But, am not able even to cover my own expenses,

it‘s a painful experience ―

4.14. Economic instability in the country / continuous inflation/ living cost

Four participants shared their concern of economic instability as a depressive

experience and used sentences like, ―Everything is increasing every day; our birr has lost

value.‖, ―I can‘t buy what I need with this income.‖, ―The living cost is increasing and things

are not predictable here‖ And ―Yesterday you buy 100 Birr today they tell you 120 or even

more, it is difficult‖.

Sara stated:

―You know the living cost is unpredictably increasing. We are struggling to survive;

things are getting worse. I am terribly worried, with the current economic issue. This

makes me to be distressed and worried. How I can cope to feed my kids? I can‘t

afford the current price of diaper and milk, it‘s just everything seems against me,

why this happens now, there are times that I really felt like this is bad time to

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 have a baby. I wonder how other mothers are coping with this crazy economic

situation. It really affected me; I know not only me all mothers like me.‖

4.15. Mothers‟ Experience of Social support

Our second objective in the qualitative part of the study was to explore the type

of social support mothers received during the postpartum period in the study area. The

participants expressed that they had different positive and negative experiences. Some

motheres received good social support from their partners, friends, and family members. On

the other hand, there are mothers who did not get enough social support. The types of support

received were mainly financial, emotional, and physical support with washing clothes and

cleaning the house.

Emotional support

During the postpartum period, many mothers encountered several distressing

situations. In this study mothers shared about their experience of emotional support. The

souces of such support are from their mothers, partners, family members, and friends.

Horenus said: ―My mother is a source of inspiration for me. She always encourages me

even when I fail to do some activities. She understands me well, the emotional support that I

got from my mom was important.‖ Mothers‘ experience specially those mothers who

delivered with cesarean sections and with stitches reflected that in their experience of

emotional distress, emotional support was very important. Lelise said:

‖My partner supported me a lot even with things that he does not had

experiences with. He cook by himself, he washes his own clothes by hands, he does

shopping for household. It‘s wonderful. He was not like this before his

encouragement and work involvement helped me to be strong emotionally. Such

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 support are good. My experence in this regard is very good. Her meals during the

first few days after delivery.

On the other hand, Belaynesh said that “my husband supported me during bathing.

Hence, I was physically weak due to the cesarean delivery.‖ Three mothers stated that their

husband had discharged several responsibilities in supporting them. They also reflected the

same experience of support from husbands such as gently carrying babies and putting them

to sleep when they wake up in the night. The support includes not only holding the baby but

also having the husband stay at home. Two of our informants Biftu said:

After I gave birth my husband started to be home early. But before my delivery he

used to stay late and he focusses outside. Now there seems a life style change. He

wants to stay home whenever he is free from work. This has encouraged me

emotionally. I never expect him to be home early because I tried, he never changed

his life style but after I gave birth, he is with me so far. At least he had seen the

reality that he is needed at home. This kind of things helped me to be relieved.

When he is out, even now I feel distressed because his presence can make a

difference in all we do. Now he has learned diaper changing, washing clothes, and

etc. He is wonderful.

In contrast, some mothers expressed their distress due to a lack of emotional support. They

explained that the roles of their partner were not sufficient and they did not understand the

mothers‘ concerns. Some partners did not encourage the postpartum mothers.

Hibo said:

We got our second child. But my husband wants me to continue doing everything on

my own. I expected at least emotional support and togetherness

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 from him, but not as my expectation he is just leaving as usual, but I needed support

from him several times.

Financial support

In a common practice in most Ethiopian rural families, it is the husband who plays the role

of bread winner. Hence, husbands provide financial provisions. Medrek said:

I was not working, I am house wife, but my husband provides the money that I

need. I have no worries on my financial needs. He does what he can. I know what he

can, I just ask accordingly. I do not ask for something that is out of our financial

scope. So, financial things are not a problem so far. The problem is he thinks if he

provides money, he is done. But that‘s not right, he has to support at home. I believe

if you provide money with no appraisal and emotional support might bring distress.

Finance is big issues but, still I need more of him not just his money.

Some postpartum mothers who participated in this study said that as part of the

traditional culture, friends, neighbors, and relatives especially those who visit postpartum

mothers give some money in showing togetherness and encouragements. Hortu said;

―Financially, I have received support as its common practice especially when the

visitor is a man, he gave money. If the visitor is women, she brings butter for my

hair. Such support is very important and useful I bought soap and other materials

with the money I received in such way‖

Four study participants added they have received money, butter, and several gifts including

clothes and diapers as well from the visitors. Hortu added: ―My friends and my family

member gave me diapers, money and visits and encouragements. That‘s very helpful. I liked

it‖. In contrast, other mothers reported a lack of financial support, struggling on their own

with no support from anyone. Etenesh said:

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 I passed through challenging experience. There was time that I felt bad, stressed and

even confused. Oh, it was difficult. Being poor is not good human being we need to

work. When I think of what I passed. I really want to thank God. Yes, I want to thank

God. Because it was even dangerous time. But I am alive now. If it was not the help

of GOD, I was not hear today talking to you. No joke. Mine is known, but what I felt

bad was when I think of my baby. Who will take care, who can help her? There is no

one that can be reliable. Or economically, I was not strong enough, Though I work, it

just enough for my expenses only. As it‘s known, our life is just hand to mouth. But I

know if I keep on working, I will be changed. I can make big things.

Support related to cleaning and washing clothes

Indeed, there are mothers who said they got enough support for cleaning and

washing clothes. Our study participant Medrek said:

I have enough social support. For my baby and even for myself I get all

clothes washed and cleaning house by my mother. My friend also supports us

when she visits us after work. Regarding washing clothes and cleaning there is

no problem.

There are also mothers who have a very good social support from their family. Sara

one of the study participant said

I get support in handling my baby when I sleep. Mom supports me a lot. She even

stays till today with me. I have a very good support from my husband as well. He took

paternity leave and annual leave from his work and stayed with us. My husband is a

very understanding and good person. He is there for me. If it was not him, it would

have been difficult. But thanks to God I have him. He cares for the baby and for all

my family as well.

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 In contrast, some mothers suffer alone for lacking social support. Etenesh said:

―I have no anyone to support in washing clothes, actually my friend supported me for a few

days otherwise, I am struggling on my own. As I said my partner does not care‖

4.16. Mothers coping mechanism with PPD

Regarding coping mechanisms mothers have their own ways of handling their

feelings. Majority of the mothers said prayer and spiritual songs are their ways to get relief.

there are also mothers who mentined, holy water, walking /physical activity, listening modern

music, taking to family member, watching movies, reading bible, asking for help and crying

4.17. Mothers experience in the hospital

We also asked our study participant regarding their feeling on the services delivered

by the hospitals. Mothers came with diversified view on the service they received. A mother

from Bishoftu hospital said ―I am thankful to all the staff here, I liked their comitment and I

am happy with their treatment.‖

Three mothers from Adama reflected positively with the service they received in the

hospital:

―I am happy, with the services, it‘s very good.‖, ―I was accepted without any payment

just for free, regarding this I am happy‖ and ―They are good, I am happy for the free

service, but they are harrying for everything, but still fine.‖

In contrast, other mothers complained on the services and the treatment by the

midwives. Another from Modjo said: ―I am not happy with this hospital. They do not

respect me; I feel they don‘t have compassion.‖

Moreover, we have received this view on dissatisfaction from a mother who

delivered at Batu Hospital,

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 I am not happy with the midwives, they did not respect me, I was even angry in

the delivery room. The expression they used, even I was insulted, it was crazy

moment dealing with such annoying midwife. They do not have to be like this,

they should respect mothers. The language they use is so bad.

As we have witnessed, some mothers praised the midwives and were full of

thankfulness and there are also mothers who had bad experiences in the hospital.

4.2. Part two of the qualitative study

4.2.1. Characteristics of the seven Professional Midwives

Seven midwives were recruited for the in-depth interviews on their views towards

the work they do with postpartum mothers and PPD. Five were female and two of them

were male midwives. Their experience levels ranged from 2 to 16 years. From which 2 of

them has work experience of sixteen years. Three had three years of experience and the

remaining two had four years and two years of work experience respectively. Their age

ranged from 25 to 35 years (Mean = 30 years). Four participants were married and three

were single. All of the study participants had first degree. And none of them used any

known screening tools for PPD.

# Age Sex Work Education Marital status Screening

experience level experience
st
1 35 Female 16 years 1 Degree Married No

2 33 Female More than 1st Degree Married No

16 years

3 25 Male 2 1st Degree Not married No

4 29 Male 4 1st Degree Married No

5 26 Female 3 1st Degree Not married No

6 25 Female 3 1st Degree Married No

7 26 Female 3 1st Degree Married No

Table 13: Characterstics of Midwives who participate in qualitative part

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Below are discussed the finding from the in-depth interview with professional midwives

What is covered in the discussion? We have discussed the midwives work in general

and their work with postpartum mothers in particular. Their own related issues and their view

towards the work as midwives, we also talked about social and economic aspect of their job

and their work environment in general by far seeing it might contribute for depression on

postpartum mothers indirectly. All midwives discussed more about their experiences working

as midwives and reflected their concern on PPD and also the midwives conferred that

attention is not given to PPD.

Below are themes developed from the conversations as midwives has their own

positive or negative contribution for PPD general perception of PPD in their own work as

midwives

Themes N= 7 (100%)

 Socio-economic aspect of their work  7 (100 %)

 Salary  7 (100 %)
 Job satisfaction  4 (57.14%)
 Supportive supervision and clinical  7 (100 %)
mentoring
 Education and knowledge of Midwives 7 (100 %)
regarding PPD is very little
 Screening experience 7 (100 %)

 Not giving attention 7 (100 %)

 Work load 7 (100 %)
 No social worker 7 (100 %)
 Lack of knowledge on handling social 7 (100 %)
issues
Table 14: Themes developed from the midwives

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4.2.2. General views about their professional life as Midwives

Socio-economic aspect of their work

Most of the seven staff participant reflected that, there is a deference or value in their

work. They mentioned they need to be respected by the government as well by being paid a

proper amount of reimbursement. According to participants, the lack of respect for the

midwife profession is a problem, such as mutual relationships between midwives, the lack of

understanding of the roles of midwives among physicians, health officers, nurses, public

opinion, and financial departments.

For me being a midwifery by itself is distressing experience here with this setting and

payments. The work load is too much and will pressurize us, but the payment is too

small. The management sees only as we are on job but nothing else, we are working

hard, with all the limitation. We work on duty where sometimes many cases come in

midnights and clients are not happy as a result of that, they are not happy as some

times we do not reach them equally one labor in one couch and another waiting and

our clients are not happy as result they do not respect us. (Batu Hospital)

In contrast midwife from Adama said:

Our clients are satisfied with our facilities. For instance, they are thankful by our

delivery services as we work as a team. In case of our absentees from the Hospital,

they check out availability of our team via our personal phone. I personally, serve

with all my potential and they are satisfied. Sometimes there might be high flow of

cases and high burden of work, but still manageable.

A male midwife from Batu has differing experience regarding the views of the family of his

clients. He said:

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 The communities‘ after their visit here; they have different perception, understanding

and attitude towards the activity conducted by midwife professionals. There are

people who has good attitude and there are people who do not have good attitude.

Some of them see it completely different angle how a man sees a woman? Even

though it‘s not that much frequent but it happens to be seldom. But still possible to

say the community has good attitude towards us (Midwifery).

One midwife reported a high workload on the two midwives available per hospital. Likewise,

one female midwife at Bishoftu Hospital said:

As a midwife we have asked several times to work by being in team but we never get

positive answer to date. In one night up to 10 or 12 mothers delivers but this is done

with small number of midwives. This should be considered, because this is the main

reason that makes mothers to complain. When you go to treat one mother the other

mother feels abandoned and may get depressed it‘s too bad. With this condition I

cannot say mothers do get good treatment from us. I also worried. For me this might

have contributed for depression during postpartum period as a bad beginning.

Salary

Many respondents talked about the payment structure; midwives are poorly paid.

Most respondents said that they received their salary regularly. Some participants indicated

that the payment structure is a sensitive subject. Participants expressed their concern that in a

different payment structure, cost savings could occur which could possibly lead to a reduction

in income for health professionals. Almost all of the participants suggested that it is necessary

to consider improvement of the remuneration by the concerned authority.

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 Our participant from Modjo Hospital said: ―My salary is not enough. The work I do,

the risk I take and the payment I get do not match. Many professionals because of this they

are shifting to other departments.‖ In addition to this view a participant from Bishoftu

Hospital said: ―There is no delay for our regular salary payment. But our concern is the

amount of payment. The payment is very less as compared to our busy schedule of work and

in comparison, to other health workers who got relatively less pressure.‖

Midwives‟ Job satisfaction

The working condition (work environment) was assessed through interviewing the

midwives. Some participants reflected that midwives are not able to perform their tasks due

to poor working conditions. The work environment was assessed whether they are well

qualified, in-service training and professional development to improve the quality of care,

provision of incentives and promotion, job stratification, supportive supervision or clinical

mentoring, training on PPD and screening, clinical decision making.

Most midwives feel they are satisfied or happy after attending normal deliveries and

providing newborn care, ante-natal and postnatal care services. They feel unhappy when there

is death of a newborn. In addition, all of them mentioned their distress with the payment.

Otherwise they liked their job as a profession: A study participant from from Bishoftu

Hospital said; “I will be happy when mothers and infants got relieved, I am happy when

mothers are happy.‖ In the same way participant from Modjo Hospital ―Everybody would be

happy at the end. I feel happy when I accomplish my own work.‖ and another Male Midwife

from Adama Hospital said ―I feel so happy at the end of my work. I‘m pleased to work than

stay idle.‖

Supportive supervision and clinical mentoring

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 From East Shewa, midwives participated in-depth interviews unanimously stated that

the supervision and mentorship support were very minimal. Female midwife said:

―Supportive supervision is very small and training on PPD is none‖ Similarly, male midwife

from Modjo Hospital said “The attention we get is poor. I do not know why. There is no

supportive supervision regarding PPD. I never heard about it‖

The majority of respondents stated that there is neither movement regarding PPD nor

mentorship program in the hospitals so far. As mentorship builds confidence of midwives, it

also helps them to be informed about new ideas and practices. This will help to provide

quality services in many aspects of the mother‘s health including PPD. All midwives (at East

Shewa zone) said that they have never taken any training regarding PPD. “I know PPD, even

though it I have never involved in trainings about PPD. At Modjo Hospital we are getting

several capacity building trainings but none of the training is about PPD‖.

Some respondents also reported a lack of skill in screening. Most expressed a desire for

training on screening of PPD.

―We did not get training on PPD and screening of PPD and we did not give any

attention as the multitude of mothers are here to deliver‖ Midwife from Bishoftu

Hospital

―I needed to have training to safely practice procedures like applying screening and

managing PPD. I do not give screening because I did not receive the training on

screening‖. Midwife from Modjo

―There are areas that I need additional training, I am not able to manage depression

cases since I don‘t have any training. So, I make a kind of oral diagnosis sometimes

and make a referral‖. Midwife from Adama Hospital

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A staff member from Batu Hospital said:

―I don‘t feel confident in handling real PPD cases. I immediately refer if I came to

know it is something depression. I encounter such cases. So, it is better if I get

additional training on them‖.

Some participants maintain that they have skills gaps due to the lack of training and

insufficient experience, and others were very interested to have the skills and blame the

working environment. Most respondents also said that their skills improved over time with

experience and additional trainings particularly in PPD is important. In general, participants

agree that training is required.

―Previously the health professionals might not be aware of PPD. They refer most

cases to other professionals. They were referring very simple cases to manage because

of lack of sufficient knowledge and skills related to PPD.‖ Midwife from Adama.

4.2.3. Midwives on their views of postpartum depression

We asked the midwives about their views and engagements with PPD.

A participant from Modjo hospital shared:

―To be honest, we don‘t really work on postpartum depression by making it priority,

you can see it no one gives time to mothers once they finished, they go to their home.

They came for vaccination again. That is it‖.

We questioned when and who should be giving responsibility to handle mothers with

postpartum depression. Midwives had clear but often differing views of when and who

should give professional support to mothers regarding emotional distress. Many midwives

reflected that discussion may not help the PP mothers at this stage:

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 ―Mothers are so inattentive with the fact that they are having a newborn; and they that

are unlikely to be interested in discussion to take time talking about their feelings and

experiences following childbirth‖.

Some midwives thought that for certain groups of women, such as for teenage

mothers, raising the subject of PPD might be useful.

―I personally suggest raising issues and testing for PPD would be more important for

the new teenage mothers as they don‘t have experience. We need to treat them in a

way that could support them to get relief. But for this we need to be trained still.‖

―Yes, they will go once we discharge, they came only for vaccination to BCG not to

us. The time they stay with us is very limited. They are just on their couple of days of

their postnatal period, hence cannot be the right time to mention.‖

Midwives were also asked if they ever informed postnatal mothers about PPD in

addition to other postnatal care.

―We are handling several clients with delivery and labor-related issues. We tend to do

our routine work in assisting with delivery. But, discussing about PPD in our realities,

it seems not possible. But I feel it‘s necessary to talk to mothers with the time frame

of 4 to 6-weeks during their postnatal visit for vaccination. I think it‘s good because

by then women are more settled and getting back to normal‖. Midwife from Adama

―I don‘t think that I need to discuss PPD in depth with them once they are done with

delivery; I just discharge them into their home.‖

In addition, a midwife from Bishoftu said:

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 ―I don‘t think many women would be very open to discussing their feeling soon after

delivery, as you can see, they came after six weeks to another department called BCG

for vaccination, they don‘t come to us. Because, like I say they have got so many

other things that they are thinking about.‖

Midwife from Adama

―It has to be in a more private setting to advise mothers by midwives, so they have

more opportunity to discuss things more fully. But as for me, theoretically, I know a

little bit about PPD, but I have done nothing practical on PPD.‖

Limited education and knowledge of Midwives regarding PPD

Some midwives recalled that this was briefly addressed during their initial midwifery

training but others could not remember receiving formal PPD education at all.

―As we are not practicing PPD treatment as midwives, I do not remember entirely, but

I had taken introductory courses and class discussion. But like I said I have not up to

date and practical engagements on PPD‖ Batu Hospital

There were variations in how midwives perceived PPD. Most felt they were not up to date, or

whether a new way to approach handling of PPD had appeared since they qualified.

―To be honest, if I am asked a detailed question about PPD, perhaps I mightn‘t be able

to respond, specially the latest updates with the themes of PPD.‖

They felt that a lot of training would be needed to bring them up to a sufficient level

of understanding to handle PPD and screening in detail to reduce emotional distress of

mothers. Talking about the PPD education they have received, one midwife shared:

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 ―I‘ve never recall practical issues about PPD. Probably I heard more about emotional

distress when we talk challenging behaviors of some mothers; specially, when actual

behavioral disturbance occurs in the ward some of staff members guess it might be

depression. But, practically speaking I have done nothing to count with PPD. We tend

to concentrate on the delivery rather than PPD. But we need to have training and

workshop on PPD.‖

Another participant from Modjo said

―It‘s up to you to know more about PPD, nobody or even agent gives you training

about PPD; yes, we don‘t get specific sort of training on it, whenever we suspect PPD

we just refer the mother to the psychiatry department.‖

Many of our study participants believed that postpartum mothers would benefit if

there is a separate counseling and treatment part that is specifically designed for PPD within

their hospital. Especially for new mothers, teenage mothers or women with significant

medical or social issues would be important. The midwives think that targeting such mothers

on screening with PPD is important and requires adequate training. They also suggested that

separate work ownership unspecific group will be vital to deal with this purpose.

Even though no midwives currently conducted screening of PPD with the latest tools,

midwives were referring mothers with challenging behaviors to the psychiatry department for

further diagnosis.

When asked what they would do when they suspect a mother has PPD, a midwife from

Adama said that:

―I believe we could do great things if we could make advise and treatment as part of

our job, if there is a system to follow mothers with PPD.‖

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A midwife from Bishoftu added that:

―It is good to be trained but since we do a lot of things in our ward, this job will be

best, if it‘s done by some other professionals not us, we do a lot here we are busy, one

after the other delivery.‖

Those who thought it would be good to be able to deal with PPD did raise concerns

that their job was already extremely busy and the amount of training that would be required

to deal with PPD and to maintain this skill would be considerable.

Midwives were also asked questions like ―Some research revealed that knowledge of

midwives on PPD can be a contributing factor for PPD. What do you think about this view?

Almost all of them accepted this view saying should they know well they can make a

difference. ―I totally agree with you, we may reduce the burden of PPD mothers if we all

trained well. We are not the one who cause, but our knowledge might reduce depression.‖

For the question Do you think views and perceptions of a professional midwives can

influence PPD? Participants unanimously agreed their influence could be high.

A study participant from Adama stated: ―Midwives work not only with depression,

we work with life, our walk is full of responsibility, so our good knowledge not only

minimize depression but also life‖. The study participants agreed with the view perceptions

of a professional midwives can influence PPD. They even suggest on job training on PPD to

raise awareness should be offered to midwives‘ staff as well.

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 CHAPTER FIVE:

DISCUSSION OF STUDY FINDINGS

Introduction

The current chapter demonstrate the discussions on major findings of the sudy. The

discussed topic includes; magnitude of postpartum depression, factors associated with

PPD, PPD and violence against women, social support and issues in relation to the

hospital has been discussed briefly.

The current study is conducted with an institution based cross-sectional survay

aiming to explore prevalence and associated factors of postpartum depression and also

would like to explore on the views of midwives however the study has got limitation both

in scope and methodology. As a common limitation in the method part; we share the views

of all methods have limitation, hence we are not free of limitation. On the other hand we

are limted to East Shewa Zone; where as Ethiopia is a country with more than 86

languages and diversified cultures with several ethnic groups. Such diversity definitely

increases the peculiarities in the social and cultural settings and meanings for any social

phenomenon. Since the research on prevalence, associated factors, exploring mothers and

midwives expirience was conducted in one of the zones from Oromia Region, Ethiopia, it

may not be representative of all areas in Ethiopia.

5.1. Magnitude of postpartum depression

The magnitude of PPD was measured using the PHQ-9 (Patient Health

Questionnaire). PHQ-9 is locally validated both in Afaan Oromo and Amharic version.

Taking from a study conducted in Ghana; the optimal cut-off to designate possible depression

was 5 and/or above (Weobong, Asbroek, Soremekun, Manu, Owusu-Agyei, Prince, & et al.,

2014). Hence, in the current research, depressed: those postpartum mothers who score >= 5

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cut off point of PHQ-9. From 9 questions each of which has 4 options giving maximum score

of 27 and a minimumm 0. Normal postpartum mothers (not depressed): those mothers who

scored < 5 cut off point of PHQ-9 (Weobong, Asbroek, Soremekun, Manu, Owusu-Agyei,

Prince, & et al., 2014). (for more read chapter three)

Accordingly, the magnitude of postpartum depression in this study was 23.2. This

finding shows a substantial proportion of mothers, i.e., 23.2%, experienced PPD. This finding

is consistent with findings from Poland 23.2% (Marzena Kaźmierczak, 2014), India 22%

(Patel, Rodrigues & DeSouza, 2002), Central Finland 22.2% (Hiltunen P. 2003), and Lahore

25% (Seema Daud, 2008). A study conducted in the capital city of Ethiopia, Addis Ababa,

revealed that nearly the same magnitude of PPD with the current study findings, i.e., 23.3%

(Addishiwet & Yohannes, 2018). Likewise, another study in Addis Ababa found a similar

result with a significant amount of PPD 23.3% (Fantahun, Cherie &Deribe, 2016).

On the other hand, the finding in this study was higher compared to findings from

Japan 7.7% (Yamamoto, Abe, Arima & et al, 2014), Iran 6.9% (Abdollahi F, et al. 2016),

Canada 8.69% (Lanes, Kuk & Tamim, 2011), Czech Republic 10.1% (Fiala & et al. 2017),

Sudan (9.2%) ( Khalifa et al.2015), Greenland (8.6%) (Iben Motzfeldt, et al. 2013), Uganda

6.6% (Nakku, Nakasi & Mirembe, 2006), Nigeria 14.6% (Adewuya, Fatoye, Ola, Ijaodola,&

Ibigbami, 2005), and the Soddo district in South Ethiopia 12.2 % (Hanlon et. al 2018).

However, the finding in this study is less than the prevalence reported in some parts

of Ethiopia and other countries. PPD in South West Ethiopia was reported to be high with a

prevalence of 33%, (Kerrie & et. al, 2018). Hanlon and colleagues (2017) reported that

28.7% of women had postpartum depression symptoms in rural Ethiopia around Butajira. In

Bale Oromia Region, South East Ethiopia, findings revealed a prevalence of 31.5% for PPD

(Tefera et al. 2015). A cross-sectional study conducted in Amhara region, northern Ethiopia

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came up with a higher result of 32.8% of mothers having PPD symptoms (Joy, Angela, Yared

& Dereje, 2014).

In addition, a study conducted in South Africa reported PPD with 34.7% and up to

50.8% in the Democratic Republic of Congo (Cooper et al. 1999; Imbula, Okitundu, &

Mampunza, 2012). In Pakistan the range of PPD is from 28%-57% (Kazi, Fatmi, & Kedir,

2006), and 35%-50% in Latin America (Wolf, Deandraca, & Lozoff, 2002), Nepal 30% (Giri,

et al. 2015), Pakistan 33.1% (Muneer, et al. 2009), Uganda 43% (Kakyo, et al 2012), Asia

63.3% (Klainin, &Arthur, 2009) and South India 45.5% (Johnson, et al. 2015).

Thus, there are discrepancies with the prevalence of PPD across regions and

countries. The discrepancy perhaps arises from the different measurement approaches related

with each study. Some of the differences could be because of the differences in study setting,

study approach, study design, study year, socio-demographic characteristics of the

participants, and type of screening tool employed. The current study was institution-based

while some of the above-mentioned studies were community-based, the current studies used

PHQ-9 scale while others used self-reported questionnaire (SRQ-20) and EPDS (Edinburg

Postpartum Depression Scale). On the other hand, there might be personal bias if some

mothers were not honest to express their true feelings and ideas. Such factors might have

contributed to the discrepancy in the findings.

5.2. Factors Associated with PPD

Within this specific sub topic as a factor associated with PPD: the researcher

reflected. Socio-demographic factors, psycho-social factors, factors related to pregnancy,

abortion, still birth and factors related to the baby.

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 Studies in low- and middle-income countries reported that PPD has some identifiable

risk factors. Depression may result from socio-demographic factors (Casey, Goolsby,

Berkowitz, Frank, Cook, Cutts, et al., 2004). The current study found that the socio

demographic factors such as maternal age, residency, level of education, husband occupation,

and income level were significantly associated with postpartum depression (PPD).

The current study is also congruent with studies conducted in Southern Africa and

Vietnam, where systematic reviews indicated that antenatal depression is affected by

socioeconomic factors like poverty (Fisher, Mello, Patel, Rahman, Tran, Holtn & et al , 2012;

Fisher, Mello, Izutsu, Tran,2011), low income (Hartley, Tomlinson, Greco, Comulada,

Stewart & et. al, 2012), and lack of education and permanent job (Fisher, Mello, Patel,

Rahman, Tran, Holtn & et al, 2012). This study is also in consistent with a meta-analysis

conducted by Stewart and et. al (2003), and another meta-analysis by Beck (2001) which

confirmed the association of sociodemographic factors with PPD.

A cross-sectional study conducted on the prevalence and associated factors

of postpartum depression in Southwest, Ethiopia revealed that PPD is associated with socio-

demographic factors such as age, marital status, economic status, and educational level of

both the postpartum mothers and their spouses (Kerie, et al, 2018). Age, maternal

educational attainment, place of residence as well as husband‘s educational attainment has a

significant association with PPD (Fiala, et al. 2017, Giri, et al. 2015; Muneer, et al. 2009 &

Patel, Rodrigues & DeSouza, 2002). However, the impact of socio-economic factors on

depression remains inconsistent; a community-based study in rural Ethiopia revealed there is

no association between socioeconomic factors and PPD. Such discrepancy might be the

difference in methods and study nature as explained above.

Furthermore, we also found from the qualitative interviews that mothers perceive that

socio-demographic factors contribute to PPD. Mothers in the study said that the socio-

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economic challenges and inability to give important and basic things to the baby makes them

feel depressed. In addition, some of the study participant mothers reported that, the source of

their emotional distress is linked with their socio-economic challenges, including, income.

Among the pregnancy-related variables, pregnancy plan, history of abortion, history

of still birth, and pregnancy history were significantly associated with having PPD. The odds

of mothers whose pregnancies were unplanned to have PPD was 3.6 times higher compared

to those mothers for whose current pregnancy was planned (COR = 3.65, 95% CI (1.90 –

7.01), p-value < 0.001). This finding is consistent with findings in Sudan (Khalifa et al.,

2015), North America (Brett, Barfield & Williams, 2008) and South Africa (Stoltenberg &

Abrahams, 2015). Likewise, Tigistu, Fantaye and Susan (2018) reported that unplanned

pregnancy was highly associated with PPD.

In congruent with this view our study participant from the in-depth interview also

mentioned that, she came to marriage because of out of wedlock pregnancy. This happening

makes her to feel distressed several times. Some mothers complained the sources of their

emotional distress unplanned pregnancy and mistiming of having a baby. There are also

studies that confirm the unplanned pregnancy and delivery brought about distress on mothers.

In the current study, previous history of having abortion and still birth were found to

be significantly associated with PPD. The current study is in line with studies conducted in

rural Ethiopia Soddo district (Hanlon & et. al 2017). This research also goes in line with the

findings of (Fisher, Tran, La B, Kriitma, Rossenthal & Tran (2010); Lancaster, Gold, Flynn,

Yoo , Marcus & Davis (2010) who found that still birth and abortion were associated with

increased maternal depression. In addition, women with stillbirth and abortion were more

likely to have postpartum depression than were women without a history of stillbirth and

abortion (Giannandrea et al., 2013). On the other hand, the odds of having PPD was found to

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be two times higher in mothers who reported a history of infant illness compared to mothers

who reported no history of infant illness. From our indepth interview also, there are mothers

who had history of abortion and still birth. That expirience of abortion was painfull memory

and still they said they have a fear and self blame, that makes them to feel less confident

weather they could be good mothers. Moreover, this makes them to feel emotionally

distressed.

5.3. PPD and violence against women

The season of PPD is mostly associated with both psychological and biological

changes of mothers. While on one hand, the mother has to deal with her new task for her

newborn, she has responsibility for the family as well. Moreover, she also has to deal with

her own physical and emotional condition. Having this reality on the ground, challenges

including violence against women by the intimate partner makes their postpartum period

depressive. In this study, the prevalence of intimate partner violence was 19.6%. The odds of

mothers who reported intimate-partner violence to have PPD were 1.9 times higher compared

to mothers who do not report intimate-partner violence (COR = 1.98, 95% CI (1.22 – 3.22),

p-value = 0.006).

A study conducted in Addis Ababa found that 23% of study-participants who were the

victims of domestic violence had symptoms of postpartum depression (Adinew & Adamu,

2018). Domestic violence was positively and significantly associated with symptoms

of postpartum depression. The current finding is less as compared to the WHO report which

says globally 1 in 3 or 35% of women have experienced some form of violence (i.e., physical

and/ or sexual violence) by an intimate partner (García-Moreno, Pallitto, Devries, Stöckl,

Watts, & Abrahams,2013). The highest prevalence of IPV has been found in Africa and

South East Asia. Along with high prevalence, there is also higher social acceptability toward

violence inflicted by a partner in these regions (WHO, 2012).

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 Substance use history of partner, social support, and intimate-partner violence were

found to have significant association with PPD. In addition, in the qualitative part of this

study, our informants also repeatedly mentioned that, substance use and intimate partners

violence is one of the major contributing factors that makes them to feel depressed. This

finding is consistent with findings from a study conducted in Mizan Aman town, Bench Maji

zone, Southwest Ethiopia (Tigistu, Fantaye & Anand, 2018).

5.4. Social support

Postpartum depression was remarkably understudied in the current study area. Some

studies indicate that social support is helpful to minimize depressive feelings and emotional

disturbance during the postpartum period. In the same way the present study revealed that

social support was significantly associated with PPD. The odds of mothers with poor and

moderate social support to be cases of PPD were 1.7 and 2.1 times higher, respectively,

compared to mothers with good social support. In support of our current findings, Leahy-

Warren et al. (2012) reported that social support was a strong contributing factor that affects

women to lead a healthy life. Other studies also indicated the positive influence of social

support for good emotional adjustment (Ballard & Radley, 2009).

In one of the studies mothers who had high levels of social support were able to

establish more secure attachments with their infants than were women with low levels of

social support (Crockenberg, 1981), suggesting that social support may be an important

resource for parents of new infants. Although good relationships with others, especially the

spouse, have been associated with adjustment and adaptive parenting in the postpartum

period, little is known about the mechanisms through which social support helps women cope

with the stress of childbearing. A systematic review by Biaggi, Conroy, Pawlby, and Pariante

(2015) suggested that the lack of a partner or social support was associated with higher rates

of antenatal depressive and anxiety symptoms while Yim et al. (2015) found that low social

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support and poor quality relationships with close others was a predictor for postpartum

depression. Fisher et al. (2012) conducted a systematic review into the determinants of

depression in low income countries and found that difficulties in the relationship between the

woman and her partner were associated with depression.

Mallick et al. (2010) indicated that family and social support are necessary for

postpartum mothers. Postpartum mothers who typically lived with their nuclear family or

relatives found to have a better emotional adjustment.

In the present study, the study sample showed a significant association between lack

of social support and postpartum depression. Social support plays a role in encouragement of

new mothers, supporting good adjustment during the postpartum period (Chen et al., 2007).

For women who juggle multiple roles, having strong and positive support from others

is correlated with a stronger immune system, higher life satisfaction, better health perception,

and fewer symptoms of depression (Arborelius & Bremberg, 2003). If women perceive they

have more social support, they have more healthy behaviors and will be more likely to

change unhealthy lifestyles (Croghan, 2005). Emotional, informational and tangible support

provided by women‘s closer social network members (e.g., partner, mother, and friends) were

suggested as an important factor in a healthy postpartum period (Rempel & Rempel, 2004).

Social support was a major motivating factor for adopting healthful eating habits and

engaging in physical activity (Chang et al., 2008). In a study of postpartum women who had

gestational diabetes, higher social support through help with child care and other

responsibilities was associated with sufficient physical activity for mothers (Smith et al.,

2005). Additionally, Keller et al. (2006) found that having friends with whom to exercise has

a positive influence on the degree of physical activity for postpartum women.

On the other hand, lack of social support impacts emotional coping and appeared to

be a significant predictor for postpartum depression during the postpartum period

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(Smith & Segal, 2011). Postpartum women cite lack of social support as a barrier to both

healthful eating and engaging in physical activity (Albright et al., 2009). Thornton et. al

(2006) found that inadequate social support has an inverse relationship with weight status

among low-income minority postpartum women. Thornton, et al., 2006). Postpartum blues

and postpartum depression may manifest in the absence of adequate social support (Allison,

Brouwer, Carter-Edwards, & Østbye, 2011).

Carron et al. (1996) examined the impact of social influences on physical activity

behavior and found moderate to large effect sizes for social support from family and

important others with exercise attitudes and behavior. It has been found that social support

from family, friends, and spouses all predict physical activity behavior among women

(Tamers et al., 2011).

In contrast, a cross-sectional study conducted in Mombasa Kenya with 429 mothers

focusing on social support and social stress reported no association between depression and

social support (Husain & et. al, 2016). Such discrepancy might be with cultural and socio-

demographic aspects of the research participants.

The current finding is also in congruent with the Psychosocial theorists which propose

the occurrence of stressful life events, such as the birth of an infant, marital problems, lack of

social support associated with the social and family environment, loss of a loved one, marital

or relationship difficulties, or serious financial or housing difficulties may precipitate the

onset of depression (Abdollahi, Lye &Zarghami, 2016).

5.5. In relation to the hospital

Within the qualitative part of the study, several issues were raised including mother‘s

satisfaction with the hospital services and the midwives‘ views and experiences with

postpartum depression. To this connection, there are mothers who are happy and there are

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also mothers who are not happy with the service and communication they had in the hospital.

Interestingly, almost all the midwives felt that their perception and knowledge can make a

difference. This view goes in line with the view of Jones, Creedy and Gamble (2011), who

reported that emotional care provided by midwives may improve mothers‘ health and well-

being andreduce stress, trauma, and depressive symptoms.

From our study participants, almost all of the participant did not have any training in

screening and PPD related issues. The midwives said they never recall practical issues about

PPD. They reflect they perhaps heard more about emotional distress when we talk

challenging behaviors of some mothers; specially, when actual behavioral disturbance occurs

in the ward some of staff members guess it might be depression. But, practically speaking I

have done nothing to count with PPD. We tend to concentrate on the delivery rather than

PPD. But we need to have training and workshop on PPD. Nurses and midwives are expected

to conduct regular medical screening for women in the postpartum period to detect depressive

symptoms (Goodman, 2004).

The provision of antepartum and postpartum emotional care can be challenging and

requires a good knowledge base for the provider to screen and assist distressed women. This

study examined East Shewa Zone midwives' perceptions regarding postpartum depression. In

this study we have seen midwives who said we are busy and who are focused on delivery.The

reality on the ground seems to not be adjusted to conduct PPD screening and checking. They

said mothers are so inattentive with the fact that they are having a newborn; and most of the

time they are dubious to be interested in discussion to take time talking of their feelings and

experiences following childbirth. Some midwives thought that for certain groups of women,

such as for teenage mothers, raising the subject of PPD might be useful.

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 The study participant midwives said there is a need to treat postpartum mothers in a

way that could support mothers to get relief. But for this to take place the research participant

midwives unanimously reflected as they need to be trained still.

In the current study, midwives reflected that they never discussed PPD with mothers,

almost all of them responded they never brought this subject to mothers. The professional

midwives had differing views on issues of discussion with PPD mothers. Some shared that

mothers‘ emotional distress and PPD whilst in hospital might be unsuitable. One midwife

suggested it should not be made soon after delivery it needs time.

The majority of midwives considered discussions about PPD with the mothers soon

after delivery is not appropriate. When they finish with delivery, the team will automatically

discharge from hospital. Moreover, concerns were raised that midwives might not address

PPD issues as it is not customary activity and they are not well trained on PPD. In addition,

midwives also felt that women might feel uncomfortable discussing their personal feelings as

they do not consider it a health problem.

The above points seems totally opposing with the views from western study litratures

which recommends actions such as: Midwives are health care professionals who interact most

with women during pregnancy and postpartum periods (Longsdon, Wisner, Billings &

Shanahan, 2006). Also, midwives who have frequent contact with women during the

perinatal period are well-positioned to provide screening and treatment for PPD (Segre,

O‘Hara, Arndt & Beck, 2010). As they meet with mothers for immunization, postpartum

health controls and healthy baby checks, health professionals may have a chance for PPD

screening. During these interactions nurses/midwives can detect risky women and patients

with symptoms of PPD.

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 Our study participantst reflected that they never used professional tools to diagnose

PPD. But the literature emphasizes the importance of conducting medical screening by

making use of appropriate tools and can guide the woman to professional assistance if needed

(Longsdon, Wisner & Pinto-Foltz , 2006).

All of the midwife participants said they do not have training and this was a challenge

for them, as they are not able to deal with PPD. This finding is congruent with the views of

Keng (2005) who concluded that the biggest handicap of midwives is the lack of sufficient

training concerning diagnosing, consulting, and guiding risky patients in the early diagnosis

and management of PPD. If postpartum depression knowledge of nurses and midwives is

insufficient, that may mislead them in identifying symptoms and PPD (Keng, 2005). On the

other hand, midwives did express concern that women may be reluctant to discuss about their

PPD experience as it is personal topic.

It was clear that the role of providing advice regarding PPD is not one that midwives

feel they have been adequately trained for, and they feel it is out of the focus areas of their

hospital. In addition, it is clear that midwives had not habitually raised the subject of

depression. This implies mothers are the ones expected to raise the topic of depression for the

midwives. But, in the current study neither of them is doing as recommended.

This study also showed that midwives find there to be many barriers to giving PPD

advice; many of the mothers have previously not identified as a problem. Women not wishing

to discuss depression as a problem was a common barrier; they are more concerned with

advice relating to their baby or cannot imagine they may have a problem of PPD.

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 CHAPTER SIX

STUDY CONCLUSIONS, RECOMMENDATIONS AND IMPLICATIONS

FOR SOCIAL WORK

6.1. Conclusion

The aim of the study was to determine the prevalence and associated factors of PPD

a explain mothers‘ experience of emotional distress in their first postpartum year. The study

also aims to determine midwives‘ view about PPD. In addition, the study explored

midwives‘ perception of Postpartum Depression. A facility-based cross-sectional mixed

method approach was employed. Five hundred postnatal mothers who gave birth in East

Shewa Zone within the past one year participated in the quantitative part of the study and 17

research participants were involved in the qualitative partof the study i.e., 10 participants

were PPD mothers and 7 were professional midwives. For the quantitative data, a simple

random sampling (SRS) technique was used to identify the sampling units from the public

health facilities based on their pre-determined patient flow rate.

The World Health Organization (WHO) acknowledged the problem of Postpartum

depression (PPD) in both high income and low income countries. WHO took various

initiatives in giving considerable attention to tackle the problem of mental health during the

postpartum period. PPD is a serious mental health infirmity categorized by a prolonged

period of emotional disturbance, occurring at a time of major life change and increased

responsibilities in the care of a newborn infant. PPD impacts a mother's thinking, feeling or

mood and may affect her ability to relate to others and function on a daily basis. Postpartum

Depression (PPD) is a serious public health problem that leads to high maternal morbidity

and mortality, enormously affecting the infant, family, and society.

In this study process we have witnessed postnatal depression as an important health

problem and currently influences the well-being, quality, and security of mothers in the East

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Shewa Zone. We have also found that maternal mental health may lead in to more serious

problems than major depression occurring in normal life periods.

Findings from the study area revealed that there was high magnitude of PPD, i.e.,

23.2 %; that means health professionals and social health workers needs to incorporate

screening strategies for depression that occur after childbirth. Postpartum depression is

higher among mothers under age 28 years. Domestic violence, unplanned pregnancy, baby

with sleeping problems, health of the baby, lack of social support and partners‘ substance

use were significantly associated with postpartum depression. This study found that

midwives‘ lack of detailed PPD knowledge and heavy work load were possible contributing

factors to PPD. If midwives are expected to be effective as providers of quality advice to

mothers with PPD, then they deserve ongoing training and support so that they can better

handle issues of PPD.

Midwives were found to be comfortable with their work with normal deliveries and

newborn care. However, there are major gaps in the management of PPD. There is no

training on PPD and screening tools. Lack of supportive supervision is one of the challenges

and feedback was also very minimal. No mentorship programs in relation to PPD. There is

high work load on the midwives most working more than 8 regular hours and have duty

session every other day. Almost all of the midwives interviewed for this study complained

about their low salary. Midwives‘ had low level of job satisfaction. As we go in further with

such discussions with midwives, it is possible that midwives‘ dissatisfaction with this aspect

of their work as an indirect contributing factor to mothers. In the study mothers said they

were not happy with some of the midwives in the hospital.

In this circumstance, in our study revealed that midwives have no special training on

PPD, they are dissatisfied with workload and salary issues, and few acknowledged

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disrespecting mothers. Hence, this and other factors when they came together may be a

contributing factor to PPD.

6.2. Implications for social workers

In sum, this study highlighted the magnitude, factors associated with PPD and

mothers‘ emotional distress in East Shewa Zone, Ethiopia. In the study we found almost one

person out of four to be a victim of PPD. This shows that social workers have a lot of work

to do in this regard. As noted in the literature, in many western countries social workers are

involved with mothers in a variety of settings. One of the concerns of social work is to

address personal and family level difficulties. Hence, dealing with such problems is a

priority area of social work especially in health and mental healthcare settings. In this

setting social work is very important, because many of the PPD cases are directly linked

with the very concern of social work, i.e., individuals, families, and communities.

To tackle this problem, social workers can develop community awareness on

postpartum depression by educating mothers, families and community leaders. This can

promote the professionalism of social workers, as well as treatment rates. Education is

important also in light of the fact that many women experience relief when they are in

therapy with a social worker who is knowledgeable about postpartum depression.

Social workers can make a difference through raising community awarness with the

existing social support groups for women who suffer by postpartum depression. Social

workers can also facilitate an accepting, supportive environment in which participants can

share their experiences and assist each other in coping with their depression. Social workers

could also be aware of the low rates of utilizing services and hence, can promote the

importance of social support in a given community.

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6.3. Implications for social work education

Social Work is a discipline involving the application of social theory and research

methods to study and improve the lives of people, groups, and societies. It incorporates

and uses other social sciences as a means to improve the human condition and positively

change societies problem with multiple interventions. Social work education is more

concerned with social problems, their causes, solutions and their human impacts. Social

work education deals with individuals, families, groups, organizations and community

which is meant for response to social problems. PPD is one of the social problems that

hinders mothers and family from normal functioning. According to our study we have got

about 23.3 % of prevalence of PPD. This result tells us as there exist social problems in

Ethiopia in general and in the study area in particular.

PPD is not the responsibility of midwives or health professionals only, but goes

beyond and it requires other professionals such as social workers. The social work

education should promote the holistic dimensions of health, including the social and

psychological components of health. This study offers insight about prevalence and factors

associated with PPD with different circumstances. Results of the study could be used to

increase the social work profession‘s accountability in relation to maternal health issues

and can help to promote an interdisciplinary approach between social work and public

health professionals to address the social determinants of maternal health.

In this study PPD was associated with the sociodemographic variables, social

support, family related, domestic violence and etc. Hence, a Social work professional

could support with a range of intervention; such as, raising awareness for mothers,

families and spouse and on the other hand, Social work professionals can provide a

worksheet to guide the social aspects of the problem in performing the early screening and

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 assessment part. After the assessment, social workers can then offer suggestions that are

relevant to each individual mother‘s unique social needs.

The seasons after delivery is mostly stated as emotionally distressful period, in

which mothers need to face several psychosocial challenges. Rendering our study

participants, lack of social support, domestic violence, socio-demographic characteristics,

lack of motherhood experience, babies‘ sleeping patterns, and etc. are factors of

depression among postpartum mothers. Therefore, counseling programs should be an

integral component of social work intervention to help mothers to cope with stressful life

events. Social workers who are working at public health sectors could take the

responsibility of encouraging mothers to seek counseling sections. Social workers should

also advocate for the opening of a counseling department at health institutions where

mothers visit for postnatal care. Curriculums of social work need to be revised with the

scope that address mothers during pregnancy and postpartum periods to help minimizing

of problems that leads to PPD.

6.4. Implications for health professionals

There are over two million live births each year in Ethiopia, (CSA, 2007). With

such realities at hand; significant number of mothers are experiencing an episode of

depression during the postpartum period. This makes depression the most common

complication of childbearing ( Stewart, 2003). A preventive approach through open

communication and early screening could be employed by health professionals during

monotonous encounters with postpartum mothers. Implementation of screening needs a

good knowledge and understanding of PPD by the health professionals. In addition,

interventions in a precautionary manner will improve mother‘s awareness and skills that

protect them from PPD. This will enhance the mothers to be effective in ensuring her own

health, and in turn the health of her baby and the whole family members.

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 As witnessed in the current study results, it would be useful for health

professionals to take account of postpartum mother‘s different characteristics marked by

socio-cultural status. Midwives need to increase their knowledge and understanding of the

periods after delivery. Developing involvement approach or model by the professional

midwives will more necessary. Such models could address the social context of maternal

health. Particularly, training and guidance are required for maternal health care providers

to integrate the early detecting and screening of postpartum depression among mothers.

Therefore, adequate devotion of the professional midwives should consider early

screening and referring of PPD cases. In a country like Ethiopia, where the rate of

postpartum depression is still high, there is a need to encourage postpartum mothers to

participate in PPD screening. Nevertheless, because of the inadequacy of time, service

and place in the current hospital systems of Ethiopia, PPD mothers are not able to get

good knowledge and information about postpartum depression and other health problems

and also their chance of discussion is very restricted. Therefore, Midwives should consider

initiating PPD related awareness raising lessons during the last trimester of pregnancy.

Moreover, the hospitals could offer various informational materials regarding PPD to be

given to the mothers. Discussion in their routine perinatal and postnatal examination will

help to design an open discussion schedule and assist in preventing the likely occurrence

of PPD.

Furthermore, midwives need to encourage spouses and other family members to

play an active role in providing care for postpartum mothers. Such action could play a

significant role in activating social support within the family. The roles of the family and

spouse, will minimize PPD as witnessed in our current study results i.e. where there is

more social support and less postpartum depression and where there is low social support

there is high PPD cases. Hence, midwives should be aware of the need of social support

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 and advise family members and spouse about the needed support for the postpartum

mothers.

6.5. Implications for local policy development

The findings in our study implies the needs of mothers during their postpartum

period. Implying the critical importance of developing policies and directives that guide

the existing services towards more holistic approach. The health policy of Ethiopia that is

more of providing maternal health care at health facilities ought to expand its outreach and

scope beyond the aim of expanding access to maternal health care service. Necessary to

include home grown solutions that decrease postpartum and related problems on mothers.

Home-grown directives and policies should be developed to improve the scope of

practice of care providers. It is necessary if the policies and guideline come up with

answers for key questions such as ‗who, what, when, where and how?‘ of intervention.

Hanlon (2012) has depicted very essential points on addressing ‗who, what, when, where

and how in relation to the existing evidence base. Taking Hanlons model in to

consideration, here are some of the components need to be aspired in Ethiopian maternal

mental health policy:

In countries like Ethiopia there is shortage of specialist health professionals in

health facilities. Therefore, it will be necessary to develop a working model to be

implemented by shared responsibility to fight PPD, the shared responsibility could make a

difference by involving, specialist health professionals with non-specialist health

professionals, public health social workers who are well trained to deliver clearly defined

elements of postpartum health care.

WHO‘s guidelines for the treatment of PPD in LAMICs, involves, psychosocial

models which are likely to be more appropriate for the majority of mothers, as taking

antidepressant and medications are complicated for a breastfeeding mother. In addition,

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willingness of postpartum mothers to take medication is also very minimal. Hence, policy

makers need to provide a doable, well organized and contextualized psychosocial

therapies to be designed by involving important stakeholders, health professionals and

public health social workers.

In our field trip during data collection, we have seen the current sceneries with a

high level of magnitude of depression among postnatal mothers. The flow of mothers to

hospital for antenatal care makes the time appropriate to contact with health services for

PPD mothers. Hence, policy makers can put directives to appropriately use this season for

effective screening, testing and supporting mothers.

There are traditional beliefs and cultures during postpartum period including

obligatory period of confinement. This perhaps affected help-seeking behavior of mothers.

With the current practice psychological interventions are very minimal in health facilities

of Ethiopia. Hence, it will be necessary if policy makers put directions to adopt an

additional home-based intervention, to reach the unreached mothers. So that we can

reduce impacts of PPD.

In addition, promote an interdisciplinary approach between public health and social

work professionals. As far as the researcher‘s knowledge, Ministry of Health (MoH) of

Ethiopia had trained thousands of community health extension workers and assigned to

work closely with mothers at community level. Future directions should be needed to train

and assign social workers who can work along with health extension workers to ensure the

holistic needs of mothers within the community, so that they can prevent PPD as well.

Moreover, it will be necessary if the Oromia Regional Health Bureau and non-

government organizations working in East Shewa Zone, tap the potential opportunities to

strengthen their bonds with the community-based associations to raise enough awareness

about PPD, to deliver training that impact the community and to assist mothers who

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experiences emotional distress through assessing during their visit at postnatal care unit

within the health facilities and in the community at large by using health extension

workers and employing social workers.

The other implication of this study goes to social work and public health education

curriculum designers. The social work educational curriculum in Ethiopia should consider

the inclusiveness of public health and community health specializations as part of the

undergraduate and postgraduate curriculum. The same is true for the public health

education program. Addis Ababa University has already started a field of specialization in

Community Health Social Work. Similar trends of training students in interdisciplinary

fields should be encouraged to be adopted by other Ethiopia universities which are running

social work and public health education programs.

Social work education should expand its spectrum to integrate Medical Social

Work and Public Health Social Work field of specializations to better build knowledge

and practice in the health settings. From literature we have learnt that social work and

public health have many in common.

―Public health and social work professions vary in their practice methods, their

intended goals are similar: to improve the health, welfare, and social well-being of

society-at-large. Both professions share an ecologic perspective for problem-solving,

and a systemic approach toward intervention that calls upon various sources to bring

about change to complex social problems. Likewise, each profession shares a core

value of ―social justice‖ and an essential role of ―service provision‖ targeted at

enhancing the lives of the disadvantaged‖ (Keefe & Jurkowski, 2013, 5).

The circumstance that public health profession gives more emphasis to prevention

while the social work wing focuses on intervention, the two professions stand in a plain to

collaborate to each other. Many advances in health and social justice can be traced back to

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 the intersection of social work and public health. Both have common values and aspire to

achieve similar goals such as: to eliminate health disparities; and to promote health,

socioeconomic, and environmental justice. Public health social work profession can be

trained and benefited from the rich traditions and complementary methods of these two

fields to enhance and promote maternal health. Public health social workers can make the

connection between prevention and intervention from the individual to the whole

population.

6.6. Implications for future research

By due consideration of the insufficiency of studies by social workers with the area

of maternal health in the study area, this study brings new descriptions to the existing

knowledge base for the current study area. This study has produced empirically-supported

evidence that can be useful to make statistical inferences and interpretative analysis about

the relationship of PPD with the stated associated factors.

Possible future research areas could be generated based on the findings of this

study. Methodologically, this study employed a mixed method study design. Tools used to

collect quantitative data were developed in a western country ‗context. The researcher

framed the interview guides for the qualitative inquiry based on the conceptual framework

of the quantitative study.

The postpartum depression was studied from the dimensions such as socio-

demographic, social aspect, birth experience and midwives view only. This might be

restricted participants not to share their opinions and experiences beyond the scope of the

study framework. Thus, future qualitative research is recommended to uncover additional

themes related to PPD.

This study was limited to East Shewa Zone. The study participants were mainly

urban residents, belonged to Oromia region. The prevalence of PPD vary across different

124
 social and demographic backgrounds. Thus, the study should be replicated using larger

samples with postpartum mothers with diverse socio-cultural backgrounds as Ethiopia is

home to people with diverse ethnic backgrounds. Other socio-demographic variables that

were not entertained in the current study should be included in future studies. Future

research could also investigate the advantages and disadvantages of traditional postpartum

practices and whether there is evidence to support the activities undertaken have impact on

PPD.

The findings of this study were compiled based on the views of postpartum

mothers and the midwives in East Shewa Zone. Further research should be designed to

accommodate the views of spouse and family members. Particularly, future studies are

needed to understand husbands‘ and other close family members‘ voices on reducing of

postpartum depression. There is a need to explore strategies employed by men to concern

themselves with their wives‘ health.

6.7. Recommendations

6.7.1. Proactive-based screeining for mothers at risk of PPD

The present study results have an important recommendation for all stakeholders

involving in maternal health sectors. First of all, mothers who are at risk for developing

postpartum depression need to open up for help and cooperate in early screenings so that their

burden will be shared and minimized. Health care workers, midwives and physicians should

be aware of the high prevalence of depressive symptoms during postpartum period. Hence, it

125
is necessary to take immediate action to end problems of postpartum depression with

appropriate interventions to address the above-mentioned contributing factors. In addition,

the identification and treatment of mothers with PPD at early stage might prevent further

consequences of PPD. In sum, this study recommends the need for early assessment and

intervention strategies which could be employed during postpartum period in order to

minimize the impact of postpartum depression on the mother and her family

6.7.2. Integretion of mental health care service with existing maternal health care

service

Active integration of mental health care service with the existing maternal health

care service would reduce the impact of PPD on mothers. Interventions such as early

detection and appropriate follow-up to reduce morbidity from postpartum mothers will

benefit all mothers, specially to new mothers, mothers with lower socio-economic

backgrounds, who feel unhappier about having their baby, and who have a history of

emotional distress experience.

6.7.3. Further studies associated with PPD among mothers

More research is needed to further verify the magnitude of PPD, factors associated

with PPD, and to address the strategies on how to address these problems through

integrating mental health care within the general maternal health services. Additional

studies are necessary to maternal mental health service development not only in East

Shewa Zone but also other parts of the country as well.

6.7.4. Contineous in service training for health care workers dealing with PPD

In order to address the gap raised by Midwives it is necessary to provide in-service

training on selected skills of importance such as screening of PPD. And address gaps of

midwives on PPD and the screening tools with more comprehensive and effective

supportive supervision and mentorship program. The researcher also recommend the

126
imortance of raising sallary scale to motivate and improve the level of payment and in-time

payment of incentives such as the risk allowances and the duty allowances. Mental health

care workers, midwives and physicians should be made aware of the postpartum depression,

and the high-risk variables which predict postpartum depression.

6.7.5. Integration of social work intervention/model in dealing with PPD

Social Work Measures should be used as an intervention model in Ethiopian setting

with counselling, either in the form of individual or group therapy, assistance to mothers

who are suffering from depression. Depressed women could also be assisted through

educational programs, learning strategies for the prevention of depression or ways to

mitigate the impacts of Postpartum depression.

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REFERENCES

Abdollahi, F., Lye, M. S., & Zarghami, M. (2016). Perspective of postpartum depression

theories: A narrative literature review. North AmericanJjournal of Medical Sciences,

8(6), 232.

Abiola, T., Udofia, O., & Zakari, M. (2013). Psychometric properties of the 3-item Oslo

Social Support Scale among clinical students of Bayero University Kano,

Nigeria. Malaysian Journal of Psychiatry, 22(2), 32-41.

Abrams, L. S., & Curran, L. (2007). Not just a middle-class affliction: Crafting a social work

research agenda on postpartum depression. Health & Social Work, 32(4), 289-296.

Adewuya, A. O., Fatoye, F. O., Ola, B. A., Ijaodola, O. R., & Ibigbami, S. M. O. (2005).

Sociodemographic and obstetric risk factors for postpartum depressive symptoms in

Nigerian women. Journal of Psychiatric Practice, 11(5), 353-358.

Adamu, A. F., & Adinew, Y. M. (2018). Domestic Violence as a Risk Factor for Postpartum

Depression Among Ethiopian Women: Facility Based Study. Clinical Practice and

Epidemiology in Mental Health: CP & EMH, 14, 109.

American Psychiatric Association (1994). Diagnostic and statistical manual of mental

disorders (4th ed). Washington, DC: American Psychiatric Association.

American Psychological Association (2015). Postpartum Depression.

American Public Health Association. (2006). Social work section newsletter.

Anselmi, L., Barros, F. C., Minten, G. C., Gigante, D. P., Horta, B. L., & Victora, C. G.

(2008). Prevalence and early determinants of common mental disorders in the 1982

birth cohort, Pelotas, Southern Brazil. Revista de saude publica, 42, 26-33.

128
Appleby, L., Warner, R., Whitton, A., & Faragher, B. (1997). A controlled study of

fluoxetine and cognitive-behavioural counselling in the treatment of postnatal

depression. Biomedical Journal, 314(7085), 932.

Azale, T., Fekadu, A., & Hanlon, C. (2016). Treatment gap and help-seeking for postpartum

depression in a rural African setting. BMC Psychiatry, 16(1), 196.

Azale, T., Fekadu, A., & Hanlon, C. (2018). Postpartum depressive symptoms in the context

of high social adversity and reproductive health threats: a population-based

study. International Journal of Mental Health Systems, 12(1), 42.

Albright, C. L., Maddock, J. E., & Nigg, C. R. (2009). Increasing physical activity in

postpartum multiethnic women in Hawaii: results from a pilot study. BMC Women's

Health, 9(1), 4.

Allison, S., Brouwer, Carter-Edwards, L., & Østbye, T. (2011). Unmet social support for

healthy behaviors among overweight and obese postpartum women: Results from

the active mothers postpartum study. Journal of Women’s Health, 20 (11). DOI:

10.1089/jwh.2010.2509

Andersson L, Sundstrom-Poromaa I, Wulff M, Astrom M, Bixo M. Implications of

antenatal depression and anxiety for obstetric outcome. Obstetrics & Gynecology

2004; 104(3):467.

Arborelius, E. U., & Bremberg, S. G. (2003). Supportive and non-supportive qualities of

child health nurses' contacts with strained infant mothers. Scandinavian journal of

caring sciences, 17(2), 169-175.

Ballard, P., & Radley, A. (2009). Give it up for baby: a smoking cessation intervention for

pregnant women in Scotland. Cases in Public Health Communication &

Marketing, 3, 147-160.

129
Baron, E. C., Hanlon, C., Mall, S., Honikman, S., Breuer, E., Kathree, T., ... & Patel, V.

(2016). Maternal mental health in primary care in five low-and middle-income

countries: asituational analysis. BMC Health Services Research, 16(1), 53.

Baumgartner, J. N., Parcesepe, A., Mekuria, Y. G., Abitew, D. B., Gebeyehu, W., Okello,

F., & Shattuck, D. (2014). Maternal mental health in Amhara region, Ethiopia: a

cross- sectional survey. Global Health: Science and Practice, 2(4), 482-486.

Beck, C. T. (2001). Predictors of postpartum depression: an update. Nursing research, 50(5), 275-285.

Bener, A., Gerber, L. M., & Sheikh, J. (2012). Prevalence of psychiatric disorders and

associated risk factors in women during their postpartum period: a major public

health problem and global comparison. International Journal of Women's Health, 4,

191.

Bitew, T., Hanlon, C., Kebede, E., Honikman, S., &Fekadu, A. (2017). Antenatal

depressive symptoms and perinatal complications: a prospective study in rural

Ethiopia. BMC Psychiatry, 17(1), 301.

Biaggi, A., Conroy, S., Pawlby, S., & Pariante, C. M. (2016). Identifying the women at risk

of antenatal anxiety and depression: a systematic review. Journal of Affective

Disorders, 191, 62-77.

Bina, R. (2008). The impact of cultural factors upon postpartum depression: a literature

review. Health Care for Women International, 29(6), 568-592.

Bruce, M. L. (2002). Psychosocial risk factors for depressive disorders in late

life. Biological Psychiatry, 52(3), 175-184.

Carney R., Freedlanda K., Millerb G., Jaffec A. Depression as a risk factor for cardiac

mortality and morbidity A review of potential mechanisms. Journal of

Psychosomatic Research 2002; 53:897

130
Carron, A.V., Hausenblas, H.A., & Mack, D. (1996). Social influence and exercise: A meta-

analysis. Journal of Sport& Exercise Psychology, 18, 1–16.

Casey, P., Goolsby, S., Berkowitz, C., Frank, D., Cook, J., Cutts, D., ... & Meyers, A. (2004).

Maternal depression, changing public assistance, food security, and child health

status. Pediatrics, 113(2), 298-304.

Chaudron, Linda H., Kitzman, Harriet J., Peifer, Karen L., Morrow, Scott, Perez, Linda M.

& Newman, Mary C. (2005). Self-recognition of and provider response to maternal

depressive symptoms in low-income Hispanic women. Journal of Women‘s Health,

14, 331-338.

Chen, C. M., Kuo, S. F., Chou, Y. H., & Chen, H. C. (2007). Postpartum Taiwanese

women: their postpartum depression, social support and health‐promoting lifestyle

profiles. Journal of Clinical Nursing, 16(8), 1550-1560.

Cohen, S. (2004). Social relationships and health. American psychologist, 59(8), 676.

Chang, M. W., Nitzke, S., Guilford, E., Adair, C. H., & Hazard, D. L. (2008). Motivators

and barriers to healthful eating and physical activity among low-income

overweight and obese mothers. Journal of the American Dietetic

Association, 108(6), 1023-1028.

Croghan, E. (2005). Supporting pregnant women through behaviour change. Nurse

Standard,19, 48-50

Cohen, S., & Wills, T. A. (1985). Stress, social support, and the buffering

hypothesis. Psychological Bulletin, 98(2), 310.

Cohen, L. S., Wang, B., Nonacs, R., Viguera, A. C., Lemon, E. L., & Freeman, M. P.

(2010). Treatment of mood disorders during pregnancy and postpartum. Psychiatric

Clinics, 33(2), 273-293.

131
Cohen, S., & McKay, G. (1984). Social support, stress and the buffering hypothesis: A

theoretical analysis. Handbook of Psychology and Health, 4, 253-267.

Cooper, P. J., Tomlinson, M., Swartz, L., Woolgar, M., Murray, L., & Molteno, C. (1999).

Post-partum depression and the mother-infant relationship in a South African peri-

urban settlement. The British Journal of Psychiatry, 175(6), 554-558.

Creswell, J. W. (2013). Research design: Qualitative, quantitative, and mixed methods

approaches. Sage.

Crockenberg, S. B. (1981). Infant irritability, mother responsiveness, and social support

influences on the security of infant-mother attachment. Child Development, 857-865.

Cutrona, C. E., & Troutman, B. R. (1986). Social support, infant temperament, and parenting

self-efficacy: A mediational model of postpartum depression. Child Development,

1507-1518.

Dalgard, O. S., Bj, S., & Tambs, K. (1995). Social support, negative life events and mental

health. The British Journal of Psychiatry, 166(1), 29-34.

Dalgard, O. S. (2008). Social inequalities in mental health in Norway: possible explanatory

factors. International Journal for Equity in Health, 7(1), 27.

Daud, S. (2017). Prevalence, predictors and determinants of depression in women of the

reproductive age group. Biomedica, 24(1), 18-22.

Davidson, K. W., Rieckmann, N., & Lespérance, F. (2004). Psychological theories of

depression: potential application for the prevention of acute coronary syndrome

recurrence. Psychosomatic medicine, 66(2), 165-173.

Dayan J, Creveuil C, Herlicoviez M, Herbel C, Baranger E, Savoye C, et al. Role of anxiety

and depression in the onset of spontaneous preterm labor. American Journal of

Epidemiology 2002; 155(4):293.

132
Dennis, C. L., & Chung‐Lee, L. (2006). Postpartum depression help‐seeking barriers and

maternal treatment preferences: A qualitative systematic review. Birth, 33(4), 323-

331.

Dennis, C. L., & Hodnett, E. D. (2007). Psychosocial and psychological interventions for

treating postpartum depression. Cochrane Database of Systematic Reviews, (4).

Doss, B. D., Cicila, L. N., Hsueh, A. C., Morrison, K. R., & Carhart, K. (2014). A

randomized controlled trial of brief coparenting and relationship interventions during

the transition to parenthood. Journal of Family Psychology, 28(4), 483-494.

Duffy, J. (2006). Participating and learning citizen involvement in social work Education in

the Northern Ireland context: A good practice guide. University of Ulster,

Londonderry.

Egeline, R. M. (2007). Identifying risk factors for postpartum depression. ProQuest.

European Union Public Health Information System, Dalgard OS, (2009). Social support:

Occurrence. 2009. http://. euphix. orgEUPHIX is a European community health

monitoring model and no journal.

Evenson, K. R., Aytur, S. A., & Borodulin, K. (2009). Physical activity beliefs, barriers, and

enablers among postpartum women. Journal of women's health, 18(12), 1925-1934

Fairchild, M. W. (1995). Women with postpartum psychiatric illness: A professionally

facilitated support group. Social Work with Groups, 18(1), 41-53.

Fernandes, M. C., Srinivasan, K., Stein, A. L., Menezes, G., Sumithra, R. S., &

Ramchandani, P. G. (2011). Assessing prenatal depression in the rural developing

world: A comparison of two screening measures. Archives of Women's Mental

Health, 14(3), 209-216.

133
Fiala, A., Švancara, J., Klánová, J., & Kašpárek, T. (2017). Sociodemographic and delivery

risk factors for developing postpartum depression in a sample of 3233 mothers from

the Czech ELSPAC study. BMC Psychiatry, 17(1), 104.

Fisher, J. R., De Mello, M. C., Izutsu, T., & Tran, T. (2011). The Ha Noi Expert Statement:

recognition of maternal mental health in resource-constrained settings is essential for

achieving the Millennium Development Goals. International journal of mental health

systems, 5(1), 2.

Fisher, J., Mello, M. C. D., Patel, V., Rahman, A., Tran, T., Holton, S., & Holmes, W.

(2012). Prevalence and determinants of common perinatal mental disorders in women

in low-and lower-middle-income countries: A systematic review. Bulletin of the

World Health Organization, 90, 139-149.

Fisher, J., Tran, T., Kriitmaa, K., Rosenthal, D., & Tran, T. (2010). Common perinatal mental

disorders in northern Viet Nam: community prevalence and health care use. Bulletin

of the World Health Organization, 88, 737-745.

Gelaye B, Williams M, Lemma S, Deyessa N, Bahretibeb Y, Shibre T, et al. (2013). Validity

of the patient health questionnaire-9 for depression screening and diagnosis in East

Africa. Psychiatry Research Journal.

Gelaye, B., Rondon, M. B., Araya, R., & Williams, M. A. (2016). Epidemiology of maternal

depression, risk factors, and child outcomes in low-income and middle-income

countries. The Lancet Psychiatry, 3(10), 973-982.

Giri, R. K., Khatri, R. B., Mishra, S. R., Khanal, V., Sharma, V. D., & Gartoula, R. P. (2015).

Prevalence and factors associated with depressive symptoms among post-partum

mothers in Nepal. BMC Research Notes, 8(1), 111.

Given, L. M. (Ed.). (2008). The Sage encyclopedia of qualitative research methods. Sage.

134
Golden, J., Conroy, R. M., Bruce, I., Denihan, A., Greene, E., Kirby, M., & Lawlor, B. A.

(2009). Loneliness, social support networks, mood and wellbeing in community‐

dwelling elderly. International Journal of Geriatric Psychiatry, 24(7), 694-700.

Goodman, J. H. (2004). Postpartum depression beyond the early postpartum period. Journal

of Obstetric, Gynecologic, & Neonatal Nursing, 33(4), 410-420.

García-Moreno, C., Pallitto, C., Devries, K., Stöckl, H., Watts, C., & Abrahams, N.

(2013). Global and regional estimates of violence against women: prevalence and

health effects of intimate partner violence and non-partner sexual violence. World

Health Organization.

Giannandrea, S. A., Cerulli, C., Anson, E., & Chaudron, L. H. (2013). Increased risk for

postpartum psychiatric disorders among women with past pregnancy loss. Journal of

Women's Health, 22(9), 760-768.

Greenberg, D., & Witztum, E. (2008). Sanity and sanctity: Mental health work among the

ultra- orthodox in Jerusalem. Yale University Press.

Grote N, Bridge J, Gavin A, Melville J, Iyengar S, Katon W. A meta-analysis of depression

during pregnancy and the risk of preterm birth, low birth weight, and intrauterine

growth restriction. Arch Gen Psychiatry 2010; 67(10):1012.

Gruen, D. S. (1990). Postpartum depression: A debilitating yet often unassessed

problem. Health &Social Work, 15(4), 261-270.

Grupe, D. W., & Nitschke, J. B. (2013). Uncertainty and anticipation in anxiety: An

integrated neurobiological and psychological perspective. Nature Reviews

Neuroscience, 14(7), 488.

135
Guo, N., Bindt, C., Te Bonle, M., Appiah-Poku, J., Hinz, R., Barthel, D., ... & Schlüter, L.

(2013). Association of antepartum and postpartum depression in Ghanaian and

Ivorian women with febrile illness in their offspring: a prospective birth cohort

study. American journal of epidemiology, 178(9), 1394-1402.

Ha, J. Y., & Kim, Y. J. (2013). Factors influencing self-confidence in the maternal role

among early postpartum mothers. Korean Journal of Women Health Nursing, 19(1),

48-56.

Hagen, E. H. (1999). The functions of postpartum depression. Evolution and Human

Behavior, 20(5), 325-359.

Halbreich, U. (2005). Postpartum disorders: Multiple interacting underlying mechanisms and

risk factors.

Hammen, C., & Brennan, P. A. (2002). Interpersonal dysfunction in depressed women:

Impairments independent of depressive symptoms. Journal of Affective

Disorders, 72(2), 145-156.

Hanna, B., Jarman, H., Savage, S., & Layton, K. (2004). The early detection of postpartum

depression: Midwives and nurses trial:A checklist. Journal of Obstetric,

Gynecologic, & Neonatal Nursing, 33(2), 191-197.

Hanlona. C (2012), Maternal depression in low- and middle-income countries. Int Health

doi:10.1093/inthealth/ihs003.

Hanlon, C., Medhin, G., Alem, A., Araya, M., Abdulahi, A., Tesfaye, M., ... & Dewey, M.

(2008). Measuring common mental disorders in women in Ethiopia. Social Psychiatry

and Psychiatric Epidemiology, 43(8), 653.

136
Hartley, M., Tomlinson, M., Greco, E., Comulada, W. S., Stewart, J., Le Roux, I., ... &

Rotheram-Borus, M. J. (2011). Depressed mood in pregnancy: prevalence and

correlates in two Cape Town peri-urban settlements. Reproductive health, 8(1), 9.

Hiltunen, P. (2003). Maternal postnatal depression: causes and consequences. International

journal of circumpolar health, 62(3), 308-309.

Howard, L. M., Piot, P., & Stein, A. (2014). No health without perinatal mental health. The

Lancet, 384(9956), 1723-1724.

Howell, Elizabeth A., Mora, Pablo A., Horowitz, Carol R. & Leventhal, Howard. (2005).

Racial and ethnic differences in factors associated with early postpartum depressive

symptoms. Obstetrics & Gynecology, 105(6), 1442-1450.

Hunker, D. F., Patrick, T. E., Albrecht, S. A., & Wisner, K. L. (2009). Is difficult childbirth

related to postpartum maternal outcomes in the early postpartum period?. Archives of

Women's Mental Health, 12(4), 211-219.

Husain, N., Cruickshank, J. K., Tomenson, B., Khan, S., & Rahman, A. (2012). Maternal

depression and infant growth and development in British Pakistani women: A cohort

study. British Medical Journal, 2(2), e000523.

Husain, N., Mukherjee, I., Notiar, A., Alavi, Z., Tomenson, B., Hawa, F., ... & Chaudhry, N.

(2016). Prevalence of common mental disorders and its association with life events

and social support in mothers attending a well-child clinic: Findings from Mombasa,

Kenya. SAGE Open, 6(4), 2158244016677324.

Illechukwu L. Psychiatry in Africa: Special problems and unique feature. Transcultural

Psychiatric Research Review 1991; 28:169.

137
Imbula, B. E., Okitundu, E. L., & Mampunza, S. M. M. (2012). Postpartum depression in

Kinshasa (DR Congo): Prevalence and risk factors. Medecine et sante

Tropicales, 22(4), 379-384.

Jacobsen, T. (1999). Effects of postpartum disorders on parenting and on

offspring. Postpartum Mood Disorders, 119-139.

Jones, C. J., Creedy, D. K., & Gamble, J. A. (2011). Australian midwives‘ knowledge of

antenatal and postpartum depression: A national survey. Journal of Midwifery

Johnson, A. R., Edwin, S., Joachim, N., Mathew, G., Ajay, S., & Joseph, B. (2015). Postnatal

depression among women availing maternal health services in a rural hospital in

South India. Pakistan journal of medical sciences, 31(2), 408.Women's

Health, 56(4), 353-361.

Kakyo, T. A., Muliira, J. K., Mbalinda, S. N., Kizza, I. B., & Muliira, R. S. (2012). Factors

associated with depressive symptoms among postpartum mothers in a rural district in

Uganda. Midwifery, 28(3), 374-379.

Kaplan, B.&Sadock, A (2010). Synopsis of Psychiatry, Behavioral Sciences/Clinical

Psychiatry. 10th ed. Philadelphia: Lippincott Williams & Wilkins.

Katon J, Russo J, Gavin A, Melville J, Katon W. Diabetes and depression in pregnancy: Is

there an association? Journal of Women's Health 2011; 20(7).

Kawachi, I., & Berkman, L. F. (2001). Social ties and mental health. Journal of Urban

Health, 78(3), 458-467.

Kazi, A., Fatmi, Z., Hatcher, J., Kadir, M. M., Niaz, U., & Wasserman, G. A. (2006). Social

environment and depression among pregnant women in urban areas of Pakistan:

Importance of social relations. Social Science & Medicine, 63(6), 1466-1476.

138
Kaźmierczak, M., Araszkiewicz, A., Gebuza, G., Mieczkowska, E., & Gierszewska, M.

(2014). Psychosocial determinants of postpartum depression. Medical and Biological

Sciences, 28(3), 25-33.

Keefe, R. H., Brownstein-Evans, C., Lane, S. D., Carter, D. B., & Polmanteer, R. S. R.

(2015). Postpartum depression and the Affordable Care Act: Recommendations for

social work educators. Advances in Social Work, 16(2), 202-213.

Keller, C., Allan, J., & Tinkle, M. B. (2006). Stages of change, processes of change, and

social support for exercise and weight gain in postpartum women. Journal of

Obstetrics and Gynecological Neonatal Nurse, 35, 232–240.

Keng, S. L. (2005). Malaysian midwives' views on postnatal depression. British Journal of

Midwifery, 13(2), 78-86.

Kerie, S., Menberu, M., & Niguse, W. (2018). Prevalence and associated factors of

postpartum depression in Southwest, Ethiopia, 2017: A cross-sectional study. BMC

Research Notes, 11(1), 623.

Kessler, R. C. (2003). Epidemiology of women and depression. Journal of Affective

Disorders, 74(1), 5-13.

Khalifa, D. S., Glavin, K., Bjertness, E., & Lien, L. (2015). Postnatal depression among

Sudanese women: prevalence and validation of the Edinburgh Postnatal Depression

Scale at 3 months postpartum. International journal of women's health, 7, 677.

Klainin, P., & Arthur, D. G. (2009). Postpartum depression in Asian cultures: a literature

review. International journal of nursing studies, 46(10), 1355-1373.

Kroenke K, Spitzer R & Wiliams J, (2001). Validity of a brief depression severity measure. J

Gen Intern Med,16:606.

139
Lanes, A., Kuk, J. L., & Tamim, H. (2011). Prevalence and characteristics of postpartum

depression symptomatology among Canadian women: a cross-sectional study. BMC

public health, 11(1), 302.

Lancaster, C. A., Gold, K. J., Flynn, H. A., Yoo, H., Marcus, S. M., & Davis, M. M. (2010).

Risk factors for depressive symptoms during pregnancy: a systematic

review. American journal of obstetrics and gynecology, 202(1), 5-14.

Leahy‐Warren, P., McCarthy, G., & Corcoran, P. (2012). First‐time mothers: social support,

maternal parental self‐efficacy and postnatal depression. Journal of clinical

nursing, 21(3‐4), 388-397.

Lester, S. W., Turnley, W. H., Bloodgood, J. M., & Bolino, M. C. (2002). Not seeing eye to

eye: Differences in supervisor and subordinate perceptions of and attributions for

psychological contract breach. Journal of Organizational Behavior, 23(1), 39-56.

Lindsay, T. (Ed.). (2009). Social work intervention. Learning Matters.

Logsdon, M. C., Wisner, K. L., & Pinto‐Foltz, M. D. (2006). The impact of postpartum

depression on mothering. Journal of Obstetric, Gynecologic & Neonatal

Nursing, 35(5), 652-658.

Logsdon, M. C., Wisner, K., Billings, D. M., & Shanahan, B. (2006). Raising the awareness

of primary care providers about postpartum depression. Issues in Mental Health

Nursing, 27(1), 59-73.

Logsdon, M. C., Birkimer, J. C., Simpson, T., & Looney, S. (2005). Postpartum

depression and social support in adolescents. Journal of Obstetric, Gynecologic, &

Neonatal Nursing, 34(1), 46-54.

Lusskin, Shari I., Pundiak, Tara M. & Habib, Sally M. (2007). Perinatal depression: Hiding

in plain sight. Canadian Journal of Psychiatry, 52(8), 479-487.

140
Mallick, D. R., Chuntharapat, S., & Chunuan, S. (2010, April). The relationships among

perceived health status, perceived self-efficacy, and health-promoting behaviors of

Bangladeshi postpartum women. The 2nd International Conference on Humanities

Miller, B. C., & Sollie, D. L. (1980). Normal stresses during the transition to parenthood.

In Coping with life crises (pp. 129-138). Boston, MA.Springer.

Miller, L. J. (2002). Postpartum depression. Journal of the American Medical

Association, 287(6), 762-765.

Miller, R. L., Pallant, J. F., & Negri, L. M. (2006). Anxiety and stress in the postpartum: is

there more to postnatal distress than depression?, BioMed Central Psychiatry, 6(1),

12.

Motzfeldt, I., Andreasen, S., Lynge Pedersen, A., & Lynge Pedersen, M. (2013). Prevalence

of postpartum depression in Nuuk, Greenland–a cross-sectional study using

Edinburgh Postnatal Depression Scale. International journal of circumpolar

health, 72(1), 21114.

Muneer, A., Minhas, F. A., Tamiz-ud-Din Nizami, A., Mujeeb, F., & Usmani, A. T. (2009).

Frequency and associated factors for postnatal depression. J Coll Physicians Surg

Pak, 19(4), 236-239.

Nakku, J. N., Nakasi, G., & Mirembe, F. (2006). Postpartum major depression at six weeks in

primary health care: prevalence and associated factors. African Health Sciences, 6(4),

207-214.

National Alliance on Mental Illness, (2015). Mental health conditions. Retrieved from

https://www.nami.org/Learn-More/Mental-Health- Conditions

141
Nonacs, R., & Cohen, L. S. (1998). Postpartum mood disorders: Diagnosis and treatment

guidelines. Journal of Clinical Psychiatry.

Norhayati, M. N., Hazlina, N. N., Asrenee, A. R., & Emilin, W. W. (2015). Magnitude and

risk factors for postpartum symptoms: A literature review. Journal of Affective

Disorders, 175, 34-52.

O'Hara, M. W., & Swain, A. M. (1996). Rates and risk of postpartum depression—a meta-

analysis. International Review of Psychiatry, 8(1), 37-54.

O'hara, M. W., Neunaber, D. J., & Zekoski, E. M. (1984). Prospective study of postpartum

depression: Prevalence, course, and predictive factors. Journal of Abnormal

Psychology, 93(2), 158.

Onwuegbuzie, A. J., & Teddlie, C. (2003). A framework for analyzing data in mixed methods

research. Handbook of mixed methods in social and behavioral research, 2, 397-430.

Padgett, D. K. (2016). Qualitative methods in social work research (Vol. 36). Sage.

Patel, V., Rodrigues, M., & DeSouza, N. (2002). Gender, poverty, and postnatal depression:

A study of mothers in Goa, India. American Journal of Psychiatry, 159(1), 43-47.

Patel, M., Bailey, R. K., Jabeen, S., Ali, S., Barker, N. C., & Osiezagha, K. (2012).

Postpartum depression: A review. Journal of Health Care for the Poor and

Underserved, 23(2), 534-542.

Payne, J. L. (2007). Antidepressant use in the postpartum period: Practical

considerations. American Journal of Psychiatry, 164(9), 1329-1332.

142
Pearlstein, T. B., Zlotnick, C., Battle, C. L., Stuart, S., O‘Hara, M. W., Price, A. B., ... &

Howard, M. (2006). Patient choice of treatment for postpartum depression: A pilot

study. Archives of Women's Mental Health, 9(6), 303-308.

Perfetti, Jennifer; Clark, Roseanne & Fillmore, Capri-Mara. (2004). Postpartum depression:

Identification, screening and treatment. Wisconsin Medical Journal, 103 (6), 56-63.

Rabin, R. F., Jennings, J. M., Campbell, J. C., & Bair-Merritt, M. H. (2009). Intimate partner

violence screening tools: a systematic review. American journal of preventive

medicine, 36(5), 439-445.

Posmontier, B., & Horowitz, J. A. (2004). Postpartum practices and depression prevalences:

technocentric and ethnokinship cultural perspectives. Journal of Transcultural

Nursing, 15(1), 34-43.

Rahman, A., Bunn, J., Lovel, H., & Creed, F. (2007). Maternal depression increases infant

risk of diarrhoeal illness: A cohort study. Archives of Disease in Childhood, 92(1),

24-28.

Rahman, A., Malik, A., Sikander, S., Roberts, C., & Creed, F. (2008). Cognitive behaviour

therapy-based intervention by community health workers for mothers with depression

and their infants in rural Pakistan: A cluster-randomised controlled trial. The

Lancet, 372(9642), 902-909.

Razurel, C., Bruchon-Schweitzer, M., Dupanloup, A., Irion, O., & Epiney, M. (2011).

Stressful events, social support and coping strategies of primiparous women during

the postpartum period: a qualitative study. Midwifery, 27(2), 237-242.

143
Rempel, L. A., & Rempel, J. K. (2004). Partner influence on health behavior decision-

making: Increasing breastfeeding duration. Journal of Social and Personal

Relationships, 21(1), 92-111.

Richmond, M. E. (1917). The social case worker‘s task. In Proceedings of the National

Conference of Social Work. Chicago: Rogers & Hall Co.

Robertson, E., Grace, S., Wallington, T., & Stewart, D. E. (2004). Antenatal risk factors for

postpartum depression: A synthesis of recent literature. General Hospital

Psychiatry, 26(4), 289-295.

Robinson, G. E., & Stewart, D. E. (2001). Postpartum disorders. Psychological Aspects of

Women's Health Care, 117-139.

Roux, L.& Barry, M. (2009). Paradigms and cadastral research. The 7th FIG regional

conference: Spatial Data Serving People: Land Governance and the Environment –

Building the Capacity, Hanoi: Societal Balance-Resources and Rights.

Rychnovsky, J., & Hunter, L. P. (2009). The relationship between sleep characteristics and

fatigue in healthy postpartum women. Women's Health Issues, 19(1), 38-44.

Matijasevich, A., Munhoz, T. N., Tavares, B. F., Barbosa, A. P. P. N., da Silva, D. M.,

Abitante, M. S., ... & Santos, I. S. (2014). Validation of the Edinburgh postnatal

depression scale (EPDS) for screening of major depressive episode among adults

from the general population. BMC psychiatry, 14(1), 284.

Segre, L. S., O'Hara, M. W., Arndt, S., & Beck, C. T. (2010). Nursing care for postpartum

depression, part 1: do nurses think they should offer both screening and

counseling?. American Jjournal of Maternal Child Nursing, 35(4), 220.

144
Senturk V, Hanlon C, Medihin G, Dewey M, Araya M, Alem A, Prince M, Stewart R. Impact

of Perinatal somatic and common mental disorder symptoms on functioning on

Ethiopian Women: The P-MaMiE population-based cohort study. Journal of

Affective Disorders 2012; 136:340.

Shenton, A. K. (2004). Strategies for ensuring trustworthiness in qualitative research

projects. Education for Information, 22(2), 63-75.

Shearer, N., & Fleury, J. (2006). Social support promoting health in older women. Journal

of Women & Aging, 18(4), 3-17.

Smith, B. J., Cheung, N. W., Bauman, A. E., Zehle, K., & McLean, M. (2005). Postpartum

physical activity and related psychosocial factors among women with recent

gestational diabetes mellitus. Diabetes Care, 28, 2650–2654.

Smith, M., & Segal, J. (2011). Postpartum Depression and the Baby Blues: Symptoms,

treatment and support for new moms. Helpguid. org.

Shrivastava, S. R., Shrivastava, P. S., & Ramasamy, J. (2015). Necessity of globally

implementing the comprehensive mental health action plan: World Health

Organization. Journal of Neurosciences in Rural Practice, 6(4), 626.

Soares, C. N., & Zitek, B. (2008). Reproductive hormone sensitivity and risk for depression

across the female life cycle: A continuum of vulnerability?. Journal of Psychiatry &

Neuroscience, 33(4),331–343.

Sobey, W. S. (2002). Barriers to postpartum depression prevention and treatment: A policy

analysis. Journal of Midwifery &Women's Health, 47(5), 331-336.

Stellenberg, E. L., & Abrahams, J. M. (2015). Prevalence of and factors influencing postnatal

depression in a rural community in South Africa. African journal of primary health

care & family medicine, 7(1), 1-8.

145
Stewart, D. E., Robertson, E., Dennis, C. L., Grace, S. L., & Wallington, T. (2003).

Postpartum depression: Literature review of risk factors and interventions. Toronto:

University Health Network Women‘s Health Program for Toronto Public Health.

Tamers, S.L., Beresford, S.A., Cheadle, A.D., Zheng, Y.,Bishop, S.K., & Thompson, B.

(2011). The associationbetween worksite social support, diet, physical activity

and body mass index. Preventive Medicine, 53, 53–56.

doi:10.1016/j.ypmed.2011.04.012

Tashakkori, A., & Teddlie, C. (Eds.). (2010). Sage handbook of mixed methods in social &

behavioral research. sage.

Tefera, T. B., Erena, A. N., Kuti, K. A., &Hussen, M. A. (2015). Perinatal depression and

associated factors among reproductive aged group women at Goba and Robe Town

of Bale Zone, Oromia Region, South East Ethiopia. Maternal Health, Neonatology

and Perinatology, 1(1), 12.

Tesfaye, M., Hanlon, C., Wondimagegn, D., & Alem, A. (2010). Detecting postnatal

common mental disorders in Addis Ababa, Ethiopia: Validation of the Edinburgh

postnatal depression scale and Kessler scales. Journal of Affective Disorders, 122(12),

102-108.

Toru, T., Chemir, F., & Anand, S. (2018). Magnitude of postpartum depression and

associated factors among women in Mizan Aman town, Bench Maji zone, Southwest

Ethiopia. BMC Pregnancy and Childbirth, 18(1), 442.

Thornton, P. L., Kieffer, E. C., Salabarría-Peña, Y., Odoms-Young, A., Willis, S. K., Kim,

H., & Salinas, M. A. (2006). Weight, diet, and physical activity-related beliefs and

practices among pregnant and postpartum Latino women: the role of social

support. Maternal and child health journal, 10(1), 95-104.

146
Turner, K. M., Sharp, D., Folkes, L., & Chew-Graham, C. (2008). Women's views and

experiences of antidepressants as a treatment for postnatal depression: a qualitative

study. Family Practice, 25(6), 450-455.

Walther, V. N. (1997). Postpartum depression: A review for perinatal social workers. Social

Work in Health Care, 24(3-4), 99-111.

Weobong B, Asbroek A, Soremekun S, Manu A, Owusu-Agyei S, Prince M, & et al. (2014).

Association of antenatal depression with adverse consequences for the mother and

newborn in rural Ghana: Findings from the don population-based cohort study. PLoS

ONE.

World Health Organization. (2001). The World Health Report 2001: Mental health: New

understanding, new hope. World Health Organization.

World Health Organization. (2005). Mental health: facing the challenges, building solutions.

Report from the WHO European Ministerial Conference. Copenhagen, Denmark:

WHO Regional Office for Europe.

World Health Organization. (2008). Maternal mental health and child health and

development in low and middle income countries: Report of the meeting, Geneva,

Switzerland, 30 January-1 February, 2008.

World Health Organization. (2012). Depression: A global public health concern. Geneva,

Switzerland: WHO.

World Health Organization. (2012). Understanding and addressing violence against women:

Intimate partner violence (No. WHO/RHR/12.36). World Health Organization.

World Health Organization. (2016). World health statistics 2016: Monitoring health for the

SDGs sustainable development goals. World Health Organization.

147
Wolf, A. W., De Andraca, I., & Lozoff, B. (2002). Maternal depression in three Latin

American samples. Social Psychiatry and Psychiatric Epidemiology, 37(4), 169-176.

Wortman, C. B. (1984). Social support and the cancer patient: Conceptual and methodologic

issues. Cancer, 53, 2339-2360.

Yamamoto, N., Abe, Y., Arima, K., Nishimura, T., Akahoshi, E., Oishi, K., & Aoyagi, K.

(2014). Mental health problems and influencing factors in Japanese women 4 months

after delivery. Journal of physiological anthropology, 33(1), 32.

Yeh, Y. C., St John, W., & Venturato, L. (2014). Doing the month in a Taiwanese postpartum

nursing center: An ethnographic study. Nursing & health sciences, 16(3), 343-351.

Yim, I. S., Tanner Stapleton, L. R., Guardino, C. M., Hahn-Holbrook, J., & Dunkel Schetter,

C. (2015). Biological and psychosocial predictors of postpartum depression:

Systematic review and call for integration. Annual Review of Clinical

Psychology, 11, 99-137.

Zink, T., Levin, L., Putnam, F., & Beckstrom, A. (2007). Accuracy of five domestic violence

screening questions with nongraphic language. Clinical pediatrics, 46(2), 127-134.

148
Annnexes

Annex I: Consent form and Information sheet 138

Introduction:

Here, I, the undersigned, a Ph.D student at Addis Ababa University College of Social

Sciences, School of Scocial Work, I will be undertaking research on a topic entitled

―Postpartum Depressions among Mothers who gave birth and attended public health facilities

of East Shewa Zone, Ethiopia in 2019.

For this study, you will be selected as a participant and before getting your consent or

permission of your participation, you need to know all necessary information related to the

study. Thus, this information will be detailed accordingly:

 Objective: To determine the magnitude of postpartum depression and assess its

associated factors among postpartum women and also aim to explore Midwifes

perception on Postpartum depression in East Shewa Hospitals and Health Centers,

Ethiopia, 2019

 Significance of the study: The effects of postnatal depression (PPD) on mothers, their

marital relationship, and their children make it an important condition to diagnose, treat

and prevent. This paper will be useful for raising community awareness by exposing the

findings. In addition, the present study will be published in reputable journals and

disseminated to other research groups and the academic community in general. Further,

the database generated from the study will be made available to other users for more in-

depth analysis.

 Methods: Facility-based cross-sectional study will be conducted from July 2019-Augest

among 500. Mothers who give birth in East Shewa Zone, Ethiopia.

 Work plan: This study planned to be completed by February 2020

149
 Participants to be included: Randomely sellected mothers who gave birth within the

last one year at the health facilities of East Shewa Zone during the time of the study.

 Confidentiality: All information you give will be kept confidential and won't be

accessible to any third party. Your name won't be registered on the question sheet so that

you will not be identified.

 Risks and Benefits of the study

Risks: The study will be carried out simply by asking you, the already prepared and

structured questions. The procedure doesn't bear any physical or psychological trauma.

Furthermore, you will not be forced to respond to the information you do not know.

Benefits: For your participation in the study no payment will be granted or has no any

special privilege to you. But, participating in the study and giving your information to

questions asked will have great input in efforts to reduce postpartum depression in the

future intervention.

 Consent: Your participation in the study will be totally based on your willingness. You

have the right not to participate from the beginning, or stop any time after starting

participation. You will not be forced to respond to the information you do not know.

 Name of the Ph.D student and advisors:

 Asnake Tesfaye Date:___________ Signature__________

Mobile : +251911315444 E-mail: [email protected]

 Professor Margaret Adamek

 Dr. Yanya Seid Mekiye

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Annex II: Questionnaires

Structured Questionnaire English Version

Addis Ababa University

College of Social Sciences, School of Social Work

Consent form that certify the respondents agreement before starting

01. Name of the Health Facility __________________________

02. Questionnaire Identification Number_______________________

Introduction

Good morning , Good afternoon [According to its convenience]. My name is

________________________. I am Nurse/Midwife professionally and now I am

collecting data from postpartum mothers of reproductive age groups(15- 49 years) for the

research being conducted to explore Postpartum Depressions among Mothers who gave

birth and attending public health facilities of East Shewa Zone, Ethiopia. By Asnake Tesfaye.

From Addis Ababa University, College of Social Sciences School of Social Work. You are

selected to be one of the participants in the study by chance. The study will be conducted

through interview. Your name and other personal identifiers will not be recorded on

data collection format and the information that you give us will be kept confidential

and will also be used for this study purpose alone. A code number will identify every

participant and no names will used. If a report of the result is published, only summarized

information of the total group will appear. The interview takes 30 minutes and is

voluntary and you have the right to participate, or not to participate or to refuse at any time

during the interview. You will not face any problem if you do not agree with the

information to be asked. Your participation on this study helps to identify factors associated

with PPD, prevalence of PPD and help to explore emotional distress expirience of mothers in

151
East Shewa Zone. If you have any questions about this study you may ask me or the

principal investigators Asnake Tesfaye (Mobile : +251911315444E-mail:

[email protected]).

 Are you willing to participate in the study?

1. Yes 2. No

 Interviewer who certified that the informed consent has been given verbally from the

respondents

Name______________________ signature_______________

Date___________________

 Result

1. Completely collected

2. Refused

3. Partially completed

4. Other (please specify)_________________________________

 Checked by:

Name ______________________ signature_________ Date__________

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Questionnaire on Postpartum Depressions among Mothers who gave birth and attended

public health facilities of East Shewa Zone, Ethiopia.

Now I would like to begin by asking you a few questions about yourself and your family:

PART 1: SOCIO-DEMOGRAPHIC VARIABLES

Code Questions Response Variables

101 Age (in years) _________ SDV 01

102 Ethnicity 1. Oromo SDV 02

(Which ethnic group do you 2. Amhara

belong?) 3. Gurage

4. Others(Specify) _____________

103 Religion 1. Orthodox SDV 03

(Which religion do you follow 2. Muslim

?) 3. Protestant

4. Catholic

5. Others (Specify)_____________

104 What is your marital status 1.Married SDV 04

currently? 2. Single

3. Widowed

4. Divorced

5. Separated

105 Educational level 1. Illiterate (Cannot read and write) SDV 05

(What is your educational 2. Literate (Able to read and write)

level?) 3. Primary school (grade 1-8)

4. Secondary school (grade 9-12)

153
 5. College diploma and above

106 Educational level of husband 1. Illiterate (Cannot read and write) SDV 06

(What is your husband 2. Literate (able to read and write)

educational level?) 3. Primary school

4. Secondary school

5. College diploma and above

107 Occupation (what is your 1. Government Employed SDV 07

occupation?) 2. Daily laborer

(What do you do for living?) 3. House wife

4. Self employed

5. Student

6. Others (specify)____________

108 Total family size _________________ total family SDV 09

size

109 Place of residence 1. Rural SDV 10

2. Urban

110 Household economy (family ________________ETB/Month SDV 11

income per month)

What is the approximate

monthly household income from

all the sources?

111 Do you have radio 0. No 1. yes SDV 12

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 112 Do you have TV 0. No 1. yes SDV 113

113 Do you have Mobile phone 0. No 1. Yes SDV 114

114 What is your husband‘s 1. Government Employed

occupation? 2. Daily laborer

3. Self employed

4. Student

5. unemployed

6. Others (specify)____________

PART 2: OBSTETRIC FACTORS

201 Have you had any pregnancy 1. Yes 0. No OBF 01

/other than/ before this child?

If No skip to Q 210

202 What was your age at first ____________year OBF 02

pregnancy? 0. I don't remember /DK….99/

(Age in years)

203 What order was your last birth? 1.First OBF 03

2.Second

3.Third

4.Fourth and above

204 How many live births have you 1. Number of children alive:_________ OBF 04

had? 2. Number of children died:________

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 (Express in number) 3. Number of still birth:_____

4. No response /DK….99/

205 Have you ever-experienced 1. Yes OBF 05

abortion? 0. No

206 If yes, How many times? 1. __________ OBF 06

(Express in no) 0. No response/ do not know (DK)

207 Did you have stillbirth? 1. Yes OBF 07

0. No

208 If yes how many times? Express 1. __________ OBF 08

in no 0. Do not know (DK)

209 What is the sex composition of Male _____ OBF 09

your Female _____

living children? (Express in no) Total _____

210 What was your last pregnancy 1.Planned OBF 10

status? 2.Unplanned

211 Do you want any more 1. Yes OBF 11

children? 0. No

212 If yes for 211: How many? Male _____ OBF 12

(Express in no) Female _____

Total _____

213 Who is Responsible for deciding 1. Wife OBF 13

on to have children 2. Husband

3. Joint discussion

156
214 Did you experience any 1.Yes OBF 14

complications before (during 0. No

your pregnancy) or after your

delivery? If no skip to 216

215 If your response is yes for Lists 1. Yes 0. No OBF 15

Q214, what type of 1. Hypertension …… ……

complication did you 2. Severe Bleeding ……… ……….

encountered? 3. Blurred Vision …….. ………

4 High Fever ………. ……….

5. Vaginal discharge ……. ………

6. Loss of Consciousness …….. …….

7. Severe Headache ….… ……

8. Pain during urination …….. ……..

9. Severe weakness …….. ……..

10. Difficulty of breathing …… ……..

11. Severe abdominal pain …….. ………

12. Malaria infection …….. ………

13.Others (specify)…………………….

216 What was the mode of your last 1.Spontanoaus vaginal OBF 16

delivery? 2.Cesserian section

3.Others(specify)

217 What was your gestational age -----------weeks -------------months OBF 17

of your last pregnancy at I don‘t know

157
 childbirth?

PART 3: PEDIATRIC FACTORS

301 Sex of your baby 1.Male PD 01

2.Female

302 Desired sex of your baby 1.Male PD 02

2.Female

3.Unspecified

303 What was birth weight of your ---------------grams PD 03

child? 99. I don‘t know

304 What did you start to feed your 1.Breast feeding PD 04

infant immediately after birth? 2.Bottle feeding

3.Other (specify------------

305 If your answer is 1 for Q304, did 1.Yes PD 05

you feed for completed 6 0. No

months?

306 Did you experience difficulty to 1.yes PD 06

feed your baby? 0. no

307 Is there difficulty of sleeping of 1.yes PD 07

your baby? 0. no

308 Infant illness at any time after 1.yes PD 08

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 birth? 0. no

309 Was there history of less than 1.yes PD 09

one-year death? 0. no

PART 4: MOTHERS‟ KNOWLEDGE ON PPD

K 401 Have you ever heard of PPD? 0. Yes MK01

1. No

2. No response

3. I don't remember

K 402 If yes, what are Source of information? 1.Health Worker MK02

2.Radio

3. News Papers

4. TV

5. Friends and families

6. Other specify

K 403 What type of information do you have on the If yes=1 If No=0 MK

feelings/ symptoms of PPD? (Read and thick ____ ____

all mentioned) ____ ____

1. Sleepiness ____ ____

2. Fear ____ ____

3. Sadness ____ ____

4. Dysphoria ____ ____

5. Tearfulness ____ ____

____ ___

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PART 5 OSLO 3-ITEM SOCIAL SUPPORT SCALE

The following 3 questions ask about how you experience your social relationships. The

inquiry is about your immediate personal experience. Please circle the option that represents

your experience.

How many people are so close to you that [1] None OSS1

501 you can count on them if you have serious [2] 1 or 2

personal problems (choose one option)? [3] 3-5

[4] more than 5

How much concern do people show in [5] A lot concern and interest OSS2

502 what you are doing (choose one option)? [4] Some concern and interest

[3] Uncertain

[2] Little concern and interest

[1] No concern and interest

How easy is it to get practical help from [5] Very easy OSS3

503 neighbors if you should need it (choose [4] Easy

one option)? [3] Possible

[2] Difficult

[1] Very difficult

160
Part 6 FAMILY HEALTH RELATED FACTORS

Now, I am going to ask you about your family member health situation

601 Was there close family member death in 1.yes FH01

this year? 0. no
602 Family member sickness currently? 1.yes FH 02

0. no
603 Family history of mental illness? 1.yes FH 03

0. no
PART 7: INTERPERSONAL RELATIONS

WAST: Even though couples get along well, there are also times of conflicts and

disagreements. Couples get irritated with the other person for many reasons, or just have

quarrels as a result of a bad mood or tired of some other activities. They may also use

dissimilar habits of trying to settle their problems. I‘m going to ask what you feel when you

have an argument with your partner.

701 How do you and your partner work out [0] no difficulty DV1

arguments? [1] some difficulty

[2] great difficulty

702 In general, how do you describe your [0] no tension DV2

relationship? [1] some tension

[2] a lot of tension

703 How is your partner treating you and the kids? [0] always well DV3

[1] well most of the time

[2] neutral

[3] not well most of the time

704 Do you feel safe in your current relationship? [0] always safe DV4
[4] never well
[1] safe most of the time

[2] neutral

[3] not safe most of the time

[4] never safe

161
705 Considering your current partners, friends, or [0] always safe DV5

any past partners or friends, are there anyone [1] safe most of the time

who is making you feel unsafe now? [2] neutral

[3] not safe most of the time

[4] never safe

PART 8: PHQ-9

Now, I‘m going to ask what you about your feeling in the past fourteen days (two

weeks).

In the past two weeks:

Variable
Code Question Response
s

801 Little interest or pleasure in doing 0), Not at all PHQ9-01

things 1), Several days

2), Nearly half the days

3), Every day

802 Feeling down, 0), Not at all PHQ9-02

depressed, or 1), Several days

hopeless 2), Nearly half the days

3), Every day

803 Trouble falling or staying asleep, or 0), Not at all PHQ9-03

sleeping too much 1), Several days

2), Nearly half the days

3), Every day

162
 Variable
Code Question Response
s

804 Feeling tired or having little energy 0), Not at all PHQ9-04

1), Several days

2), Nearly half the days

3), Every day

805 Poor appetite or overeating 0), Not at all 1), Several days 2), PHQ9-05

Nearly half the days 3), Every day

806 Feeling bad about yourself - or that 0), Not at all PHQ9-06

you are a failure or have let yourself 1), Several days

or your family down 2), Nearly half the days

3), Every day

807 Trouble concentrating on things, 0), Not at all PHQ9-07

such as reading the newspaper or 1), Several days

watching television 2), Nearly half the days

3), Every day

808 Moving or speaking so slowly that 0), Not at all PHQ9-08

other people could have noticed? Or 1), Several days

the opposite - being so fidgety or 2), Nearly half the days

restless that you have been moving 3), Every day

809 Thoughts thatmore

around a lot you than
would be better
usual 0), Not at all PHQ9-09

off dead or of hurting yourself in 1), Several days

some way 2), Nearly half the days

3), Every day

163
 Variable
Code Question Response
s

810 ADD PHQ SCORE FORM 801-809. Total Score _____ = ___ + ___ + ___ )

PART 9: HISTORY OF SUBSTANCE USE

In this question, you will inform us weather you use the following substances

901 Substance use history during 1.yes HSU01

pregnancy or after childbirth? 2.no

902 If yes, which substance? 1.ciggarrete HSU02

2.chat

3.Alcohol

4.others

903 Is your husband using the above 1.yes HSU03

substances?
2.no

904 If yes, which substance? 1.ciggarrete HSU04

2.chat

3.Alcohol

4.others

164
PART 10: Women Labor and delivery Experience

Now I am going to ask you questions about your experience during last labor and delivery.

Code Question Response Variables

Who attended your 1. Nurse/Midwife/Health officer/doctor WLDE01

1001 last birth 2. Health Extension worker

3. TBA

4. Others

1003 How did you give 1. By vaginal way WLDE02

birth? 2. By emergency caesarean section

3. By scheduled cesarean section

1005 How long did you _________ hours WLDE03

stay in the health 99) dont remember

facility after giving

birth?

165
Code Question Response Variables

1006 When you left the 1, Yes WLDE04

health facility, did
0, No - I was not happy
you feel happy?
1. Otherspecify …………………..

Interview guide with PPD Mothers

Location: ________________ Date: ________________

Time started: ________________________ Time ended: ________________

Participants Code: _________________

Introduction of Facilitators and the IDI Process:

 The interviewer introduces her (him) self

 Explains the purpose of the IDI

 Use of tape-recorder; Everything said by participant will be kept confidential and

anonymous; No right or wrong answers; Honest responses are highly appreciated

I. Mother‟s Perception on PPD and her experience of emotional distress

 Have you ever heard about PPD?

 How do you perceive PPD?

Now, let us talk more about some of the experience that you have

166
  Can you tell me about when you first started to feel distressed?

 What thoughts and feelings did you experience?

 How do you cope with your symptoms?

Probe

Participants will be further encouraged to express any issues that they felt are

relevant to their experience of distress.

II. Wrap up

Is there anything else that you would like to tell me about any of the issues that we

have discussed so far?

Thank the participant for her time and contribution.

In-depth interviews (IDIs) guide with professional midwifes who are working in the

selected health facility.

Location: ________________ Date: ________________

Time started: ________________________ Time ended: ________________

Participants Code: _________________

Introduction of Facilitators and the IDI Process:

 The interviewer introduces her (him) self

 Explains the purpose of the IDI

 Use of tape-recorder; Everything saidby participant will be kept confidential and

anonymous; No right or wrong answers; Honest responses are highly appreciated

Hello. My name is ...... I would like to talk to you about your perceptions as midwife /./ on

PPD.

 Kindly introduce your self

167
  How do you perceive your current work as midwives?

 Any other aspect of your work (socioeconomic and professional aspect)

 How do you view Postpartum Depression (PPD) with your current engagement as

midwives?

 Have you ever informed postnatal mothers about PPD in addition to other postnatal

care?

 If so, in what way?

 Did postnatal mothers tell you about her mood disorders?

How?

 Some research revealed that knowledge of midwives on PPD can be a contributing

factor for PPD. What do you think about this view?

 Do you think views and perceptions of a professional midwives can influence PPD?

How?

Is there anything else that you would like to add on the above issues? (Feel free to talk)

Thank you for your kind cooperation.

168
 Assurance of principal investigator

I, undersigned here agrees to accept responsibility for scientific ethical and technical
conduct of the research project and for provision of required progress reports as per terms and
the condition of the AAU SSW PG Program in effect at the time of the grant is forwarded as
the result of this application.
Principal investigator: Asnake Tesfaye Date._________ Signature
______________

169
 Amharic version Questioneer

የመረጃ ቅጽ

መግቢያ

እኔ ከታች ፊርማዬ የተቀመጠዉ በአዱስ አበባ ዪኒቨርሲቲ ሶሻሌ ሳይንስ ኮላጅ፣

ሶሻሌ ወርክ ት/ት ቤት የፒ ኤች ዱ ተማሪ ስሆን በቅርበ ግዜ ከወሇደ እናቶች ሊይ ―Postpartum

Depressions among Mothers who gave birth and attended public health facilities of East

Shewa Zone, Ethiopia in 2019‘‘ በሚሌ ሀሳብ ስሇ ዴባቴ ምክኒያትና የክስተት መጠን

ጥናትና ምርምር በማዴረግ ሊይ እገኛሇሁ፡፡

እርስዎም ዯግሞ በዚህ የጥናትና ምርምር እንዱሳተፉ ተጋብዘዋሌ፡፡ ተሳትፎዎት በፍሊጎት

ሊይ ብቻ የተመሰረተ መሆን አሇበት፣ በጥናቱ ሊሇመሳተፍ ከመረጡ የሚያስከትሇው ችግር የሇም፡፡

በጥናቱ ሇመሳተፍ ከመወሰንዎ በፊት ጥናቱ ሇምን እንዯሚሰራና የእርስዎ ተሳትፎ ምን

እንዯሚያካትት መረዲቱ አስፈሊጊ ነው፡፡ እባክዎ ከዚህ በታች የተሰጡ መረጃዎችን በጥንቃቄ

ሇማንበብ ጊዜ ይውሰደ ከፈሇጉም ከላልች ጋራ ይወያዩበት፡፡ ግሌጽ ያሌሆነ ነገር ካሇና የበሇጠ

መረጃ ከፈሇጉ ሉጠይቁን ይችሊለ፡፡

170
የምርምሩ አሊማ፡ጥናቱ በቅርብ ግዜ የወሇደ እናቶችን ገወሇደ በኋሊ ስሇሚያጋጥማቸው የጤና

ሁናቴንና ከእነዚህ ጋር የተያያዙ የአእምሮ ህመምን ይመሇከታሌ፡፡ ጥናቱ በወሇደ እናቶች ሊይ

ስሇሚከሰተው የአእምሮ ህመም ሲሆን የአእምሮ ህመሙ ሊይ በምን ያህሌ እናቶች ሊይ

እነዯተከሰተና ስሇምክኒያቱም ያካትታሌ፡፡

በጥናቱ እንዱሳተፉ የሚመረጡት እነ ማን ናቸው ከሊይ በተጠቀሰው ርእስ ሊይ በዋነኝነት መረጃ

ሉሰጡን የሚችለት የወሇደ እናቶች ናቸዉ እና የጠና ባሇሙያዎችም ይካተታለ፡፡

በጥናቱ ሇመሳተፍ ቢስማሙ ምን ይዯረጋሌ፡፡ ከመረጃ ሰብሳቢዎቻችን አንደ ሌክ እንዯዚሁ

ሇህክምናና ሇክትባት እናቶችን በመጡበት ጤና ተቋም በመገኘት አንዲንዴ ጥያቄዎች ይቀርብልታሌ

መጠይቆቹ እናቶች እርስ ስሊልት ማህበራዊ ዴጋፍ እና ስሇሚሰማዎት ስሜት እነዱሁም ጠቅሇሌ

ያለ መረጃዎችን ይጠይቆታሌ፡፡ ከወሉዴ ጋር ተያይዞ የሚከሰቱ የአእምሮና የጤና ችግሮችን እና

እናቶች የሚያስፈሌጋቸውን ህክምና እንዲያገኙ ስሇሚያዯርጓቸው ጉዲዮች ይጠየቃለ፡፡ ቃሇ መጠይቁ

ወዯ ግማሽ ሰአት ገዯማ ይወስዲሌ፡፡

በጥናቱ መሳተፍ ምን ጉዲት ይኖረዋሌ? በቃሇመጠይቁ መሳተፍ የሚያስከትሇው ችግር የሇም፡፡

እርስዎ በጥያቄዎቹ ዯስተኛ ካሌሆኑ መሌስ ይሰጡ ዘንዴ አይገዯደም፡፡ ቃሇ መጠይቁም ዕዚሁ ሊይ

መቆም ይችሊሌ፡፡፣ የሚገኘው መረጃ በኢትዮጵያም ሆነ በላልች ሀገሮች ያሇውን የአእምሮ ጤና

አገሌግልት እንዯሚያሻሽሇው ተስፋ እናዯረጋሇን፡፡

በሰጡን ቅዴመ መረጃ ምን እናዯርግበታሇን? ጥያቄዎቹ የእርስዎን ስም አያካትቱም፡፡ ስሇዚህ

ከፕሮጀክቱ አስተባባሪ አቶ አስናቀ ተስፋዬ እና የፕሮጀክቱ የመረጃ ሰራተኞች ውጪ ማንም ላሊ

ሰው መረጃው የእርስዎ ስሇመሆኑ የሚያውቀው አይኖርም ፡፡ የመረጃ ሰነድቹን በሚቆሇፉ መሳቢያ

/ መዯርዯርያ / እናስቀምጣሇን፡፡

ዋና አጥኚዎች የጥናቱን አስተባባሪ አቶ አስናቀ ተስፋዬ ሲሆን ሉያገኙ ከፈሇጉ ሞባይሌ ቁጥር

0911 31 54 44 በመጠቀም በስራ ሰአት በማንኛውም ቀን ሉዯውለሌን ይችሊለ፡፡ በጥናቱ

መሳተፍ የእርስዎ ውሳኔ ጉዲይ ይሆናሌ፡፡ በጥናቱ ሇመሳተፍ ከወሰኑ በማንኛውም ሰአት ምክንያት

መስጠት ሳይጠበቅብዎት በነጻነት ተሳትፎውን ማቋረጥ ይችሊለ፡፡ ይህ ጥናት በማንኛውም መንገዴ

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ጉዲት ካዯረሰብዎት የአ.አ ዩኒቨርሲቲ የሶሻሌ ወርክ ትምህርት ቤት የስነምግባር (ኢቲክስ) ተቋማዊ

የክሇሳ ቦርዴን በስሌክ ቁጥር 0115-…………… ማነጋገር ይችሊለ፡፡

ማስታወሻ፡ . . በጥናቱ ሇመሳተፍ ከወሰኑ ይህን የመረጃ ቅጽ ይሰጥዎትና

ስምምነት ግን በፊርማ እንዱያረጋግጡ ይጠየቃለ፡፡

የዋና ተመራማሪቡዴን አባሊት ስም

 አቶ አስናቀ ተስፋዬ ቀን ............................. ፊርማ ..........................

ሞባይሌ፡ ++251911315444 E-mail: [email protected]

 ፕሮፍሶር ማርጋሬት አዲመክ

 ዯክተር ንያ ሰይዴ-ሚኪይ

Annex II: Questionnaires

Structured Questionnaire Amharic Version

አዱስ አበባ ዩኒቨርሲቲ

የሶሻሌ ሳይንስ ኮላጅ ሶሻሌ ዎርክ ት/ት ቤት

በጥናቱ ሊይ ስሇመሣተፍ የስምምነት መግሇጫ ቅፅ

01. የጤና ተቋሙ ስም ………………………………………..

02. የቃሇመጠይቅ ወረቀቱ መሇያ ቁጥር …………………………

መግቢያ

ጤና ይስጥሌኝ፡ እንዯምን አዯሩ፣ እንዯምን ዋለ (እንዯ ሰዓቱ አግባብነት) ………….

እባሊሇሁ፡ ሙያዬ አዋሊጅ/ነርስ ሲሆን፤ በአሁኑ ሰዓት እዴሜያቸዉ ከ15-49 ባለ ወሊዴ እናቶች

ዙሪያ ሇሚካሔዯዉ ጥናት መረጃ ሇማሰባሰብ ነዉ የመጣሁት፡ የጥናቱ ረዕስ „‟Postpartum

Depressions among Mothers who gave birth and attending public health facilities of

EastShewa Zone, Ethiopia‟‟ ሲሆን በምስራቅ ሸዋ ዞን የጤና ተቋማት ሇከወሉዴ በኋሊ ሇጤና

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እንክብካቤ ከሚመጡ እናቶች መረጃን በመሰብሰብ ከወሉዴ በኋሊ ስሇሚከሰቱ ዴባቴ/የመጨነቅ ስሜት

መጠኑንና ምክኒያቱን ምንነት በዝርዝር የሚያካትት ጥናት ነዉ፡ ይህ ጥናት የሚጠናዉ በአዱስ

አበባ ዩኒቨርሲቲ፣ ሶሻሌ ሳይንስ ኮላጅ፣ ሶሻሌ ወርክ ት/ት ቤት የፒ ኤች ዱ ተማሪ በሆኑት በአቶ

አስናቀ ተስፋዬ ነዉ፡፡ እርስዎ ሇዚህ ጥናት ተሳታፊ እንዱሆኑ የተመረጡት በአጋጣሚ ነዉ / እንዯ

ዕዴሌ ነዉ/. ጥናቱ የሚካሄዯዉ በቃሇ መጠይቅ ነዉ፡ ስሞትና የግሌ መገሇጫዎች በዚህ መጠይቅ

ጥናት ዉስጥ አይካተትም፡ የሰጡን መረጃ በሚስጥር የምንይዝ ሲሆን ሇዚህ ጥናት አሊማ ብቻ

ይዉሊሌ፡፡ የምንጠቀምበት መሇያ ኮዴ ተሳታፊዉን በጥናቱ መካተቱን ይገሌጻሌ ምንም አይነት

ገሇጭ ስም አንጠቀምም፡፡ ይህ ጥናት አሌቆ ከታተመ የጥናቱ ዋና ግኝት ብቻ የሚዎጣ ይሆናሌ፡ይህ

ቃሇ መጠይቅ እስከ 30 ዯቂቃ ሉዎስዴ ይችሊሌ ተሳትፎዎት በፍሊጎት ሊይ ብቻ የተመሰረተ መሆን

አሇበት፣ በጥናቱ ሊሇመሳተፍ ከመረጡ የሚያስከትሇው ችግር የሇም፣ በመጠይቁ መሳተፍ ካሌፈጉ

በማንኛዉም ሰዓት ከጥናቱ ማቋረጥ ይችሊለ፡ በዚህ ጥናት ሊይ በሚያዯርጉት ተሳትፎ ስሇዴባቴ

ክስተት መንነትና ምክኒትያ እንዱሁም የእናቶችን የመዯባበት ሁናቴን በማጥናት ሇመፍትሔ

የሚያመሩ የትናት ዉጤቶችን ሇመጠቆም ይረዲሌ፡፡ በዚህ ጥናት ሊይ ማንኛዉም ጠያቄ ካልት እኔን

መጠየቅ ይችሊለ ወይም የዚህ ጥናት ዋና ተመራማሪ አቶ አስናቀ ተስፋዬን ከዚህ በታች

በተጠቀሰዉ አዴራሻ ያግኟቸዉ

(+251911315444 E-mail: [email protected]).

 በዚህ ጥናት ሊ ሇመሳተፍ ፈቃዯኛ ኖት

1) አዎን 2) አይዯሇሁም

 የቃሇመጠይቅ አቅራቢዉ ከጥናቱ ተሳታፊዋ ስምምነት ቃሊቸዉን ሰጥተዋሌ

ስም…………………………………………….. ፊርማ …………………….. ቀን …………

 ዉጤት

1. ሙለ በሙለ ተሰብስቧሌ

2. ፈቃዯኛ አሌሆኑም

3. በከፊሌ ተጠናቋሌ

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 4. ላሊ ሁኔታ ካሇ ይግሇጹ

 ያረጋገጠዉ

 ስም…………………………………………….. ፊርማ …………………….. ቀን

…………

ክፍሌ አንዴ

የእናቶች ግሊዊ መረጃ

አሁን ስሇ እርስዎና ቤተሰብዎ አጠቃሇይ ሁናቴ እጠይቆታሇሁ

S.No. መጠይቅ ምሊሽ Remark

101 እዴሜ __________(ዓመት) SDV01

102 ብሔረሰብ 5. ኦሮሞ SDV02

6. አማራ

7. ጉራጌ

8. ላሊ ከሆነ ይጥቀሱ _____________

103 እምነት 1. ኦርቶድክስ ክርስቲያን SDV03

(የምን ሀይማኖት ተከታይ ኖት?) 2.እስሌምና እምነት ተከታይ

3. የፕሮቴስታንተንት ክርስቲያን

4. ካቶሉክ ክርስቲያን

174
 5. ላሊ ከሆነ ይጥቀሱ_____________

104 በአሁን ሰዓት የጋብቻ ሁኔታዎ? 1. ያገባች SDV04

2. ሇብቻዋ ምትኖር

3. ባሇቤትዋ በህይወት የላሇ

4. የተፋታች

105 የትምህርት ዯረጃዎ ? 1. አሌተማርኩም(ማንበብና መጻፍ SDV05

አሌችሌም)

2. ተምሬያሇሁ(ማንበብና መጻፍ ችሊሇሁ)

3. የመጀመሪያ ዯረጃ ት/ት (1-8)

4. የሁሇተኛ ዯረጃ ት/ት (9-12)

5. የኮላጅ ዱፐልማና ከዛ በሊይ

106 የባሇቤትዎ የትምህርት ዯረጃ ? 1. አሌተማረም(ማንበብና መጻፍ አይችሌም) SDV06

2. ተምሯሌ (ማንበብና መጻፍ ይችሊሌ)

3. የመጀመሪያ ዯረጃ ት/ት (1-8)

4. የሁሇተኛ ዯረጃ ት/ት (9-12)

5. የኮላጅ ዱፐልማና ከዛ በሊይ

107 የስራ ሁኔታ ? 7. የመንግስት ስራ SDV07

8. የቀን ስራ

9. የቤት እመቤት

10. ነጋዳ

11. ተማሪ

12. ላሊ ከሆነ ይጥቀሱ____________

108 የቤተሰብ ብዛት በዴምሩ_________________ SDV08

109 የመኖሪያ ስፍራ 1. ገጠር SDV09

175
 2. ከተማ

110 የቤተሰባችሁ ምጣኔ ሀብት ________________ብር በወር SDV10

(የቤተሰቡ ወርሀዊ ገቢ)

ከየትኛዉም ምንጭ ምን ክሌ ገቢ

በወር ያገኛለ ?

111 ራዱዮ አልት 1. አዎ 0. የሇም SDV11

112 ቴሇቪዥን አልት 1. አዎ 0. የሇም SDV12

113 ሞባይሌ ስሌክ አልት 1. አዎ 0. የሇም SDV13

114 የባሇቤትዎ ስራ ምንዴን ነዉ ? 1. የመንግስት ስራ SDV14

2. የቀን ስራ

3. የቤት እመቤት

4. ነጋዳ

5. ተማሪ

6. ላሊ ከሆነ ይጥቀሱ____________

ክፍሌ ሁሇት

ከስነተዋሌድ ጋር የተያያዙ መጠይቆች

201 ከዚህ ህጻን በፊት ላሊ ሌጅ 1. አዎ 0. የሇም OBF

አልት ከላሇ ወዯ 10ኛ ጥያቄ ይሇፉ 01

202 በመጀመሪያዉ የእርግዝናዎ ………..ዓመት OBF

ግዜ እዴሜዎ ስንት ነበር አሊስታዉስም /ዯከ….99/ 02

176
203 አሁን በመጨረሻ የወሇደት 1. አንዯኛ OBF

ስንተኛ ሌጅ ነዉ 2. ሁሇተኛ 03

3. ሶስተኛ

4. አራተኛ

204 በህይወት ያለ ስንት ሌጆች 1. በህይወት ያለ........ OBF

አልት 2. በህይወት የላለ 04

3. ሰይወሇደ በእርግዝና የተጨናገፉ

4. ምሊሥ አሌተሰጠም /ዯከ .../

205 ማሶረዴ አጋጥሞት ያዉቃሌ 1. አዎ 0. አይ OBF

05

206 ሇ205 አዎን ከሆነ፡ ሇምን 1. ............ 0. መሌስ የሇም OBF

ያክሌ ግዜ 06

207 በህይወት የላሇ ሌጅ 1. አዎ 0. አይ OBF

ወሌዯዉ ያዉቃለ 07

208 207፣ አዎን ከሆነ ሇምን 1………… OBF

ያክሌ ግዜ 0…..አሊስታዉስም (ዯከ…99) 08

209 አሁን ያለ የሌጆችዎ ጾታ ሴት………. OBF

ምን ምን ያካተተ ነዉ ወንዴ ……….. በዴምሩ………… 09

210 የመጨረሻ እርግዝናዎ 1. የታቀዯ OBF

ሁኔታ እንዳት ነበር 2. ያሌታቀዯ 10

211 ላሊ ተጨማሪ ሌጅ መዉሇዴ 1. አዎ 0. አይ OBF

ይፈሌጋለ 11

212 211፣ አዎ ከሆነ፡ ስንት ሌጅ ሴት………. OBF

177
 ይፈሌጋለ ወንዴ ……….. በዴምሩ………… 12

213 ሌጅ መዉሇዴን በተመሇከተ 4. ሚስት OBF

ዉሳኔ የሚያስተሊሌፈዉ 5. ባሌ 13

ማነዉ 6. የጋራ ዉይይት ነዉ

214 ከመሇዴዎ በፊት 1. አዎ 0. አይ OBF

(በእርግዝናዎ ወቀት) ወይም 14

ከመዉሇዴዎ በኋሊ

ያጋጠሞት የጤና መታወክ

እክሌ ነበር

215 ሇ214 አዎን ከሆነ፡ ምን 1. አዎ 0. አይ OBF

አይነት የጤና መታወክ ነበር 1. የዯም ብዛት .... ....... 15

ያጋጠሞት 2. ከባዴ የዯም መፍሰስ ..... .....

3. የዯበዘዘ እይታ ........ ......

4. .ከበዴ ያሇ ትኩሳት ..... .....

5. ሇረጅም ግዜ በብሌትዎ ፈሳሽ መፍሰስ

...... .....

6. ራስን መሳት ......... ......

7. ከባዴ ራስ ምታት

8. ሽንት በመሽናት ግዜ ህመም .... ....

9. የዴካም ስሜት .......... ......

10. የመተንፈስ ችግር ........ ......

11. ከባዴ የአንጀት ህመም ..... .......

178
 12. የወባ በሽታ ....... .....

13. ላሊ ካሇ ይጥቀሱ ...........

216 ሌጅዎን የወሇደበት ሁናቴ 1. በተፈጥሮዊ አወሊሇዴ OBF

ምን አይነት ነበር 2. በቀድ ጥገና /ኦፐሬሽን/ 16

3. ላሊ ካሇ ይጥቀሱ ............

217 ምን ያህሌ ግዜዎ ነበር …………. ሳምንት ………. ወር OBF

ሲዎሌደ /የስንት ወር ……………. አሊስታዉስም 17

እርጉዝ ነበሩ ሲወሌደ/

ክፍሌ ሶስት ከህጻናት ጋር የተያያዙ ጉዲዮች

301 የሌጅዎ ጾታ ምንዴ ነዉ 1. ወንዴ 2. ሴት PD 01

302 እርስ የሚሹት የሌጆ ጾታ 1. ወንዴ 2. ሴት PD 02

ምንዴነዉ 3 አሌተጠቀሰም

303 ሌጅዎ በተወሇዯበት/ችበት ወቅት ……………ኪ.ግ PD 03

ክብዯቱ/ቷ ምን ያህሌ ነበር 99. አሊዉቅም

304 ሌጅዎ እንዯተወሇዯ ምን 1. ጡት መጥባት PD 04

መጥባት ጀመረ/ች 2. ጡጦ መጥባት

3. ላሊ ካሇ ይጥቀሱ .........

305 የመጀመሪያዉ መሌሳቸዉ ከሆነ፡ 1. አዎ 0. አይ PD 05

ስዴስት ወር በሙለ ጡት ብቻ

179
 አጠቡት

306 ሌጆን በመመገብ ወቅት አስቸጋሪ 1. አዎ 0. አይ PD 06

ነገር ነበር

307 ሌጅዎ የመተኛት ችግር 1. አዎ 0. አይ PD 07

አሇባት/በት

308 ህጻንዋ/ኑ የታመመበት ወቅት 1. አዎ 0. አይ PD 08

ነበር

309 ከዚህ በፊት ከአንዴ አመት 1. አዎ 0. አይ PD 09

በታች የሆነ ሌጅ አርፎብዎት

ያዉቃሌ

ክፍሌ 4፡ የእናቶች በዴባቴ/መጫጫን/ ሊይ ያሇቸዉ እዉቀት

K 401 ስሇ ዴባቴ ሰምተዉ ያዉቃለ 0. አዎ MK01

1. አይ

2. መሌስ የሇም

3. አሊስታዉስም

K 402 ሰምተዉ ከነበረ የመረጃ ከምን ምንጩ 1. ከጤና ባሇሙያ MK02

አገኙት 2. ራዮ

3. ጋዜጣ

4. ቲቪ

5. ከጉዋዯኛ ና ቤተሰብ

6. ላሊ ካሇ ይጥቀሱ ........

180
K 403 ምን አይነት መረጃ ነበሮት በተሇይ አዎ 0. አይ____ MK

በሚሰማዎት ስሜት ሊይ ____

1. የእንቅሌፍ መብዛት/መዛባት ____ ____

2. ፍርሃት ____ ____

3. ንዳት ____ ____

4. ዯስታ ማጣት/ክብዴ ማሇት ____ ____

5. እንባ መተናነቅ/ ሆዯ ባሻነት ____ ____

ክፍሌ 5 የኦስል 3-አይተም ሶሻሌ ሰፖርት እስኬሌ

የሚከተለት 3 ጥያቄዎች ዯግሞ ከቤተሰብዎም ሆነ ከጎሮቤትዎ ጋር ያሇዎትን ማህበራዊ

ግንኙነት በተመሇከተ ይሆናሌ፡፡ እባክዎ ሇጥያቄዎቹ ከተሰጡት ምርጫዎች የእርስዎን

ማህበራዊ ሁኔታ የሚመሇከተውን ይምረጡ፡፡

በህይወትዎ ዉስጥ የቅርብ የሆኑ፤ [1] ማንም [2] 1 ወይም 2 OSS1

501 ችግርዎትንና ዯስታዎትን የሚካፈለ [3] ከ 3-5 [4] ከ5 በሊይ

ስንት ሰዎች አለ;

181
 ላልች ሰዎች እርስዎ [5] በጣም ይጨነቁሌኛሌ /ያስቡሌኛሌ OSS2

502 በሚያዯርጓቸው ነገሮች ሊይ ምን ያህሌ [4] በመጠኑ ይጨነቁሌኛሌ/ያስቡሌኛሌ

የሚጨነቁሌዎትና የሚያስቡሌዎት [3] እርግጠኛ መሆን አሌችሌም

ይመስሌዎታሌ; [2] ብዙም አያስቡሌኝም

[1] ጨርሶ አያስቡሌኝም

ከጎረቤትዎ እርዲታ ባስፈሇገዎ ጊዜ [5] በጣም ቀሊሌ OSS3

503 እገዛ ማግኘት ምን ያህሌ ቀሊሌ ነው? [4] ቀሊሌ

[3] ቀሊሌ ባይሆንም ርዲታ ማግኘት

እችሊሇሁ

[2] ከባዴ ነው

[1] በጣም ከባዴ ነው

ክፍሌ 6 የቤተሰብ ጤና ሁናቴን በተመሇከተ

አሁን ስሇ እርስዎ ቤተሰብ የጤና ሁናቴን በተመሇከተ እጠይቆታሇሁ

601 በዚህ አመት ዉስጥ ከእርስዎ ቤተሰብ 1. አዎ 0. አይ FH01

በሞት የተሇየ ይኖር ይሆን?

602 ከቤተሰብዎ አባሌ የታመመ አሇን? 1. አዎ 0. አይ FH 02

603 በቤተሰብዎ ታሪክ ዉስጥ የአዕምሮ 1. አዎ 0. አይ FH 03

ህመምትኛ ነበርን/አሇን?

ክፍሌ 7፡ ስሇማህበራዊ ግንኙነት

በትዲር ምንም ያህሌ መዋዯዴ/መፋቀር ቢኖርም አሌፎ አሌፎ ግን አሇመግባባት

ሉከሰት ይችሊሌ፡፡ ስሇሆነም እርስዎ ከባሇቤትዎ ጋር ባሌተስማሙ ጊዜ

የሚሰማዎትን ስሜት ከዚህ በታች እጠይቅዎታሇሁ፡፡

182
701 ከባሇቤትዎ ጋር ባሌተስማሙ ጊዜ [0] ምንም ችግር የሇም DV1

ችግሩን ሇመፍታት ምን ያህሌ [1] የተወሰነ ችግር አሇ

ያስቸግርዎታሌ? [0] ምንም ችግር [2] በጣም

የሇም [1] የተወሰነ ችግር አሇ

[2] በጣም

702 በአጠቃሊይ ከባሇቤትዎ ጋር [0] ምንም አያስጨንቅም DV2

ያሇዎት ቤተሰባዊ/ማህበራዊ/ [1] የተወሰነ ያስጨንቃሌ

ግንኙነት መሻከር እርስዎን ምን [2] በጣም ያስጨንቃሌ

ያህሌ ያስጨንቅዎታሌ?

703 ባሇቤትዎ ሇእርስዎና ሇሌጆችዎ [0] ሁሌጊዜ ጥሩ ነው DV3

የሚያዯርጉትን እንክብካቤ እንዳት [1] ብዙ ጊዜ ጥሩ ነው

ይገሌጹታሌ? [2] ጥሩ ወይም መጥፎ የሚባሌ አይዯሇም

[3] ብዙ ጊዜ ጥሩ አይዯሇም

[4] በፍጹም ጥሩ አይዯሇም

704 አሁን ከባሇቤትዎ ጋር ባሇዎት [0] ሁሌጊዜ ከሥጋት ነፃ ነኝ DV4

ቤተሰባዊ/ማህበራዊ/ ግንኙነት [1] ብዙ ጊዜ ከሥጋት ነፃ ነኝ

ምን ያህሌ ሥጋት ይሰማዎታሌ? [2] አስጊ ነው ወይም አይዯሇም ሇማሇት

ያስቸግራሌ

[3] ብዙ ጊዜ የሰጋኛሌ

[4] ሁሌጊዜ ያሰጋኛሌ

183
705 ከባሇቤትዎ ወይም ላልች [0] ሁሌጊዜ ከሥጋት ነፃ ነኝ DV5

የቤተሰብ አባሊት ጋር ያሇዎት [1] ብዙ ጊዜ ከሥጋት ነፃ ነኝ

ማህበራዊ ግንኙነት ምን ያህሌ [2] አስጊ ነው ወይም አይዯሇም ሇማሇት

ያሰጋዎታሌ? ያስቸግራሌ [3] ብዙ ጊዜ የሰጋኛሌ

[4] ሁሌጊዜ ያሰጋኛሌ

ክፍሌ ስምንት ፡ PHQ-9 የዴባቴ መሇኪያ

መመሪያ፡ የሚከተለት ዓረፍተ-ነገሮች እርስዎ ባሇፉት ሁሇት ሳምንታት ዉስጥ የተሰማዎን

ስሜት የሚዲስሱ ሲሆን በሰንጠረዡ የተቀመጡትን ዓረፍተነገሮች መሰረት በማዴረግ የእኔን

ስሜት ይገሌፃሌ ብሇው የሚያምኑትን ዓረፍተነገር ስር በሚገኙው ቁጥር ሊይ የ "X"

ምሌክትን ያስቀምጡ፡፡

Variable
Code Question Response
s

801 ባሇፉት ሁሇት ሳምንታት ውስጥ 0. በፍፁም 2. ከ7ቀናትበሊይ PHQ901

የእሇት ተእሇት ተግባርዎን

ሇማከናወን (ሇመስራት) ያሇዎት 1. ከ7ቀናትያነሰ 3. ከሞሊጎዯሌ በየቀኑ

ተነሳሽነት ሇምን ያህሌ ቀን ቀንሶ

ነበር

802 ባሇፉት ሁሇት ሳምንታት ውስጥ 0. በፍፁም 2. ከ7ቀናትበሊይ PHQ902

የመከፋት፣ የመዯበት ወይም ተስፋ

የመቁረጥ ስሜት ሇምን ያህሌ ቀን 1. ከ7ቀናትያነሰ 3. ከሞሊጎዯሌ በየቀኑ

ይሰማዎ ነበር;

184
 Variable
Code Question Response
s

803 ባሇፉት ሁሇት ሳምንታት ውስጥ 0, በፍፁም 2. ከ7ቀናትበሊይ PHQ903

ሇምን ያህሌ ቀን እንቅሌፍ

አሌወስዴዎ ብል ወይም በዯንብ 1, ከ7ቀናትያነሰ 3. ከሞሊጎዯሌ በየቀኑ

መተኛት አቅቶዎት ወይም

እንቅሌፍ እየበዛብዎት ይቸገሩ

ነበር;

804 ባሇፉትሁሇትሳምንታትውስጥ 0, ፍፁም 2. ከ7ቀናትበሊይ PHQ904

ሇምን ያህሌ ቀን የዴካም ወይም

805 የአቅም ማነስ ሳምንታት

ባሇፉትሁሇት ስሜት ይሰማዎት
ውስጥ 1, በፍፁም
0, ከ7ቀናትያነሰ 3.2.ከሞሊጎዯሌ በየቀኑ
ከ7ቀናትበሊይ PHQ905

ነበር; ያህሌ ቀን የምግ ብፍሊጎትዎ

ሇምን

ከተሇመዯዉ በሊይ ጨምሮ ወይም 1, ከ7ቀናትያነሰ 3. ከሞሊጎዯሌ በየቀኑ

ቀንሶብዎት ነበር;

806 ባሇፉት ሁሇት ሳምንታት ውስጥ 0, በፍፁም 2. ከ7ቀናትበሊይ PHQ906

ሇምን ያህሌ ቀንራስዎን የመጥሊት

ወይም ዋጋየሇኝም 1, ከ7ቀናትያነሰ 3. ከሞሊጎዯሌ በየቀኑ

የማሇትወይምራሴንም ሆነ

ቤተሰቤን አሳዝኛሇሁ/አሳፍሬያሇሁ/

የሚሌስሜት ተሰምቶዎት ነበር;

807 ባሇፉት ሁሇት ሳምንታት ውስጥ 0, በፍፁም 2. ከ7ቀናትበሊይ PHQ907

ሇምን ያህሌ ቀን በሚሰሩት ስራሊይ

1, ከ7ቀናትያነሰ 3. ከሞሊጎዯሌ በየቀኑ
ሃሳብዎን

መሰብሰብ/ሌብየማሇትችግር

(ሇምሳላ፡ከሰዎች ጋር ሲጨዋወቱ 185

ትኩረት ሰጥቶ ማዲመጥ)

አስቸግሮዎት ነበር;
 Variable
Code Question Response
s

808 ባሇፉት ሁሇት ሳምንታት ውስጥ 0, በፍፁም 2. ከ7ቀናትበሊይ PHQ908

ሇምን ያህሌ ቀን ሇላልች ሰዎች

እስከሚታወቅ ዴረስ በእንቅስቃሴዎ 1, ከ7ቀናትያነሰ 3. ከሞሊጎዯሌ በየቀኑ

ወይም በንግግርዎ በጣም ቀስ

ብሇዉ ወይም በተቃራኒዉ

809 ባሇፉትሁሇትሳምንታትውስጥ
መረጋጋት አቅቶዎት፣አንዴ ቦታ 0, በፍፁም 2. ከ7ቀናትበሊይ PHQ909

ብሞት ይሻሊሌ ብሇዉ

አርፎ መቀመጥ ወይምአስበዉ
መቆም

ወይም ራስዎንሆነዉ
እስከማይችለ በሆነ ነበር;
መንገዴ 1, ከ7ቀናትያነሰ 3. ከሞሊጎዯሌ በየቀኑ

ሉጎደ አስበዉ ነበር;

ክፍሌ ዘጠኝ፡ ስሇ አሌኮሌ መጠጦች

በዚህ መጠይቅ ዉስጥ የተጠቀሱትን አይነት ነገሮችከተጠቀሙ ይነግሩናሌ

901 በእርግዝናዎ ወቅት ወይም ከወሇደ 1, አዎ 0. አይ HSU01

በኋሊ መጠጥ ወይም እንዯጫትና ሲጋራ

ይጠቀሙ ነበር ወይ ?

902 አዎን ካለ ከተጠቀሱት ዉስጥ የትኛዉን 1. ሲጋራ HSU02

አይነት ይጠቀሙ ነበር ? 2. ጫት

3. የአሌኮሌ መጠጥ

4. ላሊ ካሇ ይጥቀሱ

903 ባሇቤትዎ ከሊይ የተጠቀሱትን 1, አዎ 0. አይ HSU03

ይጠቀማለ?

186
904 አዎን ካለ ከተጠቀሱት ዉስጥ የትኛዉን 1. ሲጋራ HSU04

አይነት ይጠቀሙ ነበር ? 2. ጫት

3. የአሌኮሌ መጠጥ

4. ላሊ ካሇ ይጥቀሱ

ክፍሌ 10፡ የእናቶች የወሉዴ ሁናቴን በተመሇከተ

አሁን ዯግሞ የእርስዎን የወሉዴ ሁናቴን በተመሇከተ እጠይቆታሇሁ

Variable
Code Question Response
s

በወሉዴ ሰዓት 5. ነርስ/ ሚዴዋይፍ/ ድክተር/ ና መኮንን LDE01

1001 ያዋሇዴዎት ማን ነበር ? 6. ላሊ ካሇ ይጥቀሱ ......................

7. አሊዉቅም

1002 አወሊሇዴዎ እንዳት 4. በተፈጥሮ የአወሊሇዴ ስርዓት LDE02

ነበር? 5. በዴንገተኛ የቀድ ህክምና

6. አስቀዴሞ ቀጠሮ በተያዘሇት ቀድ

ህክምና

1003 ከወሇደ በኋሊ በህክምና _________ ሰዓት/.............ቀን LDE03

ማዕከለ ሇምን ያህሌ 99) አሊስታዉስም

ግዜ/ሰዓት ቆዩ?

187
 Variable
Code Question Response
s

1004 የህክምና አገሌግልት LDE04

1, አዎ
ጨርሰዉ ሲወጡ ዯስተኛ
0, አይ ዯስተኛ አሌነበርኩም
ነበሩ?
ላሊ ካሇ ይጥቀሱ …………………..

የቃሇ መጠይቅ መመሪያ ሇዕናቶች

ስፍራ: ________________ ቀን:

________________

የተጀመረበት ግዜ: __________________ የተጠናቀቀብ ግዜ:

________________

የተሳታፊዋ ኮዴ: _________________

የቃሇ-መጠይቅ ጠያቂዉ መተዋወቅና ስሇ መጠይቁ በቂ ማብራሪያ ስሇ መስጠት

 ቃሇ መጠይቅ ጠያቂዉ ራሱን ያስተዋዉቃሌ

 የመጠይቁን አሊማ በሚገባ ያብራራሌ

 መቅረጸ-ዴምጽ እንዯሚተቀም እና በተሳታፊዎች የሚነሱ ምሊሾችም ሆነ

ማብራሪያዎች ሚስጥራዊ ይሆናለ፤ ትክክሌና ስህተት መሌስ አይኖርም

፣ ሀቀና ምሊሾች ግን ይበረታታለ፡፡

III. እናቶች ዴባቴንና እንዳት ይቀበለታሌ

188
  ከወሉዴ በኋሊ ስሊሇ ዴባቴ ሰምተዉ ያዉቃለ ?

 ከወሉዴ በኋሊ ያሇን ዴባቴ እንዳት ያዩታሌ?

አሁን ዯግሞ በዴባቴ ዙሪያ ስሊልት ሌምዴ እንነጋገር

 የመዯባበት ስሜት ሇመጀመሪያ ጊዜ የተሰማዎት መቼ ነበር ?

 ምን አይነት ሀሳብና ስሜት ነበር የሚሰማዎት ?

 ከነዚህ ምሌክቶችን እንዳት ተቋቋሙት?

ማጣሪያ፡ ተሳታፊዎች ከመዯባበት ሌምዲቸዉ ጋር የተያያዘ ማንኛዉም

ስሜትና ሁናቴቸዉን እንዱያወሩ በዯንብ ይበረታታለ

IV. ማጠቃሇያ

ከተነጋገርነዉ ሀሳብ ጋር በተያያዘ ሉጨምሩ፣ ሉብራሩ የሚፈሌጉት ነገር አሇ

ሇመግሇጽ ነጻ ይሁኑ

ስሇጊዜዎ እና ስሊዯረጉት አስተዋጽኦ እናመሰግናሇን፡፡

የቃሇ መጠይቅ መመሪያ ጤና ባሇሙያዎች

ስፍራ: ________________ ቀን:

________________

የተጀመረበት ግዜ: __________________ የተጠናቀቀብ ግዜ:

________________

የተሳታፊዋ ኮዴ: _________________

189
የቃሇ-መጠይቅ ጠያቂዉ መተዋወቅና ስሇ መጠይቁ በቂ ማብራሪያ ስሇ መስጠት

 ቃሇ መጠይቅ ጠያቂዉ ራሱን ያስተዋዉቃሌ

 የመጠይቁን አሊማ በሚገባ ያብራራሌ

 መቅረጸ-ዴምጽ እንዯሚተቀም እና በተሳታፊዎች የሚነሱ ምሊሾችም ሆነ

ማብራሪያዎች ሚስጥራዊ ይሆናለ፤ ትክክሌና ስህተት መሌስ አይኖርም

፣ ሀቀና ምሊሾች ግን ይበረታታለ፡፡

ዴባቴን በተመሇከተ እንዯጤና ባሇሙያነቶ የእርስዎን አመሇካከት ሇመረዲት

ወዯተዘጋጀዉ መጤቅ ሌዉሰዴዎ

 ከወሉዴ በኋሊ የሚከሰትን ዴባቴ እንዳት ያዩታሌ/ ይቀበለታሌ ?

 ላልች ከወሉዴ በሐዋሊ የሚዯረጉ ክብካቤ ጎን ሇጎን እናቶችን ስሇ ዴባቴ

ይነግሯቸዋሌ ወይ? በምን መሌኩ?

 እናቶች ከወሉዴ በኋሊ ስሇመዯባበት ስሜታቸዉ ይነግሯችኋሌ ወይ?

እንዳት/ በምን መሌኩ?

 አንዲንዴ ጥናቶች የጤና ባሇሙያዎች/አዋሊጆች/ የዴባቴ እዉቀት ሇዴባቴ

የራሱ አስተዋጽኦ አሇዉ ይሊለ ፤ ስሇዚህ አመሇካከት እርስዎ ምን ይሊለ ?

 የአዋሊጆች/የጤና ባሇሙያዎች የዴባቴ እዉቀት ፣ በዴባቴ ሊይ ተጽዕኖ

ያሳዴራሌ ብሇዉ ያስባለ ? እንዳት?

190
ማጠቃሇያ

ከተነጋገርነዉ ሀሳብ ጋር በተያያዘ ሉጨምሩ፣ ሉብራሩ የሚፈሌጉት ነገር ካሇ

ሇመግሇጽ ነጻ ይሁኑ

ስሇጊዜዎና ስሊዯረጉት አስተዋጽኦ እናመሰግናሇን፡፡

Assurance of principal investigator

I, undersigned here agrees to accept responsibility for scientific ethical

and technical conduct of the research project and for provision of

required progress reports as per terms and the condition of the AAU

SSW PG Program in effect at the time of the grant is forwarded as the

result of this application.

191
Principal investigator: Asnake Tesfaye Date._________

Signature ______________

Afan Oromo Version Questineer

Waraqaa Odeeffannoo

Seensa: Ani maqaan kiyya armaan gaditti kan ibsame, Yuunvaristii Finfinneetti, Koolleejjii

Saayinsii Hawaasaatti, barataa Barnoota Sooshaal Woorkii, yommuun ta‘u, mata-duree

“Postpartum Depressions among Mothers who gave birth and attended public health

facilities of EastShewa Zone, Ethiopia‖ jedhu irratti bara 2011 qorannoo adeemsisuufan jira.

192
Qorannoo kanaaf, akka hirmaataatti kan filatamtu yommuu ta‘u, heeyyama yookaan

waliigaltee kee argachuun dura odeeffannoowwan qorannicha ilaalchisan hunda beekuu

qabda. Kanaafuu, odeeffannoon kun haala armaan gadiitiin bal‘inaan dhiyaateera:

 Kaayyoo: Hanga miira nuffii da‘iinsaan boodaa murteessuu fi dhimmoota isa wajjin

walqabatan dubartoota da‘an gidduutti jiran qorachuuf, akkasumas ilaalcha deessistoonni

miira nuffii dubartoota da‘an irratti jiruu kan Hospitaalotaa fi Buufatoota Fayyaa Shawaa

Bahaa keessatti argamanii, Itiyoophiyaa, bara 2012 qorachuu irratti kan xiyyeeffate dha.

 Barbaachisummaa qorannichaa: Dhiibbaawwan miira nuffii da‘iinsaan boodaa

haadholii irratti jiru, walitti-dhufeenya gaa‘ela isaanii keessaa, fi daa‘imman isaanii haala

qorachuu fi furmaata barbaaduuf barbaachisaa ta‘e dha. Qorannoon kun argannoowwan

ifa gochuun hubannoo hawaasaa cimsuuf fayyada. Kana malees, qorannoon ammaa kun

joornaalota beekkammoo ta‘an irratti maxxansamee gareewwan qorannoo garabiraa fi

hawaasa akkaadaamiitti kan tamsaasamu ta‘a. Akkasumas, qabeen odeeffannoo ykn

daataa-beeziin qorannoo kanaan akka maddu taasisamu qorannoo fi xiinxallii

gadifageenya qabuuf tajaajilamtoota garabiraatiif akka dhiyaatu ni taasisama.

 Toftaalee: Qorannoon hunda-galeessaa (cross-sectional) faasiliitii-bu‘uureffate

Adoolessa bara 2011 hanga Hagayyaatti haadholii 500 Godina Shawaa Bahaa,

itiyoophiyaa keessatti da‘an irratti ni gaggeessama.

 Sagantaa Hojii: Qorannoon kun hanga Guraandhala bara 2012 tti kan xumuuramu ta‘a.

 Hirmaattota qorannicha keessatti hammataman: Dhaabbilee eegumsa fayyaa Godina

Shawaa Bahaa keessatti dubartoota waggaa tokko darbe keessatti da‘an keessaa

carraadhaan (randomely) ni filatamu.

 Icciitii: Odeeffannoon ati kennitu hunduu icciitiidhaan kan qabamanii fi qaamni sadaffaa

akka hin argine ni taasisama. Maqaan kee waraqaa gaaffii irratti hin barreessamu.

193
 Sodaawwanii fi Faayidaalee Qorannichaa

Sodaawwan: Qorannoon kun gaaffilee qophaa‘anii jiran isin gaafachuun kan

adeemsisamu ta‘a. Adeemsi qorannichaa dhiibbaa qaamaas ta‘ee dhiphina sammuu kan

uumu miti. Kana malees, gaaffii hin beekne irratti deebii akka kennitu dirqama hin qabdu.

Faayidaalee: Qorannoo kana keessatti hirmaachuu keetiif kaffaltiin siif kaffalamu

yookaan faayidaan addaa siif kennamu hin jiru. Haa ta‘u malee, qorannoo kana keessatti

hirmaachuun gaaffilee gaafatamtaniif deebii kennuun keessan sagantaalee

garafuulduraatti rakkoo nuffii da‘iinsaan booda haadholii irratti uumamu furuudhaaf

faayidaa cimaa ni qabaata.

 Waliigaltee: Qorannoo kana keessatti hirmaannaan keessan guutumaan-guutuutti fedhii

keessan irratti kan hundaa‘e dha. Jalqaba irraa kaasee yookaan yeroo kamiyyuu taanaan

qorannicha keessatti hirmaachuu dhiisuu ni dandeessa. Odeeffannoo hin beekneef akka

deebii kennitu dirqama hin qabdu.

 Maqaa barataa digirii 3ffaa (Ph.D) fi Gorsitootaa:

 Asnaaqaa Tasfaayee Guyyaa:___________ Mallattoo:__________

Moobaayila : +251911315444 Iimeelii: [email protected]

 Gorsaa Muummee Pirofeesar Maargaareet Aaddaamqee fi It/Aanaa Gorsaa

Dr. Yaaniyaa Sa‘iid Makiyyaa

Miiltoo II: Waraqaa Gaaffilee

Waraqaa Gaaffii Caaseffame: Afaan Oromoo

Yuunvaristii Finfinnee y

Koolleejjii Saayinsii Hawaasaa, Kutaa Barnootaa Sooshaal Woorkii

Waraqaa gaaffilee qorannoo mata-duree: ―Postpartum Depressions among mothers who gave

birth and attending public health facilities of EastShewa Zone, Ethiopia‖.

194
Unka Waliigaltee Hirmaattonni Qorannichaa Gaaffii-deebiin Dura Kennan

03. Maqaa Dhaabbata Eegumsa Fayyaa __________________________

04. Lakkoofsa Addaa Waraqaa Gaaffii___________________________

Seensa

Akkam bultan, Akkam ooltan (akka mijataa ta‘etti). Maqaan kiyya ____________________

jedhama. Ani ogummaadhaan Narsii/Deessistuu yommuun ta‘u, yeroo ammaatti haadholii

da‘anii fi gareen umurii isaanii (waggaa 15-49) ta‘an irraa odeeffannoo qorannoo miira nuffii

(Postpartum Depressions) haadholii da‘anii irratti uumamu ilaalchisee Godina Shawaa

Bahaatti Dhaabbilee Eegumsa Fayyaa keessatti tajaajila argachaa jiran irratti adeemsisamuuf

sassaabaan jira. Qorannicha kan adeemsisu ykn kan qorachaa jiru Asnaaqaa Tasfaayee nama

jedhamu yommuu ta‘u, Yuunvaristii Finfinneetti, Koolleejjii Saayinsii Hawaasaatti, barataa

Kutaa Barnootaa Sooshaal Woorkii (Social Work) dha. Qorannoo kana keessatti akka

hirmaattan carraadhaan filatamtaniittu. Qorannichi adeemsa gaaffii-deebiitiin kan

gaggeessamu ta‘a. Maqaan keessanii fi odeeffannoowwan eenyummaa keessan ibsan unka

sassaabbii odeeffannoo irratti hin galmeessamu; akkasumas, odeeffannoowwan isin naaf

kennitan icciitiidhaan kan qabamuu fi kaayyoo qorannoo kanaatiif qofaa tajaajilarra kan oolu

ta‘a. Maqaan hirmaattotaa hin barreessamu; kanaafuu, lakkoosfi koodii kan ibsamu ta‘a.

Argannoon qorannoo kanaa kan maxxansamu yoo ta‘e, odeeffannoon cuunfaa garee hundaa

gabaabaatti kan dhiyaatu ta‘a. Adeemsi gaaffii fi deebii kun yeroo daqiiqaa 30 kan fudhatu

yommuu ta‘u guutumaan-guutuutti fedhii irratti kan hundaa‘e waan ta‘eef, hirmaachuuf

yookaan hirmaachuu dhiisuuf, akkasumas yeroo kamiyyuu hirmaannaa keessan addaan

kutuuf mirga ni qabdu. Odeeffannoo gaafatamtan ilaalchisee yoo walii hin galiin rakkoon isin

mudatu hin jiru. Qorannoo kana keessatti hirmaachuun keessan dhimmootaa fi rakkoolee

miira nuffii da‘iinsaan boodaa (PPD) dubartoota Godina Shawaa Bahaa hubachuuf faayidaa

195
qaba. Qorannoo kana ilaalchisee gaaffii kamiyyuu yoo qabaatan ana gaafachuu yookaan

qorattoota muummee Asnaaqaa Tasfaayee (Moobaayila : +251911315444 Iimeelii:

[email protected]) gaafachuu ni dandeessu.

 Qorannoo kana keessatti hirmaachuuf fedhii qabdaa?

2. Eeyyee 2. Lakki

 Adeemsisaa gaaffii fi deebii hirmaatichi waliigaluu isaa afaan ibsachuu isaa mirkaneesse

Maqaa ______________ Mallattoo_____________ Guyyaa__________________

Argannoo: A) Guutummaan sassaabameera B) Ni dide C) Hanga tokkoon xumuurameera

D) Kan biraa (maaloo, ibsi)

 Kan qorate:

Maqaa ______________ Mallattoo_____________ Guyyaa__________________

Waraqaa Gaaffilee qorannoo mata-duree: “Postpartum Depressions among Mothers who

gave birth and attended public health facilities of EastShewa Zone, Ethiopia” jedhu.

Amma, gaaffilee murtaa‘an dhuunfaan isinii fi maatii keessan ilaallatan gaafachuun jalqaba:

KUTA –I DHIMMA HAAWAASUMMAA /Oddefannoo Dhunffa/

Code Gaafii Deebii Variables

101 Umuriin keessan meeqaa ? _________ SDV 01

waggaadhaan guutaa

102 Saba 9. Oromoo SDV 02

10. Amaaraa

11. Guraage

12. Kan bira ibsaa______

196
 _____________

103 Amantaa 1. Muslima SDV 03

2. Ortoodoksii

3. Pirootestaantii

4. Kan biro ibsaa________

104 Sadarkaa gaa‘ilaa keessan 1. kan hin heerumne SDV 04

maala fakkaataa? 2. kan herumtee

3. kan hiikte

4. kan jalaa du‘e

5. kan waliin jiraatu otto wal hin

fudhiin

105 Sadarkaa barumsaa 1. Sadarkaa 1ffaa (kutaa1-8) SDV 05

2. Sadarkaa 2ffaa (kutaa 9-12)

3. Diploma ykn barumsa levelii

4. Digiriii 5. Digirii 2ffaa fi isa oli

106 Sadarkaa barumsaa abba mana 1. Sadarkaa 1ffaa (kutaa1-8) SDV 06

2. Sadarkaa 2ffaa (kutaa 9-12)

3. Diploma ykn barumsa levelii

4. Digiriii 5. Digirii 2ffaa fi isa oli

107 Gosa hojii keessan kan ammaa 13. Hoji Mottumma SDV 07

hojjeechaa jirtan maalii ? 14. Hoji dhunfa

15. Hadha mana

16. Daldala

17. Barattuu

Kan bira ibsaa______

197
 108 Gosa hojii abbaa mana keessan 1. Hoji Mottumma SDV 08

kan ammaa hojjeechaa jirtu 2. Hoji dhunfa

maalii ? 3. Hadha mana

4. Daldala

5. Barattuu

Kan bira ibsaa______ ___________

109 Nama meeqatu mana keessan _________________ SDV 09

keessa jiraata lakkoofsan guutaa

(Baayina maatii)

110 Jireenga kessanni Essa dha? 1. Badiya SDV 10

2. Meggala

111 Miindan ji‘aan argachaa jirtan ________________ SDV 11

meeqa qarshiidhaan guutaa?

112 Radiyooni qabda? 1. Eeyye 2. lakki SDV 12

113 Televisionni qabda? 1. Eeyye 2. lakki SDV 113

114 Mobayyillii Qabda 1. Eeyye 2. lakki SDV 114

KUTAA 2: DHIMMOOTA DA‟IINSA WAJJIN WALQABATAN

201 Daa‘ima kanaan dura ulfooftee 1. Eeyyee 0. Lakki OBF 01

turtee?
‗Lakki‘ yoo ta‘e gara G.210 tti

darbi

202 Yeroo jalqabaatiif yommuu ____________ waggaa … OBF 02

198
 ulfooftetti umuriin kee meeqa hin yaadadhu /DK..99/

ture? (umurii waggaadhaan)

203 Yeroo darbe kan deesse yeroo 1) 1ffaa 2). 2ffaa OBF 03

meeqaffaadhaafi 3). 3ffaa 4). Arfaffaa fi isaan oliif

204 Daa‘imman lubbuun jiran 1). Baay‘ina daa‘imman lubbuun jiranii :___ OBF 04

meeqa deesse? (lakkoofsaan 2) Baay‘ina daa‘imman du‘anii:________

ibsi) 3) Baay‘ina daa‘imman du‘anii dhalatanii:_

4) Deebii hin qabu /DK….99/

205 Rakkoon ulfi irraa bahuu si 1). Eeyyee 0). Lakki OBF 05

quunnamee beekaa?

206 Yeroo meeqa? (lakkoofsaan 1. __________ OBF 06

ibsi) 0. Deebii hin qabu/ hin beeku (DK)

207 Daa‘ima du‘e deessee beektaa? 1. Eeyyee 0. Lakki OBF 07

208 ‗Eeyyee‘ yoo ta‘e yeroo 1. __________ OBF 08

meeqaaf? Lakkoofsaan ibsi ) 0. Hin beeku (DK)

209 Saalli daa‘imman kee amma Dhiirri: ______ OBF 09

jiranii dhiiraa fi dhalaan meeqa? Dhalaan _______,

(lakkoofsaan ibsi) ida‘amaan_________

199
210 Haalli ulfaa kee yeroo darbee 1. Kan karoorsame OBF 10

akkam ture? 2.Kan hin karoorsamne

211 Daa‘imman dabalataan da‘uu ni 1. Eeyyee 0. Lakki? OBF 11

barbaaddaa?

212 Daa‘imman meeqa? Dhiira _____ OBF 12

(Lakkoofsaan ibsi) Dhalaa _____

Ida‘ama _____

213 Daa‘ima da‘uuf kan murteessu 1.Niitii OBF 13

eenyu dha? 2.Dhirsa

3. Waliin maryachuudhaan

214 Ulfa yeroo darbee ykn isa 1. Eeyyee OBF 14

xumuuraa keessatti rakkoon 0. Lakki

fayyummaa sirra gahe jiraa?

215 Deebiin kee G.214 dhaaf Lists 1. Yes 0. No OBF 15

‗Eeyyee‘ yoo ta‘e, rakkoo 1. Dhiibbaa dhiigaa .......... .......

fayyaa akkamiitu simudate? 2. Dhukkuba busaa ............ ........

3. Dhhigni hedduu dhiiguu ..... .........

4. sirriitti arguu dadhabuu, ....... ..........

13. ol-deebisa ......... .........

14. dhaqna-gubaa cimaa ......... ..........

15. waan dhangala’oo karaa qaama

walhormaataa bahuu .......... .........

200
 16. of-wallaaluu ........... ........

17. mata-dhukkubbii cimaa ta’e ...... ........

18. yeroo fincaan fincaa’uu

dhukkubbiin itti dhagahamuu ......... .........

19. baay’ee dadhabbiin itti

dhagahamuu, hafuura ............. .........

20. baafachuuf rakkachuu .............. ..........

21. dhukkuba garaa cimaa ta’e

dhukkuba busaan faalamuu ......... .........

22. kan biraa (adda baasi)….................

216 Yeroo darbe ykn yeroo 1. Haaluma baramaan ciniinsuudhaan OBF 16

xumuuraatiif yommuu deessu

2. Wal‘aansa baqaqsanii deessisuutiin
haala akkamiitiin deesse
3. Kan biraa (ibsi)

217 Yeroo darbe ykn yeroo 1) Daa‘ima lubbuun jiru OBF 17

xumuuraatiif yommuu deessu 2) Daa‘ima du‘e

eega deesseen booda maaltu 3) Lubbuun eega dhalatee booda

uumame? battalumatti du‘e

4). Kan biraa?

KUTAA 3: DHIMMOOTA KUNUUNSA DAA‟IMMANII

201
301 Saala daa‘ima ykn mucaa keetii: 1) Dhiira 2) Dhalaa PD 01

302 Saalli ati barbaaddu kan feetu 1) Dhiira PD 02

2) Dhalaa 3) Adda hin baasne

303 Mucaan kee yommuu dhalatu/ttu Giraama------ 99. Hin beeku PD 03

ulfaatinni qaamaa meeqa ture?

304 304. Daa‘imni kee aakuma 1) Harma hoosisuu PD 04

dhalateen nyaata maal

2) Aannan xuuxxoo hoosisuu
nyaachisuu jalqabde?
3) Kan biraa (adda baasii ibsi)----------

305 G304 dhaaf deebiin kee 1 yoo 1) Eeyyee 0) Lakki PD 05

ta‘e, ji‘a 6 guutuudhaaf nyaata

kana kennitee?

306 306. Daa‘ima kee akka nyaata 1) Eeyyee 0) Lakki PD 06

argatu gochuuf si rakkisee turee?

307 307. Idaa‘imni kee rafuudhaaf 1) Eeyyee 0) Lakki PD 07

rakkoon ni mudataan turee?

308 Daa‘imni kee eega dhalateen 1) Eeyyee 0) Lakki PD 08

booda dhukkubsatee turee?

309 Daa‘imni umurii waggaa 1) Eeyyee 0) Lakki PD 09

tokkoon gadii si jalaa du‘ee

beekaa?

202
 KUTAA 4: BEEKUMSA MIIRA NUFFII DA‟IINSAAN BOODAA (PPD)

K 401 Waa‘ee miira nuffii da‘iinsaan boodaa (PPD) 1) Eeyyee 2) Lakki MK01

kanaan dura dhageessee beektaa? 3) Deebiin hin jiru

0) Hin yaadadhu

K 402 Eeyyee yoo ta‘e, maddoonni odeeffannoo kee 1) Hojjetaa Fayyaa MK02

maal fa‘i? 2) Raadiyoo

3) Gaazexaa

4) TV 5)

Hiriyootaa fi maatiiwwan

6) Kan biraa adda baasi

K 403 Miira nuffii da‘iinsaan boodaa fi mallattoolee Eeyyee=1 Lakki=0 MK

isaa ilaalchisee odeeffannoo akkamii qabda? ____ ____

(kanneen tarreessaman dubbisuun mallattoo itti ____ ____

taasisi) Toftaa: ____ ____

Yeroo hedduu herribni qabachuu, ____ ____

sodaa, ____ ____

jeeqamuu miiraa, ____ ____

gadda, ____ ____

yaada ifaa qabaachuu dadhabuu fi boo‘uu. ____ ____

____ ____

KUTAA -7: ISKEELII DEEGGARSA HAWAASAA OSILOO-3

203
Code Questions Response Variables

Osiloo 1: Namoonni ati itti-dhiyeenya 1= hin jiru OSS1

501 cimaa waan qabduuf rakkoon dhuunfaa 2= 1–2

cimaa ta‘e yoo simudate gargaarsa naaf 3= 3–5

godhu jettee itti amantu meeqa dha? 4= 5+

Osiloo 2: Waan ati gootu ilaalchisee 1=hin jiru OSS2

502 namoonni xiyyeeffannaa kennan meeqa 2= xiqqoo

ta‘u? 3= meeqa akka ta‘an murteessuu

hin danda‘u

4=muraasa

5= hedduu

Osiloo 3: Deeggarsa yeroo barbaaddutti 1=vbaay‘ee ulfaataa OSS3

503 ollaa kee irraa deeggarsa qabatamaa ta‘e 2=ulfaataa dha

argachuuf hangam salphaa dha? 3=ni danda‘ama

4=salphaa dha

5=baay‘ee salphaa dha

204
KUTAA 6: Gaaffii Waayyee Maatii

601 Waggaa baranaa miseensi maatii sijalaa 1), Eeyyee (0) Lakki FH01

du‘e jiraa?

602 Yeroo ammaa miseensi maatii sijalaa 1), Eeyyee (0) FH 02

dhukkubsate jiraa? Lakki

603 Seenaa dhukkuba sammuu maatii keessatti 1), Eeyyee (0) FH 03

jiru? Lakki

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KUTAA 7: WALITTI-DHUFEENYA NAMOOTA GIDDUU

Dhirsii fi niitiin ykn abbaa manaa fi haadha manaa walitti-dhufeenya gaarii ta‘e yoo

qabaatanillee, yeroon walitti-bu‘iinsii fi waliigaltee dhabiinsi itti uumamus ni jiraata.

Abbaan manaa fi haati manaa namoota garabiraa wajjin sababoota garaagaraa irraa kan

ka‘e waliigaltee dhabuu ni danda‘u, yookaan sababa hojiilee garabiraatiin dadhabaniif

yookaan gammachuun waan itti hin dhagahamiiniif walitti bu‘iinsi uumamuu ni danda‘a.

Kana malees, barsiifata garaagara ta‘een rakkoolee isaanii hiikuuf yaaluu ni danda‘u.

Amma abbaa manaa kee wajin yommuu mormii qabaattu maal akka sitti dhagahamu si

gaafachuun barbaada.

701 Atii fi abbaan manaa kee waliigaltee dhabiinsi DV1

yommuu jiraatu akkamitti hiikuuf yaaltu? [0] Rakkoon hin jiru

*1+ Rakkoo murtaa’aa

[2] Rakkoo cimaa

702 Akka waliigalatti, walitti-dhufeenya keessan DV2

akkamitti ibsita? [0] Rakkoon hin jiru

[1] rakkoo muraasa

[2] rakkoolee hedduu

703 Abbaan manaa kee si’ii fi ijoollee keesssan [0] yeroo hunda gaarii dha DV3

haala gaariin isin kunuunsaa? beeku [1] yeroo hedduu gaarii dha

[2] giddu-galeessa

[3] yeroo hedduu gaarii miti

[4] gaarii ta’ee hin beeku

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704 Walitti-dhufeenya keessan yeroo ammaa [0] yeroo hunda nagaa dha DV4

ilaalchisee nageenyi sitti ni dhagahamaa? [1] yeroo hedduu nagaa dha

[2] giddu-galeessa

[3] yeroo hedduu nagaa miti

*4+ nagaa ta’ee hin beeku

705 Abbaa manaa kee yeroo ammaa, hiriyoota kee, [0] yeroo hunda nagaa dha DV5

yookaan abbaa manaa kee fi hiriyoota kee [1] yeroo hedduu nagaa dha

kanaan durii keessaa namni akka nageenyi sitti [2] giddu-galeessa

hin dhagahamne si taasisu ni jira? [3] yeroo hedduu nagaa miti

*4+ nagaa ta’ee hin beeku

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KUUTA 8: Gaaffiilee Waa‟ee PHQ-9 (Patient Health Questionnaire-9)

Variable
Code Question Response
s

801 Torbee lamaan kan keessatti yeroo ammamiif 0. Homtuu hinjiru EDPD01

rakkinoota armaan gaditti eeraman kun 1. Guyyaa xiqqoo

hammam isin mudaatee beeka. 2. Guyyaa baay‘ee

Hojii yeroo hojjetan fedha dhabdan ykn 3. Guyyaa hunda

fedhiin hojiidhaaf qabdan hir‘atee beekaa?

802 Torbee lamaan kan keessatti yeroo ammamiif 0. Homtuu hinjiru EDPD02

rakkinoota armaan gaditti eeraman kun 1. Guyyaa xiqqoo

hammam isin mudaatee beeka. 2. Guyyaa baay‘ee

Fedhii dhabuu, abdii utachuu akkasumaas 3. Guyyaa hunda

nama jibbisiisu/dukaakkiin isin qunamee

turee?

803 Torbee lamaan kan keessatti yeroo ammamiif 0. Homtuu hinjiru EDPD03

rakkinoota armaan gaditti eeraman kun 1. Guyyaa xiqqoo

hammam isin mudaatee beeka. 2. Guyyaa baay‘ee

Hiriba dhabuun jeeqamuu akkasumaas yeroo 3. Guyyaa hunda

baay‘ee rafuu isin qunamee beekaa?

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 Variable
Code Question Response
s

804 Torbee lamaan kan keessatti yeroo ammamiif 0. Homtuu hinjiru EDPD04

rakkinoota armaan gaditti eeraman kun 1. Guyyaa xiqqoo

hammam isin mudaatee beeka. 2. Guyyaa baay‘ee

Dadhabin namatti dhagahamuu akkasumaas 3. Guyyaa hunda

human dhabbuu isin qunamee beekaa?

805 Torbee lamaan kan keessatti yeroo ammamiif 0. Homtuu hinjiru EDPD05

rakkinoota armaan gaditti eeraman kun 1. Guyyaa xiqqoo

hammam isin mudaatee beeka. 2. Guyyaa baay‘ee

Fedhii nyaata dhabuu akkasumaas humna oli 3. Guyyaa hunda

nyaachuu isin qunamee beekaa?

806 Torbee lamaan kan keessatti yeroo ammamiif 0. Homtuu hinjiru EDPD06

rakkinoota armaan gaditti eeraman kun 1. Guyyaa xiqqoo

hammam isin mudaatee beeka. 2. Guyyaa baay‘ee

Waa‘ee ofitti gadduu akkasumaas maaltu na 3. Guyyaa hunda

dhiibdee namatti dhagahamuu , of gatuu,

kufatiin ofii namatti dhagahamuu

akkasumaas kufatiin maatii namatti

dhagahamuu isin qunamee beekaa?

807 Torbee lamaan kan keessatti yeroo ammamiif 0. Homtuu hinjiru EDPD07

rakkinoota armaan gaditti eeraman kun 1. Guyyaa xiqqoo

hammam isin mudaatee beeka. 2. Guyyaa baay‘ee

Yeroo ofii wanta tokko irratti xiyyeeffachuu 3. Guyyaa hunda

dhabuu akkasumas waa‘ee ofii fi maatii maal

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ta‘u jedhani xiyyeeffachuu dhabuu fkn

bareeffama adda addaa dubbisuu ,

 Variable
Code Question Response
s

808 Torbee lamaan kan keessatti yeroo ammamiif 0. Homtuu hinjiru EDPD08

rakkinoota armaan gaditti eeraman kun 1. Guyyaa xiqqoo

hammam isin mudaatee beeka. 2. Guyyaa baay‘ee

Suuta jedhanii deemu fi dubbachuu faallaa 3. Guyyaa hunda

kana

809 immmoo
Torbee asii fi kan
lamaan achiikeessatti
deemu hanga
yeroo namni
ammamiif 0. Homtuu hinjiru EDPD09

biraa nama armaan

rakkinoota irratti baruutti kan durakun
gaditti eeraman waliin 1. Guyyaa xiqqoo

wal bira qabamee

hammam yeroo beeka.
isin mudaatee ilaalmu isin 2. Guyyaa baay‘ee

Jiraachuu irra du‘a filaachuu fi karaa ta‘een

qunamee beekaa? 3. Guyyaa hunda
Ida‟ama
offi balleessuuf yaaduun isin qunamee

beekaa ?

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KUTAA 9: SEENAA WANTOOTA ARAADA NAMA QABSIISANITTI

FAYYADAMUU

Gaaffii kana keessatti, wantoota araada nama qabsiisan armaan gaditti ibsaman kan

fayyadamtu ta‘uu kee ilaalchisee odeeffannoo nuuf kennita.

901 Yeroo ulfaa yookaan eega deesseen 1. Eeyyee HSU01

booda wantoota araada nama 0. Lakki

qabsiisanitti fayyadamteettaa?

902 ‘Eeyyee’ yoo ta’e, maalitti 1. Tamboo/sijaaraa HSU02

fayyadamte? 2. Jimaa

3.Dhugaatii nama

maceessu

4. Kanneen biraa

903 Abbaan manaa kee wantoota armaan 1. Eeyyee HSU03

olitti ibsaman kanneenitti ni 0. Lakki

fayyadamaa?

904 Eeyyee’ yoo ta’e, maalitti 1. Tamboo/sijaaraa HSU04

fayyadama? 2. Jimaa

3.Dhugaatii nama

maceessu

4. Kanneen biraa

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KUTAA 10: Muuxannoo Dubartoonni Ciniinsuu fi Da‟iinsa Irratti Qaban

Amma gaaffilee haalota ciniinsuu fi da‘iinsaa ati yeroo darbe yeroo daa‘ima deessu ture

ilaalchisee jiran sin gaafadha.

Code Question Response Variables

1. Essaati deesse? (1). Manatti WLDE01

1001 (2). Wiirtuu eegumsa fayyaatti

(3). Gara hospitaalaa osoo deemaa jiruu

4) Kan biraa

8.

1002 Akkamitti deesse? 1) Haala baramaadhaan ciniinsuudhaan WLDE02

2) Wal‘aansa yeroo ariifachiisaatiin

3) Wal‘aansa baqaqsanii deessisuutiin

4)Wal‘aansa

1003 Eega deessiin booda _________ Sa‘aatii ___ WLDE03

yeroo hangamiitiif
99) Hin yaadadhu
wiirtuu eegumsa fayyaa

keessa turte?

1004 Yeroo wiirtuu eegumsa 1) Eeyye 2) Lakki- hin gammanne WLDE04

fayyaa keessaa baatu 3) Kan biraa, adda baasii ibsi……

gammachuun sitti

dhagahamee turee?

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 Qajeelcha Gaaffii fi Deebii Haadholii Miira Nuffii Da‟iinsaan Boodaa (PPD) Qaban

Wajjin

Teessoo: ________________ Guyyaa: ________________

Sa‘aatii mariin itti jalqabame: ________________________

Sa‘aatii mariin itti xumuurame: ________________

Koodii hirmaattuu: _________________

Haal-mijeessitootaa fi Adeemsa IDI wajjin walbarsiisuu:

 Haal-mijeessaan/ssituun mataa isaa fi nama yaadannoo qabu hirmaattotatti ni

beeksisa.

 Kaayyoo IDI ilaalchisee ibsa kennuu

 Akkaataa ittifayyadama teeppii waraabduu: wantoonni hirmaattonni dubbatan

hunduu icciitiidhaan kan qabaman ta‘u; Deebiin sirrii ta‘e yookaan dogoggora ta‘e

hin jiraatu; Deebiiwwan amanamummaadhaan deebisaman hedduu ni jajjabeessamu

1. Beekumsaa fi Amala Miira Nuffii Da‟iinsaan Boodaa (PPD) Irratti Jiru

a. Waa‘ee miira nuffii da‘iinsaan boodaa (PPD) dhageessee beektaa?

b. Beekumsa yookaan odeeffannoo qabdu kana eessaa argatte?

c. Rakkoo nuffii da‘iinsaan boodaa (PPD) irratti ilaalcha akkamii qabda?

2. Muuxannoo haadholii rakkoo miira nuffii da‟iinsaan boodaa qaban ilaalchisee

qabu

Amma, muuxannoo dhimma kana irratti ati qabdu ilaalchisee bal‘inaan haa maryannu

 Yeroo miirri nuffii sitti dhagahamuu jalqabe anatti himuu ni dandeessaa?

 Yaaddanii fi miiraawwan akkamiitu sitti dhufaa turan?

 Mallattoowwan kanneen haala akkamiitiin to‘achaa turte?

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  Gargaarsa argachuuf yaalii taasiste keessatti muuxannoon siquunname maali

(yaalii gooteetta yoo ta‘e)?

 Gargaarsa argachuu ilaalchisee haalli ture maal fakkaata?

Xiinxali: Hirmaattonni muuxannoo isaanii miira dhiphinaa ilaalchisee jiran ibsachuu yoo

barbaadan akka ibsatan ni jajjabeessamu.

3. Deeggarsa hawaasummaa?

a. Akka waliigalaatti, yeroo gammachuun sitti hin dhagahmne gorsa argachuudhaaf

eenyu bira deemta ykn eenyuun maryachiista?

b. Miira dhiphinaa fi gammachuu dhabuu ilaalchisee odeeffannoo argachuuf

eenyuun mariisista ykn eenyu bira deemta?

c. Jeeqamuu miirota keetii ilaalchisee deeggarsa argachuuf yookaan gorsa

argachuuf eenyu bira deemta ykn eenyuun mariisista?

d. Yeroo deeggarsa barbaaddutti namoonni si gargaaruu danda‘an ni jiru?

e. Rakkoon cimaan yoo si quunname namoonni gargaarsa naaf taasisu jettee itti

amantu meeqatu jiru?

f. Namoonni waa‘ee kee yookaan nageenya kee ilaalchisee xiyyeeffannaa hangam

kennu?

g. Yeroo ati barbaaddutti ollaan kee deeggarsa ati barbaadde siif kennuun isaanii

hangam salphaa dha?

h. What kind of social support did you get so far? by whom?

i. Was it helpful for you? how did it helped you?

j. Yeroo gammachuun sitti hin dhagahamnetti gahee hiriyootaa fi maatii keetii

akkamitti ilaalta?

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4. Xumuuruu/guduunfuu

Dhimmoota hanga ammaatti irratti maryachaa turre ilaalchisee waanti ati dabalataan

anatti himuu barbaaddu jiraa?

Hirmaattuun yeroo ishee aarsaa gootee waan hirmaatteef galateeffadhu.

215
Qajeelcha gaaffii fi deebii ogeeyyii deessistoota ta‟an wiirtuulee eegumsa fayyaa

filataman keessa hojjetan wajjin gadifageenyaan adeemsisamu.

Akkam. Maqaan kiyya ………………….. jedhama. Miira nuffii da‘iinsaan booda haadholii

irratti mul‘atu (PPD) ilaalchisee yaada kee irratti maryachuun barbaada.

 Akka ogeessa da‘iinsaatti (midwife) haadholii wajjin hojjechuu akkamitti ibsita?

 Miira nuffii da‘iinsaan booda haadholii irratti mul‘atu (PPD) ilaalchisee ilaalcha

akkamii qabda?

 Miira nuffii da‘iinsaan booda haadholii irratti mul‘atu (PPD) haadholii fi daa‘imman

irratti dhiibbaa akkamii qaba?

 Waa‘ee jeeqamuu miiraa ilaalchisee haadholiin odeeffannoo akka argatan taasistee

beektaa?

 Haadholiin ulfaa yookaan eega da‘aniin booda miirri isaanii jeeqamuu isaa sitti

beeksisan jiru? Akkamitti?

 Leenjii Miira nuffii da‘iinsaan booda haadholii irratti mul‘atu (PPD) qorachuu

fudhattee/argatteettaa?

 Miira nuffii da‘iinsaan booda haadholii irratti mul‘atu (PPD) fi akkaataa to‘annoo

isaa ilaalchisee hanga ammaatti leenjii fudhatteettaa?

 Qorannoowwan tokko-tokko akka agarsiisanitti, haalli keessummeessuu ogeeyyii

deessistootaa miira nuffii da‘iinsaan booda haadholii irratti mul‘atu (PPD) gaarii

waan hin taaneef kun rakkinicha ni cimsa jedhu. Waa‘ee argannoo qorannoowwan

kanneenii maal yaadda?

 Akka ogeessa deessistuutti rakkoo miira nuffii da‘iinsaan booda haadholii irratti

mul‘atu (PPD) hiikuuf furmaata ta‘a kan jettu maali?

216
Dhimmoota hanga ammaatti irratti maryachaa turre ilaalchisee waanti ati

dabalataan anatti himuu barbaaddu jiraa? Hirmaannaa keetiif galatoomi.

217
Mirkaneessa qorataa muummee

Ani maqaan kiyya armaan gaditti kan ibsame naamusa saayinsawaa fi teekiniikaa adeemsa

qorannoo kanaa keessatti hordofameef ittigaafatamummaa kanin fudhadhu ta‘uu kiyya nan

mirkaneessa; akkasumas, bu‘uura qajeelfamoota Yuunvaristii Finfinneetti Kutaa Barnootaa

Sooshaal Woorkiitti Sagantaa Poosti- giraajuweetiitti pirojaktiin qorannichaa kan

adeemsisame ta‘uu nan mirkaneessa.

Qorataa muummee: Asnaaqaa Tasfaayee Guyyaa._________ Mallattoo

_______

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 Assurance of principal investigator

I, undersigned here agrees to accept responsibility for scientific ethical and technical
conduct of the research project and for provision of required progress reports as per terms and
the condition of the AAU SSW PG Program in effect at the time of the grant is forwarded as
the result of this application.
Principal investigator: Asnake Tesfaye Date._________ Signature
______________

219