Effectiveness of Textile Materials in Gynaecology and Obstetrics

Lupine Publishers| Journal of Reproductive

Abstract

The article reviews some significant advances in the use of textile materials in obstetrics and gynaecological procedures. Some developments in texture suture materials have been highlighted. Despite millennia of experience with wound closure biomaterials, no study or surgeon has yet identified the perfect suture for all situations. In recent years, a new class of suture material-barbed suture-has been introduced into the surgeon's armamentarium. Focus has been directed on barbed suture to better understand the role of this newer material in obstetrics and gynaecology. Cellulose nonwoven modified with chitosan nano particles has been developed and its physical-chemical, morphological and physical-mechanical aspects characterized in order to explore their possible use in medicine as gynaecological tampons. Tampons have been developed using viscose fibres coated by chitosan dissolve in acetic or lactic acids both inhibit the growth of micro organisms and adjust the pH. Such a tampon proved better than existing ones and thereby proves beneficial for pregnant women.

Keywords: Suture material; Suture characteristics; Barbed sutures; Medical tampons; Viscose; Chitosan; Wound closure

Introduction

The relationship between wound closure biomaterials and surgery dates back as far as 4000 years, when linen was used as a suture material. The list of materials used to close wounds has included wires of gold, silver, iron, and steel; dried gut; silk; animal hair; tree bark and other plant fibers; and, more recently, a wide selection of synthetic compositions. Despite millennia of experience with wound closure biomaterials, no study or surgeon has yet identified the perfect suture for all situations. Natural polymers like cellulose, starch and chitosan find use in pharmacy and medicine due to their desired properties like biocompatibility, lack of toxicity and allergenic action [1,2]. Prepared from natural polymers are materials that mimic the extracellular matrix; they reveal a soft and strong but also elastic structure which provides mechanical stability to tissue and organs [3,4].

The availability and low price is the economic assets of natural polymers. Environment protection issues, now strongly pronounced by the European Union, also speak for the use of natural polymers, which are seen as environmentally-friendly. In general, natural polymers enjoy a growing interest. They are primarily used in modern medical devices contributing to advanced healing procedures. Chitosan counts as a polymer and is in abundance in nature, revealing beneficial biomedical properties like antibacterial activity against Escherichia coli and Staphylococcus aureus, which is primarily responsible for septic shock [5-7]. During the recent years, cellulosic fibres have been used in the development of medical textile products as proved by the literature available [8,9]. Owing to their active surface area, strength and molecular structure, cellulosic fibres exhibit enormous possibilities in the design of bioactive, biocompatible, and advanced materials [10]. One such area of application could be cellulose tampons which are used by women and have biodegradable and antimicrobial properties. It protects from physiological and pathological vaginal discharge, which could otherwise increase the vaginal pH beyond the desirable limit of 3.6-4.5 [11].

Developments in Suture Materials

A perfect suture would have the following properties:

a. Adequate strength for the time and forces needed for the wounded tissue to heal
b. Minimal tissue reactivity
c. Comfortable handling characteristics
d. Unfavourable for bacterial growth and easily sterilized
e. Nonelectrolytic, noncapillary, nonallergenic, and noncarcinogenic

This review discusses the wound healing process and the biomechanical properties of currently available suture materials to better understand how to choose suture material in obstetrics and gynaecology. Inflammatory tissue reactions due to the presence of suture material will persist as long as the foreign body remains within the tissue. Determining the balance between the added strength the suture provides to the tissues while they heal versus the negative effects of inflammation is central to choosing the proper suture. Irrespective of the knot configuration and material, the weakest spot in a surgical suture is the knot and the second weakest point is the portion immediately adjacent to the knot, with reductions in tensile strength reported from 35% to 95% depending on the study and suture material used. Applying our current understanding of the wound healing process and the biomechanical properties of the variety of available suture materials, obstetricians and gynaecologists should choose suture material based on scientific principles rather than anecdote and tradition.

Stages in Wound Healing

The following stages are involved in wound healing and inflammatory responses

A. Inflammation [12-16]
B. Proliferation [17]
C. Maturation an remodelling [12,13]

Suture Characteristics that Assist Surgeons

The following are the different categories of suture classification that are considered to best assist surgeons in choosing the proper suture material for their surgeries. These are:

i. Suture size [18].
ii. Tensile strength [19-21].
iii. Absorbable versus nonabsorbable [22-27].
iv. Multifilament versus monofilament [28-31]
v. Stiffness and flexibility [32,33].
vi. Smooth versus barbed [34-42].
vii. Barbed suture [43].

Practical Aspects to be considered in Suture Materials

A perfect suture has adequate strength for the time and forces needed for the wounded tissue to heal; minimal tissue reactivity; comfortable handling characteristics; is unfavourable to bacterial growth and easily sterilized; and is nonelectrolytic, noncapillary, nonallergenic, and noncarcinogenic.

a) Inflammatory tissue reactions due to the presence of suture material persist as long as the foreign body remains within the tissue. The degree of tissue reaction depends largely on the chemical nature and physical characteristics of the suture material.
b) Suture classifications that best assist surgeons in choosing the proper suture material for surgery include suture size, tensile strength, absorbability, structure, flexibility, and surface texture.
c) The perfect suture material should retain adequate strength throughout the healing process and disappear afterward with minimal associated inflammatory reaction.
d) Irrespective of the knot configuration and material, the weakest spot in a surgical suture is the knot and the second weakest point is the portion immediately adjacent to the knot, with reductions in tensile strength reported from 35% to 95% depending on the study and suture material used.
e) Bidirectional barbed sutures may offer multiple advantages: they eliminate the need for a knot, which effectively reduces wound tissue reactions; there is a more uniform distribution of wound tension across the suture line, yielding more consistent wound opposition; and the secure anchoring of barbed suture at 1 mm intervals may provide a reduction in gaps and thereby create a more "watertight" seal. On the downside, currently available barbed sutures are produced in a limited variety of materials and sizes.

Reflecting the age-old dictum, "It's always important to never say always and never," there is no one best suture or suture material for all surgical procedures. Although sutures have been reflecting the age-old dictum, "It's always important to never say always and never," there is no one best suture or suture material for all surgical procedures. Although sutures have been complications, surgeons must constantly review not only their technique, but the adjuvant materials they use in their craft. This review focused on absorbable suture materials for use in basic obstetric and gynaecologic procedures. It is meant to be neither comprehensive nor definitive. Rather, it is intended to introduce newer technologies and reinforce old concepts. Applying our current understanding of the wound healing process and the biomechanical properties of the variety of available suture materials, obstetricians and gynaecologists should choose suture material based on scientific principles rather than anecdote and tradition. Tissue characteristics, tensile strength, reactivity, absorption rates, and handling properties should be taken into account when selecting a wound closure suture. The currently available suture materials and their relative general characteristics have been listed [44].

With these considerations in mind, in most obstetric and gynaecologic procedures (excluding suspension procedures and oncologic procedures in which either adjuvant chemotherapy and/ or radiation therapy is anticipated), there is little role for either nonabsorbable sutures or collagen gut sutures [45]. The newer synthetic absorbable sutures consistently display both theoretical and clinically proven advantages for wound healing over their older, naturally derived cousins. The introduction of bidirectional barbed sutures has the potential to dramatically alter the wound closure landscape by both equalizing the distribution of disruptive forces across the suture line and eliminating the need for surgical knots.

Use of Barbed Sutures

Sutures and surgery have been tied together since the first operations were performed. Throughout the history of surgery, the variety of materials used to close wounds has included wires of gold, silver, iron, and steel; dried gut; silk; animal hairs; tree bark and other plant fibers; and, more recently, a wide selection of synthetic compositions. Despite the multitude of different procedures performed with a host of different wound closure biomaterials, no study or surgeon has yet identified the perfect suture for all situations. In recent years, a new class of suture material-barbed suture-has been introduced into the surgeon's armamentarium. Currently, there are 2 commercially available barbed suture products: the Quill™ SRS bidirectional barbed suture product line (Angiotech Pharmaceuticals, Inc., Vancouver, BC, Canada) and the V-Loc™ Absorbable Wound Closure Device product line (Covidien, Mansfield, MA). These synthetic sutures eschew the traditional, smooth, knot requiring characteristic of sutures in favour of barbs that serve to anchor the sutures to tissue without knots. This review focuses specifically on barbed suture to better understand the role of this newer material in obstetrics and gynaecology. Given the paucity of published data on the V-Loc sutures, the review will mostly focus on Quill bidirectional barbed sutures.

Key Considerations

In the author's opinion, there are few scientific data to support the current use of either plain or chromic gut sutures in any surgical procedure. A recent study of porcine gastrointestinal closure burst- strength pressures in wounds closed with barbed suture were no different than repairs performed with traditional knotted, smooth suture lines. When considerations for blood loss and hemostatis are added, the need for faster, more secure suture lines becomes readily apparent. To this end, barbed suture materials are an ideal solution. As with myomectomy closures, hysterotomy closures during caesarean delivery are facilitated by the use of barbed suture. The barbed sutures more easily draw the tissue edges together and the 1-mm spacing between the barbs seems to yield better hemostasis.

Important Practical Aspects

I. A new class of suture material-barbed suture-has been introduced; these synthetic sutures eschew the traditional, smooth, knot requiring characteristic of sutures in favour of barbs that serve to anchor the sutures to tissue without knots.
II. The 6 categories of suture classification believed to best assist surgeons in choosing the proper suture material for their surgeries are suture size, tensile strength, absorbability, filament construction, stiffness and flexibility, and surface characteristics (smooth or barbed).
III. A knot-secured, smooth suture creates an uneven distribution of tension across the wound. Although the closed appearance of a wound may be that of equal tension distribution, there is unequal tension burdens placed on the knots. This tension gradient across the wound may subtly interfere with uniform healing and remodelling.
IV. Although the data are limited and almost exclusively based on studies with bidirectional suture, barbed suture lines appear to be at least as strong if not stronger than traditional, knotted, smooth suture lines.
V. To choose the best suture material for an obstetrics- gynaecology procedure, surgeons should take into account all the variables present, such as a tissue's collagen structure, blood supply, disruptive forces, and potential for infection. When these characteristics are considered, the physical characteristics of barbed sutures make these materials an attractive option.

Comparison between Smooth and Barbed Sutures

In 1956, Dr. J. H. Alcamo was granted the first.com patent for a unidirectional barbed suture, although the concept dates back to 1951 when the idea of using barbed sutures was presented for tendon repairs [46,47]. The first.com Food and Drug Administration (FDA) approval for barbed suture material was issued in 2004 to Quill Medical, Inc., for its Quill bidirectional barbed polydioxanone suture [48]. In March 2009, the FDA approved the V-Loc 180 barbed suture from Covidien. Whether bidirectional or unidirectional barbed suture is better is unknown, although there are reported complications of unidirectional barbed sutures migrating or extruding [49,50].

This problem is thought to have been due to the lack of counterbalancing forces on the suture line. Barbed sutures are available in a variety of both absorbable and nonabsorbable monofilament materials. Specifically, currently available bidirectional and unidirectional barbed suture materials include PDO, polyglyconate, poliglecaprone 25, glycomer 631, nylon, and polypropylene. Bidirectional barbed sutures are manufactured from monofilament fibers via a micromachining technique that cuts barbs into the suture around the circumference in a helical pattern. The barbs are separated from one another by a distance of 0.88 to 0.98 mm and are divided into 2 groups that face each other in opposing directions from the suture midpoint (Figure 1) [51].

Figure 1:

Needles are swaged onto both ends of the suture length. Owing to its decreased effective diameter as a result of the process of creating barbs, barbed suture is typically rated equivalent to 1 USP suture size greater than its conventional equivalent. For example, a 2-0 barbed suture equals a 3-0 smooth suture. Unidirectional barbed sutures are similarly manufactured from monofilament fibers, but needles are swaged onto only 1 end whereas the other end maintains a welded closed loop to facilitate initial suture anchoring (Figure 2). Unlike bidirectional barbed suture, unidirectional barbed suture is rated equal in strength to its USP smooth suture counterpart. However, this strength rating difference between the 2 barbed varieties is the result of labeling differences rather than an actual material benefit.

Figure 2:

Importance of suture knots

It is difficult for many surgeons to think about suture material without an accompanying knot. Nonetheless, the surgical knot used with a length of smooth sutures is a significant necessary evil that is accepted as the only irrefutable means to anchor suture material within a wound. A knot-secured, smooth suture inevitably creates an uneven distribution of tension across the wound. Although the closed appearance of a wound may be that of equal tension distribution, there is unequal tension burdens placed on the knots rather than on the length of the suture line. This tension gradient across the wound may subtly interfere with uniform healing and remodelling. The weakest spot in any surgical suture line is the knot. The second weakest point is the portion immediately adjacent to the knot, with reductions in tensile strength reported from 35% to 95% depending on the study and suture material used [52,53].

When functional biomechanics are considered, this finding should not be surprising considering both the effects of slippage of suture material through the knot and the unavoidable suture elongation that occurs as a knot is formed and tightened. Given the excessive relative wound tension on the knot and the innate concerns for suture failure due to knot slippage, there is a predilection toward overcoming these concerns with excessively tight knots. However, surgical knots, when tied too tightly, can cause localized tissue necrosis, reduced fibroblast proliferation, and excessive tissue overlap, all of which lead to reduced strength in the healed wound [54]. A surgical knot represents the highest amount and density of foreign body material in any given suture line. The volume of a knot is directly related to the total amount of surrounding inflammatory reaction [55]. If minimizing the inflammatory reaction in a wound is important for optimized wound healing, then minimizing knot sizes or eliminating knots altogether should be beneficial as long as the tensile strength of the suture line is not compromised. Finally, with minimally invasive laparoscopic surgeries, the ability to quickly and properly tie surgical knots has presented a new challenge. In cases where knot tying is difficult, the use of knotless, barbed suture can securely re-approximate tissues with less time, cost, and aggravation [56,57].

Although the skills necessary to properly perform intra- or extracorporeal knot tying for laparoscopic surgery can be achieved with practice and patience, this task is a difficult skill that most surgeons still need to master to properly perform closed procedures. In addition, laparoscopic knot tying is more mentally and physically stressful on surgeons and, more importantly, laparoscopically tied knots are often weaker than those tied by hand or robotically [58-62].

Barbed Sutures in Practical Use

The choice and use of sutures in obstetrics and gynaecology (ob- gyn) is based more on anecdote and experience than data. Though many of the suture materials routinely used in myomectomies, hysterectomies, and caesarean deliveries have endured the test of time, this should preclude neither the application of scientific review nor the quest for improvement. In addition to understanding the physical properties and characteristics of the variety of available sutures, surgeons need to consider the tissue and physiologic milieu into which suture will be placed before choosing the material to use. For example, in general, the suture-holding strength of most soft tissues depends on the amount of fibrous tissue they contain. Thus, skin and fascia hold sutures well whereas brain and spinal cord tissue do not. Further along this line, healthier tissues tend to support sutures better than inflamed, edematous tissues.

To choose the best suture material for an ob-gyn procedure, surgeons should take into account all the variables present, such as a tissue's collagen structure, blood supply, disruptive forces, and potential for infection. When these characteristics are considered, the physical characteristics of barbed sutures make these materials an attractive option. The first use of barbed sutures in gynaecologic surgery was reported by Greenberg and Einarsson in 2008 [56]. Since that report, numerous print and video publications have followed. Inprocedures such as laparoscopic myomectomy and hysterectomy, the use of barbed sutures has become commonplace. Myomectomy re-approximation of the myometrium after removal of myomas requires a suture material that adequately addresses the need for a prolonged wound disruptive-force reduction, hemostasis, and minimal tissue reactivity.

Traditionally, this suture has been either a polyglycolic acid suture or polydioxanone. However, as noted earlier, braided sutures cause more tissue abrasion and inflammation than monofilaments, and the transition from open to closed procedures has introduced the difficulty of laparoscopic suturing. When considerations for blood loss and hemostatis are added, the need for faster, more secure suture lines becomes readily apparent. To this end, barbed suture materials are an ideal solution. Their synthetic, monofilament configurations should minimize local inflammation, and their absorption profiles and tissue pull-through strengths are well within the parameters needed for reduction of disruptive forces. Further, because barbed sutures allow for only minimal tissue recoiling, closing spaces such as myomas defects is easier with each subsequent suture pass exposed to less tension than the previous bite. Finally, without the need for knot tying, wound closure times and blood loss are significantly reduced [63-65].

Barbed sutures are used in obstetric and gynaecologic procedures in following areas

a) Hysterectomy [66-71].
b) Sacrocolpopexy [72-74].
c) Caesarean delivery [75-79].

Barbed suture is a relatively new but exciting addition to the variety of suture materials. As experience grows with barbed sutures, more applications for its use will likely arise [80]. Obstetric and gynaecologic surgeons who are interested in choosing the best materials for their operations should benefit from better understanding the underlying principles of wound healing and suture material biomechanics, and may discover many advantages to the use of barbed suture.

Chitosan Modified Cellulosic Nonwoven Material

It also displays activity against the fungi Candidiaalbicans, which often produces vaginal candidiasis [81,82], and antiviral action, for example against the human papilloma virus (HPV), which is the cause of cervical carcinoma [83-85]. Thanks to its ability of controlled slow- release, chitosan is often used as carrier of active substances. Various sterilization methods can be employed for chitosan without upsetting its structure and physical-chemical properties [86]. Its beneficial properties ensure chitosan is widely used in pharmacy and medicine as a safe, non-toxic polymer originating from nature [86,87]. Both natural and synthetic polymers like PLA, poly (DL-lactideco-glycolide) and PP are often modified with chitosan [88-91]. The process is intended to prepare new materials with beneficial biological, physical-chemical and mechanical properties [91-93]. The modified composite materials obtained open wide avenues of application and contribute to the introduction of new healing techniques. The incorporation of chitosan into the cellulose matrix yields devices with high biological activity and good mechanical strength.

The medical devices have potential use in gynaecology as medical materials with beneficial biological and mechanical properties. Basic cellulose material with built-in chitosan nanoparticles provides optimal and controlled diffusion of chitosan to the mucous membrane of the vagina and ovarium. Tampons holding antimicrobial chitosan particles may also find use as post-operation dressings and in the healing of diseases and infections due to high antimicrobial activity; alternatively they may be employed for carrying active substances. This is crucial because infections and gynaecological ailments are problems women are mostly plagued with. More than 40 microorganisms are the reason for infections in the region of female sexual organs. The copolymer system proposed also permits to minimalise irritation due to the adjustment of chitosan concentration as the active agent. It is also hoped that the more developed surface of the biopolymer material shall provide better contact with the vagina and neck of the uterus, thus enhancing the antimicrobial effect. The use of modern biopolymer medical devices opens new ways in medicine.

Assessment of the impact of chitosan nanoparticles added to a cellulose matrix upon biological activity and toxicity was the aim of the research conducted. Structural examinations and estimation of chemical purity, as well as antibacterial and useful properties were made. Prepared was a system to control the medical device in respect of microorganism growth and fulfilment of quality requirements of medical devices [94,95]. This article presents preliminary studies on the assessment of the effect of modification of cellulose nonwoven with nanoparticles of chitosan upon biological activity, toxicology and mechanical properties. The addition of nano chitosan was supposed to influence antimicrobial properties; however it was necessary to verify the correlation between the concentration of chitosan and the activity. A very important purpose was to examine how the addition of chitosan would influence the mechanical properties and chemical purity. It is necessary to guarantee optimum activities and the safety of human life and health simultaneously. Therefore according to the standards and scientific literature available, research methods were selected and used to assess cellulose nonwovens for their possible use in medicine as gynaecological tampons. Cellulose fibres used in the preparation of the nonwovens have good properties, both physical- mechanical and physical chemical, including chemical purity.

The addition of chitosan in the amount of 0.25 and 0.5% to the nonwoven caused an inhibition of the growth of E. coli, while such an effect was not observed with S. Aureus. Nonwoven with a 1.4% content of chitosan completely stopped the growth of bacteria E. coli and S. Aureus. The initial material revealed antifungal activity against C. Albicans on at the level of 91.7%; the addition of 0.5% of chitosan entirely inhibited the growth of microorganisms. Antifungal activity of the nonwoven with 0.25% of chitosan against C. albicans was slightly below 100%. Based on the results of physical-mechanical testing, it was found that the nonwoven with 0.5% of chitosan has the best mechanical and useful properties [96]. Assessment of the chemical purity of the materials tested points, at best, to useful properties in the case of nonwoven with 0.5% of chitosan. The structure of the fibres examined after extraction simulating normal use was not disturbed, which may evidence safe use of the hygiene material manufactured. Summarizing the results of the examinations, it may be concluded that the initial cellulose fibres are a good raw material for use in the preparation of innovative medical devices.

Use of Chithsan Based Viscose Material

An increase in pH may cause a reduction in the natural defence of the vagina. This suggests conduciveness for development of bacteria and hence prone to development of bacteria [11-12,9798]. A number of techniques and formulations have been evolved in order to manage the problem of increased pH value of the vagina, than the normal [13,99]. But these have been unsatisfactory from the practical point of view considering the usage and acceptability. Therefore, the development of materials for prevention and treatment of gynaecological infections still represent a significant challenge. Chitosan is the next most abundant polysaccharide found on earth, in comparison with cellulose. It is a biopolymer that is polycationic and covers a broad spectrum of medical properties activity, such as antibacterial, antifungal, and haemostatic properties [100]. Chitosan possesses many desirable characteristics with regard to vaginal infections. It is effective against vaginal candidiasis, toxic shock syndrome, treatment of ovarian cancer, and ensures safe pregnancy and proves conducive in avoiding premature child birth.

Chitosan is found highly suitable for adsorption onto cellulose fibres and thereby impart antimicrobial activity. The functionalization of viscose cellulose using chitosan has been investigated. The objective is to assess the potential use of such a material for the development of new tampons, which apart from maintaining/creating the desired physiological pH value would also possess antibacterial and antimycotic properties. The tampons do not exhibit negative effects, such as inflammation risks, and infections from yeasts, and on repeated use, help to sustain the required moisture in the vagina.

Conclusion

Textile materials have made their entry into many areas of medical textiles, of which gynaecology and obstetrics is one such. Textile sutures are one well explored area. In the choice of a wound closure suture tissue characteristics, tensile strength, reactivity, absorption rates, and handling properties should be considered. The wound healing process and the biomechanical properties of currently available suture materials have been reviewed to better understand how to choose suture material in obstetrics and gynaecology. Despite the multitude of different procedures performed with a host of different wound closure biomaterials, no study or surgeon has yet identified the perfect suture for all situations. In recent years, a new class of suture material-barbed suture-has been introduced into the surgeon's armamentarium. The barbed suture has been studied to better understand the role of this newer material in obstetrics and gynaecology. The impact of the addition of chitosan nanoparticles upon the biological activity and toxicity of the materials prepared.

Methodology was prepared for the examination of the gynaecological devices in the range of their useful properties, notably the mechanical strength, surface density and absorption. Aqueous extracts were examined after an extraction process that simulated standard use of the medical device, and after a surplus extraction. The content of water-soluble-, surfactant- and reductive substances was estimated as well as the contents of heavy metals like cadmium, lead, zinc and mercury by the ASA method. Morphology examination permitted to assess the impact of the extraction processes on the fibre structure. Antibacterial activity against Escherichia coli and Staphylococcus aureus, and antifungal activity against Candida albicans was measured. Altogether examinations were made to assess whether the cellulosic nonwoven modified with chitosan nanoparticles meets the demands of medical devices and lends itself to the manufacture of tampons. The suitability of chitosan-acetic acid treated tampons for gynaecological use has been evaluated. The use of such tampons could prove beneficial for pregnant women, as in vitro trials have confirmed resistance of the tampons against Streptococcus Agalactiae bacteria, which pose serious problems for pregnant women and their infants.

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Prevalence of Postpartum Depression and Associated Factors among Postnatal Women Attending At Hiwot Fana Specialized University Hospital, Harar, East Ethiopia, 2015/2016

Lupine Publishers| Reproductive System and Sexual Disorders 

 

Abstract

Background: Postpartum depression is a common occurrence which is often undiagnosed when symptoms are not severe and may progress into severe or chronic state if unrecognized and untreated. Being the most frequent form of mental illness in the postpartum period, it can begin as early as two weeks after delivery. It is also the most common complication of childbearing and as such represents a considerable public health problem affecting women and their families.
Objective: To assess the prevalence of postpartum Depression and associated factors among postnatal women who are attending at Hiwot Fana Specialized University Hospital, Eastern Ethiopia, 2016.
Methods: The study was conducted by using institutional based cross-sectional study design and non probability convenience sampling technique, until the required sample size of 122 was attained. The data was collected by using a structured, pre designed questionnaire from February 22/02/2016-March 22/03/2016. The data was analyzed manually and presented by using frequency table and graphs.
Results: A total of 122 postnatal mothers were involved into this study and all of them were analyzed. This study found a prevalence of PPD one week after delivery at HFSUH was 13.11%. Recent pregnancy was reported as unwanted by 2.46% and partner’s support was perceived as inadequate by 19% of the respondents and Caesarian section was 38.52%. Almost all, 95.90 % exclusively breast fed their infants and minor illnesses had occurred to 13.11% of the infants. Premature baby 5.74%, poor satisfactions with medical care 22.13%, family history of mental illness 3.28% were strongly associated with PPD. The other factors such as neonate illness, residence, desired new born sex, hypertension, and hyper emesis had also their own significant association. Educational status, number of birth, age, place of delivery and sex of new born had no significant association with PPD.
Conclusion: This study found a prevalence of PPD among women delivering at HFSUH, one week after delivery was 13.11% which is a significant high value and compared well with other studies. The findings in this study may form the bases for the need of routine screening of PPD in the post natal care especially those mothers with unplanned pregnancy, premature baby, poor support systems, poor satisfaction with medical care, family history of mental illness, and stressful life events which were highly associated with PPD. This would help prevent PPD at all levels hence a healthy mother.
Recommendation: Psychiatry staff of HFSUH should collaborate the services given for psychiatric cases and other gynecologic and obstetrics as well as general medical conditions. Routine screening for mental illness just like other reproductive problems for mothers attending hospital during delivery and after delivery is necessary. Finally, ministry of health should design policy that interactively provides mental illness of mother and their reproductive problems.
Ethical consideration: The study was conducted after ethical clearance had been given from Haramaya University College of Health and Medical Science. Ethical clearance letter was submitted to Hiwot Fana Specialized University Hospital and management body permitted to conduct research.

Introduction

Background

Postpartum depression also known as postnatal depression is a non psychotic depressive disorder of variable severity and it can begin as early as two weeks after delivery and can persist indefinitely if untreated. Most of the time, it occurs within the first three month after delivery. The illness can cause distress and impair a mother’s ability to carry out her normal tasks, care for herself and care of her baby. It is a clinical depression with symptoms that can include a feeling of fatigue, social withdrawal, sadness, changes in sleeping and eating patterns, and guilt (including related to ability to care for the infant), crying, loneliness and low self esteem lasting longer than two weeks or beginning two weeks or more after delivery [1,2]. The term “Post¬partum Depression” encompasses several mood disorders that follow childbirth. Important developments in the study of PPD include its association with symptoms of anxiety and bipolar disorders in addition to those of depression [2].
Becoming a mother can be difficult this is due to a major psychological shift from viewing oneself as a woman who is pregnant to viewing oneself as a new mother. This major emotional shift may create problems. Following childbirth, seesawing emotions and heightened emotional responses may occur [3]. The biological mechanism of PPD is believed to coincide with that of major depressive disorder. Depression in general is a disease of neuronal circuit integrity, which has been shown in studies by a reduction in brain volume of individuals diagnosed with major depressive disorder. Interestingly, the amount of volume loss correlates directly with the number of years of ill¬ness. Stress and depression act to reduce numerous brain pro¬teins that promote neuronal growth and synapse formation, and antidepressant medications have been shown to increase these and other protective proteins, thereby reversing the mechanism of depression.
These underlying neurobiological changes result from developmental interactions between genetic susceptibility and environmental factors (i.e., the psychosocial stresses ac¬companying motherhood) rather than a simple “chemical im¬balance,” as previously believed. Specifically, the neurobiolog¬ical effects of rapid postpartum hormone withdrawal predispose women with established risk factors to PPD. An interesting distinction that makes PPD unique from other depressive disorders is that it is marked by a prominent anxi-ety component. This may be why so many cases of PPD are missed, as many clinicians use the Patient Health Question¬naire which covers depressed mood and dysphoria, but not anxiety-as their primary screening technique. The stress of caring for a newborn or even the circumstances surrounding labor and delivery may precipitate the first symp¬toms of PPD [4].
Multiple risk factors for postpartum depression have been suggested as no single cause has been identified. Personal vulnerability, personal traits and social factors such as unplanned pregnancy occupational instability, single parenthood and marital discord have been cited. The effects of postnatal depression on the mother, her marital relationship, and her children make it an important condition to diagnose, treat and prevent. The mother unable to provide care to her infant as manifested by decreased adherence to regular check up well baby visits and increased frequency health care provider’s visits due to infant problems. Lastly depressed mothers have lower rates of gratification and enjoyment in their mothering role compared with non-depressed mothers. The patterns of symptoms in women with postpartum depression are similar to those in women who have depression unrelated to childbirth apart from the fact that the content may focus on the delivery or baby. Evidence from epidemiological and clinical studies suggests that mood disturbances following childbirth are not significantly different from affective illnesses that occur in women at other times [5,6].

Statement of the problem

Postnatal depression (PND) is a global public health issue. It is the most common complication of childbearing and as such represents a considerable public health problem affecting women and their families. The effects of postnatal depression on the mother, her marital relationship, and her children make it an important condition to diagnose, treat and prevent [2]. Postpartum Depression (PPD) encompasses several mood dis¬orders that follow childbirth. It affects 10-15% of new mothers, but many cases of PPD remain undiagnosed. Thus, prevalence rates in the developing world range from being equal to almost double that of developed countries. Risk factors identified in these studies include previous psychiatric problems, life events in the previous year, poor marital relationship and economic deprivation. Female infant gender was found to be an important determinant of postnatal depression in India but not in South Africa.
These studies found that postnatal depression was associated with high degrees of chronicity, disability and disturbances of mother infant relationship [7]. Postpartum common mental disorders such as depression and anxiety are increasingly recognized for their burden in low resource countries such as Ethiopia. However; the magnitude of postpartum depression in Ethiopia is not well established so identifying magnitude of postpartum depression and associated factors in our country is essential to minimize mental illness that is related to mothers who give birth. Estimates for depression during and after pregnancy have range from 9% to 20%, and for postpartum common mental disorder, the estimates have been as high as 33%, even if these problems are there, there is no good awareness and satisfactory intervention especially for those who live in remote area from the health center [8].
Multiple risk factors for postpartum depression have been suggested as no single cause has been identified. Personal vulnerability, personal traits and social factors such as unplanned pregnancy, occupational instability, single parenthood and marital discord have been cited. Screening for postpartum depression would improve the ability to recognize these disorders and hence necessitate enhanced care that ensures appropriate clinical outcomes [6]. Untreated postpartum depression can have adverse long term effects. For the mother, the episode can be the precursor of chronic or recurrent depression. For her children, a mother’s ongoing depression can contribute to emotional, behavioral, cognitive and interpersonal problems in later life. If postpartum depression is to be prevented by clinical or public health intervention, its risk factors need to be reliably identified, however, numerous studies have produced incomplete consensus on these [5].
This research is relevant because the prevalence of PPD and its associated factors are not well known as well as there is no proper intervention. Determining the prevalence of PPD is critical to manage and prevent further complication. It will also help to identify its impacts on mother and child. The purpose of this study is to evaluate the prevalence of PPD and associated factors; it is expected to sensitize the health care professionals and policy makers on the importance of maternal mental health and the need for routine screening for postpartum depression by disseminating/ reporting the result of the research at Hiwot Fana Specialized University Hospital by the year 2015/16.

Significance of the study

In Ethiopia there are no published researches (up to our reading) on PPD and its associated factors, due to this our study plays an important role to determine and solve the problem by disseminating the result to concerned bodies. This study provides an evidence base from which further studies can be done and compared, not just at this hospital only, but from other hospitals in Ethiopia. It serves as initial to do further research and a pioneering study for our junior students and other investigators toward future studies among related subjects. It also expands our knowledge about the various aspects of PPD among Harar women in order to focus on coming researches. Significance to public health and maternal health practice: This study is expected to unveil and draw the attention of health care practitioners to many ignored aspects of PPD and its associated factors, in order to give them more focus towards the integration of PPD screening during the care of pregnant and postpartum women.
Significant to health care decision makers: The study is expected to urge health care decision makers to consider this important topic – PPD in the planning and delivering of health care services.

Study Objectives

General objective

a. To assess the prevalence of postpartum Depression and associated factors among postnatal women attending at Hiwot Fana Specialized University Hospital, Harar, Eastern Ethiopia in 2015/16.

Specific Objectives

a. To determine the prevalence of PPD among postnatal women attending at Hiwot Fana Specialized University Hospital, Harar, Eastern Ethiopia in 2015/16.
b. To identify the factors that associated with PPD among postnatal women attending at Hiwot Fana Specialized University Hospital, Harar, Eastern Ethiopia in 2015/16.

Methods

Study Area

This study was conducted in Harar, the capital of the Harari national state. Harar is the capital city of Harari Regional state is located in Eastern part of Ethiopia which is 525 Km from Addis Ababa with a total area of 17.20 Km2. According to the regional profile 90% of the region is estimated to be “woinedega” (Between 1000-1500m) and situated at 900, 230 Altitude and 420, 240 longitude and with elevation of 1600 feet above the sea level According to the 2007 census, the regional state of Harari has a total population of 183,415. The region has 77.6% health coverage, two Zonal Hospital MAH and HFSU, one regional public health laboratory and research center and one nursing school. Moreover, there are two other governmental hospital army Hospital and Public Hospital [9]. Among Hospitals HFSUH, Jegola Hospital and Army Hospital provide psychiatry service. Jegola Hospital has 1 0PD and 2 staffs (1BSC, 1 advanced Diploma psychiatric Nurses) and in Army Hospital 1 0PD (1Psychiatry nurse). HFSUH has 7 beds, 2 OPDs, 10 staffs (8BSc psychiatry Nurses, 2 Diploma Psychiatry Nurses, But currently no psychiatrist), and also there are 2 gynecology ward and 1 OPD, 14 obstetrics ward and 6 pediatric [10].

Study design and period

Study design: Institutional based cross sectional study design was used to determine prevalence of postpartum depression and associated factors among postnatal women attending at Hiwot Fana Specialized University Hospital.
Study period: The study was conducted from February 22/02/2016-March 22/03/2016.

Population

Source population: All postnatal mothers who attended at Hiwot Fana Specialized University Hospital.
Study population: A postnatal mother who attended at Hiwot Fana Specialized University Hospital during the data collection period and who’s the data was taken.

Sample size determination and sampling technique

Sample size determination: The formula that we have used to calculate sample size in the study was:

Equation 1:

Where d = margin of error= 5% in case of our study
α = level of confidence (95%- 1.96)
P = Prevalence of point under consideration that taken as 50% because there is no known prevalence.
By this no=sample size

Equation 2:

no = 384
We add Non respondent rate =10%, from this no=423
We Use reduction formula because our total population is less than 10,000 (the average of total post natal
women in the last year on February and this year on January is 170).

Equation 3:

Equation 4:

Sampling technique: Data was taken from patients who are present at a time of data collection, because of this, non probability convenience sampling technique was applied to select study unit among PPD patients.

Inclusion and exclusion criteria

Inclusion criteria:

a. Post natal women who are attending at Hiwot Fana Specialized University Hospital.
b. Age 15-47 or reproductive age group.
c. Ability and acceptance to consent to participate in the study.
Exclusion criteria
d. Patients, who cannot able to communicate,.
e. Patients, who have depression that persist beyond 1 year after giving birth.
f. Patients who are not volunteer to participate in the study.

Study variables

Dependent variable

Postpartum depression

Independent variable

Socio demographic factors:
a. Age
b. Occupation
c. Residence
d. Income
e. Marital status
f. Educational status
g. Pregnancy and birth related factors:
h. obstetric history
i. complication during delivery
j. place and type of delivery
k. whether mother wanted pregnancy to occur
l. medical problem or chronic diseases
m. New born related factors:
n. desired gender of new born,
o. whether the new born has any diseases
p. whether the new born is delivered before 9-month
q. whether he/she is fed by breast or formula or both
r. Maternal and family related factors:
s. relationship with her husband and her family members
t. support and help provided by her husband
u. Psychosocial and psychological factors:
v. personal and family history of mental illness
w. history of depression during the last pregnancy
x. stressful life event like loss of loved one

Data collection procedure

Data collection: Data was collected by using both interview guided structured questionnaire and standard questionnaires by three Data collectors, every data collector interviewed the participants to the questionnaire voluntarily after informed consent has obtained by convincing the patient, their information was confidential.
Data collection instrument: The structured and standard questionnaire which contains the following:
a. Socio-demographic history(age, sex, marital status, education, occupation, residence, income)
b. Pregnancy and birth related factors (obstetric history, complication, place and type of delivery, whether mother wanted pregnancy to occur, medical problem or chronic diseases).
c. New born related factors (desired gender of new born, whether the new born has any diseases, whether the new born is delivered before 9-month, whether he/she is fed by breast or formula or both)
d. Maternal and family related factors(relationship with her husband and her family members, support and help provided by her husband)
e. Psychosocial and psychological factors(personal and family history of mental illness, history of depression during the last pregnancy, stressful life event)
f. Edinburg post natal depression scale
All the above tools were used to determine the prevalence and associated risk factors of postpartum depression among post natal women attending at Hiwot Fana Specialized University Hospital.

Data quality control

The quality of data was kept by preparing each and every question related to our specific objectives and we incorporated comments obtained in Amharic language and we conducted it. We were also tried to improve our data by sharing information from advisor and using standard data collection tools. Clear discussion was done by group members about the purpose and procedures of the study. The group members were decided to peruse non respondents by explaining the objective of study clearly. The collected data was checked out for the completeness, accuracy and clarity by principal investigator. This quality checking was done daily after data collection and amendment was made before the next data collection measure.

Data processing and Analyzing

Data processing: The collected data was processed manually and using scientific calculators and the raw data was processed by using tallying sheet, filling mater sheet, editing, cleaning and checking for completion.
Data Analyzing: The data was analyzed by using table, figure, frequency, percentages, and cross tabulation. Finally the finding of the study was summarized, presented, discussed based on the nature of questions. The association of factors was analyzed by calculating odd ratio and chi- square.

Ethical Consideration

The study was conducted after ethical clearance is given from Haramaya University College of Health and Medical Science. Ethical clearance letter was submitted to Hiwot Fana Specialized University Hospital and management body was permitted to conduct research. The objectives of study were clarified to Hiwot Fana Specialized University Hospital and informed consent was agreed as well as notified to patients and their information was not observed by other body that was for the sake of research. A patients verbally counseled regarding their ability to chose whether or not they wanted to participate in the study and the fact that they would not be victimized should they chose not to participated.

Results

A total of 122 mothers were interviewed, all were eligible for analysis (with 100% response rate). Results were presented in tables, percentages, and graphs followed by narration as shown below.

Section one: Demographic information:

Table 1: Socio-demographic characteristics of the participants in Harar town, Hiwot Fana Specialized University Hospital from February 1-30, 2016

Figure 1: Sociodemographic characteristics (religion) of the participants in Harar town, Hiwot Fana Specialized University Hospital from February 1-30, 2016. Out of the total participants 51.64% were not employed, 8.20% government employed, 1.64% self employed, 25.41% farmer, 0.82% student, and 12.26% merchant.

As Table 1 show below 47.54% were aged 20-24 years, 28.69% were aged 25-29, 0.82% was single and the rest were married 50.82% were unable to read and write, 22.13% had schooled up to primary level and 64.75% were Oromo. 56.56% of participants were lived in urban and the rest were in rural. 54.10% of the participants had <750 birr per month per individual of the family. Muslims were the majority of them which accounts 75.41%, followed by Orthodox 19.67%, and protestant 4.92% (Figures 1 & 2). Out of the total participants 51.64% were not employed, 8.20% government employed, 1.64% self employed, 25.41% farmer, 0.82% student, and 12.26% merchant.

Figure 2: Sociodemographic characteristics (occupational status) of the participants in Harar town, Hiwot Fana Specialized University Hospital from February 1-30, 2016.

Section two: Pregnancy and Birth related factors:

Table 2: Pregnancy and Birth related factors of the participants in Harar town, Hiwot Fana Specialized University Hospital from February 1-30, 2016.

Table 3: marital and Family relationship satisfactions of the participants in Harar town, Hiwot Fana Specialized University Hospital from February 1-30, 2016

As the above Tables 2-6 show that 23.77% of respondent mothers were primigravida (being pregnant for the first time). 30.83% and 69.17% of respondent mothers were primipara (giving birth for the first time) and multipara (giving ≥2 birth). 57.14% of the respondents had 1 miscarriage and stillbirths and the rest had ≥2 miscarriage and stillbirths. 92.62% of respondent mothers had no any problems that faced the rest 7.38% had pregnancy related problems during their last pregnancy. Except 1 mother all the rest mothers gave birth in hospitals. 61.48% of the participating mothers delivered their babies by vaginal delivery, 38.52% delivered their babies by caesarean section, 2.46% reported the use of vacuum during delivery and 2.46% reported episiotomy was done during birth.27.87% and 50.00% of mothers reported receiving very good and good medical care during birth. In contrast, 19.67% & 2.46% reported that the medical care was Satisfactory and poor respectively.

Table 4: common PPD symptoms with respect to EPDS of the participants in Harar town, Hiwot Fana Specialized University Hospital from February 1-30, 2016

Table 5: Association between PPD and Sociodemographic variables of the participants in Harar town, Hiwot Fana Specialized University Hospital from February 1-30, 2016

Table 6: Association between PPD and Pregnancy and Birth variables of the participants in Harar town, Hiwot Fana Specialized University Hospital from February 1-30, 2016

Section three: New born related factors: (these questions are related to your last baby)

Figure 3: New born related factors of the participants in Harar town, Hiwot Fana Specialized University Hospital from February 1-30, 2016.

63(51.64%) of the participating mothers gave birth to a male baby and 59(48.36%) gave birth to a female. When the mothers were asked about the preferred or desired sex of the baby, 91(74.59%) chose a male, 31(25.24%) chose a female (Figures 3 & 4). 16(13.15%) of mothers reported that their baby was ill, but 106(86.85%) of mothers reported that their baby was free from illness. 10(8.20%) of mothers reported that their baby admitted neonate intensive care unit soon after birth, but for the rest. 7(5.76%) of the mothers reported that their baby was premature or delivered before completing 9 months of pregnancy and the rest mothers reported that their baby was full term.117(95.90%) of the mothers reported that breast feeding is the sole feeding type and 5(4.10%) reported using formula feeding exclusively.

Figure 4: New born related factors of the participants in Harar town, Hiwot Fana Specialized University Hospital from February 1-30, 2016.

Section four: Marital and Family Relationship Factors

The participating mothers were asked five questions regarding their satisfaction and evaluation of their relationship with their husband, their own families, their mother’s in-laws and their husband families in general. About 0.83% of respondents had very poor relationships, 1.65% had poor relationships, 14.87% had satisfactory relationships, 53.73% had good relationships and 28.92% had very good relationships with their husband.0.82% of respondents got very poor, 4.96% got poor, 13.22% got satisfactory 52.07% got good and28.92% got very good help and support from their husband.3.28%, 12.30%, 55.72% and 28.70% of respondents had poor, satisfactory, good and very good relationships with their own family respectively. About 4.13%, 14.05%, 55.37% and 26.45% of the respondents had poor, satisfactory, good and very good relationships with their mother’s in-law respectively. 4.13% of respondents had poor, 14.88% had satisfactory, 54.54% had good and 26.45% had very good relationship with their husband family in general.

Section five: psychosocial and psychological history

Figure 5: psychosocial and psychological characteristics of the participants in Harar town, Hiwot Fana Specialized University Hospital from February 1-30, 2016.

Figure 5, Only 1(0.82%) reported having personal mental history and 4(3.28%) having family mental history. The participating mothers were asked about 11 psychosocial stressors and if they had experienced any of them during their pregnancy. Among them 11(9.02%) had experienced at least one stressful life event. The most reported stressor was death of a dear person affecting 6(33.33%) of mothers, followed by recurrent verbal abuse 3(16.67%), financial problems 3(16.67%), accidents or injuries 2(11.11%), physical abuse 2(11.11%), abandon a dear person 1(5.56%) and housing problems 1(5.56%) and the rest stressors such as work place problems, separation or divorce, severe illness of you or dear person and difficulty in dealing with your children accounts zero percent (0%)(Figure 6).

Figure 6: prevalence of stressful life events during pregnancy in Harar town, Hiwot Fana Specialized University Hospital from February 1-30, 2016.

Section six: Edinburgh Depression Scale

From Table 4.

Prevalence of postpartum depression

According to this result, out of the 122 mothers participated, 16(13.11%) were found to have postpartum depressive symptoms as measured by an EPDS score of ≥ 13. Potential risk factors for PDD were shown below by Tables 7-11. Undesired and unplanned pregnancy, poor satisfaction with medical care, premature new born, poor support provided by husband, poor relationship with husband family, recurrent verbal abuse, and family history of mental illness had strong association with PPD. 16 out of 122 study participants screened positive for postpartum depression as tabulated from a score ≥ 13 on the EPDS (Figure 7).

Table 7: Association between PPD and Pregnancy and Birth related stressors of the participants in Harar town, Hiwot Fana Specialized University Hospital from February 1-30, 2016.

Table 8: Association between PPD and new born related factors of the participants in Harar town, Hiwot Fana Specialized University Hospital from February 1-30, 2016

Table 9: Association between PPD and social support and family Relationship variables of the participants in Harar town, Hiwot Fana Specialized University Hospital from February 1-30, 2016

Table 10: Association between PPD and mental and psychological variables of the participants in Harar town, Hiwot Fana Specialized University Hospital from February 1-30, 2016.

Table 11: shown below seven of the tested 11 stressful life events during pregnancy was significantly associated with the presence of PPD. These were: abandon a dear person 1(100%) has PPD compared to 12.40% of not reporting this event), recurrent verbal abuse (66.7% had PPD compared to 11.76% of not reporting this event and it had odds of 15), accidents or injuries (50% had PPD compared to 12.50% of not reporting this event and it had odds of 7) and death of a dear person (50% had PPD compared to 11.21% of not reporting this event and it had odds of 7.92). 2. Association between PPD and mental and psychological variables (stressful life events) of the participants in Harar town, Hiwot Fana Specialized University Hospital from February 1-30, 2016.

Figure 7: Prevalence of PPD among mothers attending at Hiwot Fana Specialized University Hospital from February 1-30, 2016.

Factors associated with PPD

a. Socio Demographic Characteristics
Among the total participants those who were from rural had 1.35 odds than urban women. Factors such as age, religion, ethnicity, occupation, marital status, educational status, and income had no significant association with PPD according to this finding. From above table primigravida had odds of 1.55 than multigravida and prim parity had odds of 1.14 than those with milt parity. High Odds ratio of PPD were associated with; mothers who had abortion for the first time 4.67, Caesarean section delivery 2, episiotomy during their delivery 3.47, Unplanned pregnancy 15, and poor satisfaction by medical care 9. Among the pregnancy related problems as shown below by Table 7, high odds ratio of PPD were associated with hyper emesis 5 and hypertension 7. The rest of problems had no significant association with the disorder. Under new born related factors high odds of PPD were associated with desired male sex 6, mothers who have premature newborn 11 and mothers who had baby with health problem 2.6. The other factors had no significant association with PPD [1-14].
As the table below show, the association between family relationship and PPD was tested.PPD (EPDS cut off ≥ 13) was significantly associated with poor husband and marital relationship satisfaction with PPD rate of 38.1% and 8% among mothers reporting poor and good relationship respectively (OR= 7.1), poor husband help and support with PPD 39.13% and 7.70% among mothers reporting poor and good support and help respectively (OR=8.4) and poor mother in-law relationship satisfaction with PPD rate of 36.36% and 8% among mothers reporting poor and good relationship respectively (OR=6.5). Poor relationships with husband’s family in general had odds of 8.4. As table shown below one of mother reported a personal history of mental illness and she had PPD. Family history of mental illness had odds of 7.42. In general high odds of PPD were associated with undesired and unplanned pregnancy, poor satisfaction with medical care, hypertension and hyper emesis, desired new born sex (male), admission of newborn to ICU, premature new born, poor relationship with husband, husband families, mother-in-law, poor support from husband, family history of mental illness, recurrent verbal abuse, accident and death of dear person.

Discussion

Prevalence and its Associated Factors

The aim of this study is to determine the prevalence of PPD and its associated factors of mothers who attained at HFSUH. There are also another studies conducted on this topic which done in the different part of the world. Research conducted in Brazil by using cohort study, a total of 1,340 pregnant women were identified. The prevalence of postpartum depression was 16.5%. The adjusted analysis found the risk factors for PPD to include lower socioeconomic status, not living with a partner, previous stressful events [11]. While this study shows the prevalence of PPD was 13.11%. The associated factors that strongly linked with PPD were unplanned pregnancy, premature baby, poor support systems, poor satisfaction with medical care, and family history of mental illness, recurrent verbal abuse, accident and death of loved one.
The aim of this study is to determine the prevalence of PPD and its associated factors of mothers who attained at HFSUH. There are also another studies conducted on this topic which done in the different part of the world. Research conducted in Brazil by using cohort study, a total of 1,340 pregnant women were identified. The prevalence of postpartum depression was 16.5%. The adjusted analysis found the risk factors for PPD to include lower socioeconomic status, not living with a partner, previous stressful events [11]. While this study shows the prevalence of PPD was 13.11%. The associated factors that strongly linked with PPD were unplanned pregnancy, premature baby, poor support systems, poor satisfaction with medical care, and family history of mental illness, recurrent verbal abuse, accident and death of loved one. variation might be the difference in sample size, and regional/ culture of society. In addition to this, the research done in France was specific to women with premature baby.
Research conducted in Iran by using cross-section study out of 6,627 women in their postpartum period were identified and screened for possible depression using BDI. Of these, 57.1% were screened possible cases of depression and based on BDI scores, 20% (1324) fell within the mild range of scores, 18.3% (1211) within the moderate range, and 18.9% (1251) within the severe range. Previous history of an affective disorder, history of depression is consistently a strong risk factor for PPD. The research also found a 35.8% prevalence rate of severe depression (based on BDI score) in women with a past history of depression [13]. But in this study the prevalence of PPD was 13.11%. The associated factors that strongly linked with PPD were unplanned pregnancy, premature baby, poor support systems, poor satisfaction with medical care, and family history of mental illness, recurrent verbal abuse, accident and death of loved one.
The other factors such as cesarean section, episiotomy, neonate illness, desired new born sex, hypertension, and hyper emesis had also their own significant association. This great difference is may be due to sample size, screening instrument and geographical location/living circumstance of society might be contributed. Out of the 149 Pakistani women assessed at 12 weeks in the postnatal period, using the Edinburgh Postnatal Depression Scale (EPDS), Multidimensional Scale of Perceived Social Support (MSPSS) and Personal Information Questionnaire (PIQ),53 scored 12 or above on the EPDS, giving an estimated prevalence of postnatal depression of 36%. Sixty-six percent of the women screening positive in the postnatal period had significant levels of Psychological distress in the antenatal period [14]. In this study the prevalence of PPD was 13.11%.
The associated factors that strongly linked with PPD were unplanned pregnancy, premature baby, poor support systems, poor satisfaction with medical care, and family history of mental illness, recurrent verbal abuse, accident and death of loved one. The other factors such as cesarean section, episiotomy, neonate illness, desired new born sex, hypertension, and hyper emesis had also their own significant association. The variation when compared might be due to timing at which the study was done three months after delivery, multiple screening instrument use, and slight difference in sample size. On the other hand, when we compare this result with similar studies done in Africa which found the prevalence of PPD at Kenya was 10.6% and its associated factors were being unemployment and low household income, were significantly associated with PPD. High Odds ratio of PPD were associated with; sex of infant not desired, being on medication, pregnancy not wanted, prim parity, and been single.
Factors such as age, C/section as mode of delivery were insignificantly associated with PPD [6]. While this study shows the prevalence of PPD was 13.11%. The associated factors that strongly linked with PPD were unplanned pregnancy, premature baby, poor support systems, poor satisfaction with medical care, and family history of mental illness, recurrent verbal abuse, accident and death of loved one. The other factors such as cesarean section, episiotomy, neonate illness, desired new born sex, hypertension, and hyper emesis had also their own significant association. The reasons for this slight difference may be timing at which the study was done three months after delivery, the cultural variation and slight variation in their sample size. The fact that the literature demonstrates a wide variations in what is considered as a significant score on the EPDS, may be the prevalence would have been higher had the significant score been lowered to 11 or 12 as described in the development of the EPDS. Further the prevalence obtained in this study could be an underestimate since some mothers may not have attended post natal care especially if they felt like they were physically well, if they are uneducated or of low socio economic status.

Limitation

Hospital based population may have placed a highly selective group of respondents as seen in the high number of mothers delivered via cesarean section (38.52%) and women’s who have post natal complication. This could have been due to mothers delivered via cesarean section and women are who have post natal complication coming for postnatal care at HFSUH. Most of post natal mothers attained care up to 2 weeks after delivery, so post natal mothers after this period of time didn’t present at study area. There might be mothers who are not available during data collection this decrease the number of cases.

Conclusion

This study found a prevalence of PPD among women delivering at HFSUH, one week after delivery was 13.11% which is a significant high value and compared well with other studies. The associated factors that strongly linked with PPD were unplanned pregnancy, premature baby, poor support systems, poor satisfaction with medical care, and family history of mental illness, recurrent verbal abuse, accident and death of loved one. The other factors such as cesarean section, episiotomy, neonate illness, desired new born sex, hypertension, and hyper emesis had also their own significant association. Residence, educational status, number of birth, age, place of delivery and sex of new born had no significant association with PPD. The findings in this study may form the bases for the need of routine screening of PPD in the post natal care especially those mothers with unplanned pregnancy, premature baby, poor support systems, poor satisfaction with medical care, family history of mental illness, recurrent verbal abuse, accident and death of loved one. This would help prevent PPD at all levels hence a healthy mother.

Recommendations

We would like to recommend
a) Psychiatry staff of Hiwot Fana Specialized University Hospital should collaborates the services given for psychiatric cases and other gynecologic and obstetrics as well as general medical conditions.
b) The result should be available for the Hiwot Fana staff to alert them on magnitude of PPD.
c) Hiwot Fana staff should be routinely screen for mental illness just like other reproductive health problems for mothers attending hospital during delivery and after delivery.
d) Researchers should have do further researches by different study design, at other health institutions.
e) Haramaya University College of health and medical science, Hiwot Fana Specialized University Hospital should plan common policy to intervene the identified problem.
f) Finally ministry of health should design policies that interactively provide service on mental illness of mother and their reproductive problems.

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