RMH5012: Post-Partum Depression in Benin: A Qualitative Study

This research project, prepared for the Doctor of Public Health program (RMH5012), investigates post-partum depression (PPD) through a qualitative study focusing on the perceptions and views of Beninese women. The study delves into the classification of postpartum mental disorders, theoretical perspectives surrounding PPD, and diagnostic approaches. It reviews existing literature, outlines the methodology including a systematic review and primary qualitative research, and details the study design, population, sample size, data collection, and analysis methods. The project also addresses ethical considerations, dissemination plans, and a budget/timeline. The introduction highlights the global concern of PPD, its impact on maternal and child health, and the varying cultural influences on its perception and management. The study aims to critically analyze the understandings of PPD within the context of Benin, a nation with unique healthcare challenges. The research considers medical pluralism and the potential for under-reporting due to stigmatization. The project explores the classification of postpartum mental disorders, theoretical perspectives like the medical and feminist models, and the Bowlbly attachment theory. It also considers the role of social support and cultural factors in the manifestation and treatment of PPD. The study aims to contribute to a deeper understanding of PPD within the specific context of Benin, considering the limitations and implications of the findings.

Doctor of Public Health
Module: Advanced Independent Public Health Research Project Preparation
and Management
Module code: RMH5012
Credits: 40
Topic: Post-Partum Depression: A Qualitative Study to critically the
Perceptions and Views of Beninese Women of Post-Partum Depression

Contents
1. Introduction/Background:...................................................................................................1
1.1 Classification of postpartum mental disorders:........................................................2
1.2 Theoretical perspectives surrounding PPD..............................................................3
1.3 Diagnosis of PPD..........................................................................................................5
1.4 Rationale and significance of study...........................................................................6
2.0 Aim:.....................................................................................................................................6
2.1 Objectives:.....................................................................................................................6
3.0 Literature review:..............................................................................................................7
4.0 Methods...........................................................................................................................10
4.1 Phase 1: Systematic review......................................................................................11
4.2 Second Phase - The Primary Qualitative Research:............................................12
4.2.1 Philosophical considerations and perspectives..............................................12
4.3 Research question:....................................................................................................15
4.4 Study Design:..............................................................................................................15
4.5 Study population.........................................................................................................17
4.6 Sample Size................................................................................................................17
4.7 Inclusion and Exclusion Criteria...............................................................................17
4.8 Data collection:............................................................................................................18
4.9 Data Analysis..............................................................................................................18
4.10 Limitations..................................................................................................................18
5.0 Ethics............................................................................................................................19
6.0 Dissemination Of Study Findings.............................................................................19
7.0 Budget and timeline....................................................................................................20
References:............................................................................................................................21
Appendices...............................................................................................................................29
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1. Introduction/Background:
Post-partum depression (PPD) has been surrounded by diverse varying views,
concepts and descriptions across cultures, individuals and beliefs. There has been a
global concern in mental health on the increasing rate of mental health problems and
this does not exclude the occurrence of mental health problems in pregnancy and
around the period surrounding pregnancy. It remains of public health concern.
According to Grace et al. (2003), PPD is described as a mental health condition that
can affect maternal behaviour and consequently affect the child’s behavioural,
cognitive, and emotional development of child. This highly impact on family as PPD
leads to affecting on lifestyle of mother. Also, the child may develop symptoms of
depression due to genetics. Likewise, Pin et al, (2013) describe it as an affective
disorder that occurs in women predominantly following childbirth. As a disease which
has no physical symptoms and affects various cultures as it changes lifestyle of
women. Due to it values, ethics, etc. of women changes, there have been varying
influences of confounders related to individual, societal and cultural differences on
the approaches to PPD. This study will critically the understandings and the views
and perceptions of women towards what post-partum depression and the
approaches which have been analyse in the Republic of Benin. In this it is stated that
there Benin is small town and poor nation. Also, primary health care services are not
available. So, different approaches of PPD is followed. Medical pluralism is defined
as the employment of more than one medical system or the use of both conventional
and complementary and alternative medicine for health and illness.
Although depression occurs in both men and women, PPD is the most prevailing
psychiatric disorder following childbirth (Field, 2010), about 85% of women will have
some type of emotional distress during the post-partum period among whom about
10-20% may develop PPD (Miller, 2002). Born et al. (2004) suggest that PPD is
characterised by the occurrence of symptoms of depression within the first 12
months of the post-partum period. Whereas, Brockington, (2004), suggested that it
starts between the second and sixth week and the duration and outcome depends
on early diagnosis and management, Kelly et al., (2001), suggest that about 80% of
cases of PPD are not diagnosed due to ineffective treatment and not treated despite
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high prevalence and the severity of the disease. This leads to a long term negative
consequence for the mother, her child and the family (Gulamani et al., 2013). The
expression of feelings and emotions of an individual is directly affected by the
beliefs and the social values of individual population hence the way PPD is
perceived may differ between the higher-income and the lower-and-middle-income
countries. This is because low income nation does not have sufficient resources.
Also, the health care worker are not experience enough so they do not know how to
perceive PPD. But in high income country health people are experienced. They know
how PPD is perceived. Callister et al. (2010) suggested that the occurrence of PPD
is directly related to how the woman receives care during the postpartum period and
her social surroundings. Halbreich et al. (2006) emphasised that western diagnostic
methods applied uniformly across other cultures may result in PPD being missed for
instance; Chinese women tend to express more somatic symptoms whereas women
in America may express more affective symptoms. This is because in China the
diagnostic method used is limited but in US there are various methods. Due to that in
women symptoms are easily identified. It can be harmonised that different people
from different cultures have varying manifestation of PPD and influences the
identification. This is because they follow various beliefs and ethics which influence
their behaviour and use of PPD. It also led to change in their perception due to which
expression differs. The social support also get effected due to culture.
In the report published by WHO in 2019 it stated that around 10% of pregnant
women and 13% of postpartum women experience mental health problems in the
depression
In developing nations the figure is high it is 15.6% during pregnancy and 19.8% after
birth of child. Supportively, previous reviews, (Robertson, 2004), showed similar
occurrence rates with increased rates in LMIC with major depression reported at
34% and higher rates recognised in black Caribbean women; which may suggest
that an increased prevalence may be related to culture. it is because the prevalence
occur due to ethics and values in culture. thus, it affect on rise in prevalence. In
studies in Ghana reported stigmatisation around behaviour and sociocultural beliefs
that is social class, orientation, etc. may influence the reporting of PPD as PPD may
be missed by health visitors. Due to it, the health care professionals are not able to
analyse the behaviour of patient. This may infer that the prevalence of PPD maybe
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under-reported in settings with significant barriers to reporting such as stigmatisation
of mental health. In contrast to these, Sawyer et al. (2010) suggested that African
women experienced PPD at rates similar to reports in the high-income countries.
However, Halbreich and Karkun (2006), suggested that the global prevalence rate of
10-15 % may be untrue due to wide range of individual prevalence suggested from 0
to 60%. No countries with diverse socioeconomic and cultural factors. It can be
concluded that culture influence the PPD in women. Besides that, in low income
nations there is high prevalence rise. This is because of change in socio culture.
1.1 Classification of postpartum mental disorders:
Although other mental health problem with similar symptoms as PPD may occur in
women at other times in their life, the Diagnostic Statistical Manual 5 (DSM-5) used
in the United States and the International Classification of Diseases (ICD-10) used
internationally as there are no barriers and it have been employed by health care
professionals in the classification of PPD based on the time of occurrence and the
symptomatology, these classification systems have been limited by the onset of
symptoms occurring in the first month to sixth week postpartum but do not account
for the later onset of symptoms. Maternal mental health problems have been
classified into post-partum blues, post-partum depression and post-partum psychosis
(Fitelson et al., 2011); the helmen hierarchy of resort where people first try one thing
and then try another till when they are satisfied. In this there are some related
patterns of resort which led to acculturation issue. Likewise, in treatment choice as
well there can follow hierarchy. The important aspect of health is preventive
behaviour. But the main is recognition of symptoms. Owing to cross-cultural
differences, symptoms are not always grouped together in the same way cross-
culturally. However they may be grouped, some of the important factors that people
in all cultures consider when evaluating symptoms. however, Rai et al. (2015)
considered other additional classifications like post-traumatic stress disorder (PTSD),
obsessive-compulsive disorder (OCD) and post-partum anxiety. Post-partum blues
represents a transient and self-limiting phenomenon occurring within 3-5 days post-
partum which is attributable to hormones and stress and maybe amenable through
providing family reassurance and social support (Dowlati and Meyer, 2020).
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PPD represents a spectrum of conditions in which the woman tends to express
negative thoughts towards her neonate and has some criteria for distinguishing from
major depression severe symptoms like sleep problems, pervasive mood
depression, low energy, anxiety, suicidal ideation, guilt, preoccupation about baby’s
safety and well-being (Rai et al., 2015). Postpartum psychosis represents a
spectrum that constitutes a psychiatric emergency which may occur on the
background of previous psychiatric conditions in pregnancy, bipolar disorder, and
family history of major psychiatric condition (Friedman, 2012; Spinelli, 2009.
Anderson (2012) suggested that previous obstetric emergencies and background of
recurrently sick infant may result in cause of PTSD in women due to which PPD id
developed. With PPD anxiety disorder is related. This can highly impact on
pregnancy and mental health.
1.2 Theoretical perspectives surrounding PPD
Becks (2002) highlighted that three models that help to explore the context of
individual, socioeconomic and mother and partner factors respectively. The medical
model which is individualistic sees mothers as a subject that is acted upon by
biological factors and drawing which remedies are on pharmacological interventions
and electroconvulsive therapy to attain a personal effect (Godderis, 2011). Whereas
the feminist model developed by Christine de pisan contradicts the medical model, it
reflects that the health of the mothers is influenced by socio-cultural in which there
comes ethics, values, etc. which differ from each other and political contexts not
appreciated by the medical model and that the health of the mothers does not follow
thoughts of masculine school (Pierson, 2012). Subsequently, this affirms that a
feminist-cognitive approach which validates women’s issue as the central stage of
the intervention encouraging nurturance of oneself (Becks,2002). The Bowlbly
attachment theory is construed in context of strong emotion and its bond between
women and their partners and therefore recommends the application of interpersonal
psychotherapy and emotionally focused family therapy (Becks,2002; Lefkovics et al.
2014). Further theories such as the interpersonal theory developed by Harry stack
focus on humans being a social subject that their personalities are not dependent on
their intrapsychic experiences but on their interpersonal experience hence remedy
may be determined by interpersonal psychotherapy focusing on relationship
modification and its expectations (Becks, 2002). Finally, the self-labelling theory
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developed by Edwin and lemert conceptualizes mental problems as deviance of
emotional being and failing to manage the emotion and suggests voluntary treatment
and support as potential in the management (Mivšek and Zakšek, 2012; Becks,
2002).
The strength of Bowlby attachment theory is that child gain attachment with worker
and this help practitioner to support child. But weakness is that it lacks scientific fact
so it is not tested. The strength of interpersonal theory is that it focuses on person
history as well. And weakness is that changes in society and in individual can not be
kept. This means that it is difficult to kept changes. The strength of self labelling
theory is that doing self labelling covers all activity including criminal as well. And
criminal activity depends on member of society and personality of individual. But with
change in society the labelling also changes. Thus, individual can rationalise their
deviant behaviour.
Although these theories may not have been absolutely implemented in LMIC
This is because the theory helps in understanding what changes has occurred in
society. But it is critiqued that these theories can not be useful to understand
construct in low middle income nations it is because the changes in society does not
define construct in community. It may be useful in understanding individual and
cultural constructs in the LMIC communities. Along with it, sometimes because of
economic condition as well LMIC can be understood. In addition, an explanatory
system is a system of beliefs and relations among beliefs that provide the
environment in which one statement may or may not be taken as a cause for another
statement.
A framework which has underscored health intervention in South Africa is the PEN-3
cultural model (Hiratsuka, 2016). This explores the implication of culture in the
influence of public health interventions enabling a researcher to unfold the cultural
practices important in analysing good health behaviour as it recognises the unique
cultural practices which may have either neutral or negative effect on health
behaviour (Airhihenbuwa et al., 2009; Iwelunmor et al., 2014). Figure 1.0 depicts 3
domains, cultural empowerment, cultural identity and relationships and expectations,
which interact to influence health.
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Fig. 1.0 showing the PEN-3 Model
(Source : Hasan et.al., 2019 )
Descriptions from this model may be useful in exploring perspectives on PPD as its
identification and organisation of community, group and individual level factors that
influence health enables integrating influence of cultural perspective in health related
issues. Also, it is said that cultural identity is related to relationship and expectation.
Moreover, cultural empowerment comes from cultural identity and what are
relationship in it. thus, there is great impact of culture on health. With ith the
Relationships and Expectations domain, perceptions or attitudes about the health
problems, the societal or structural resources such as health care services that
promote or discourage effective health seeking practice.
1.3 Diagnosis of PPD
Although several theories have considered a few factors such as hormones as part
of what may influence occurrence of PPD, there are limited diagnostic investigations
that may be helpful in the diagnosis of depression that is PPD. Even though this is
the case, screening for PPD has employed tools which capture the series of
functional and emotional symptoms rather than physical symptoms to diagnose PPD.
The Edinburgh Postnatal Depression Scale (EPDS) which utilizes a 10-point scale
with a positive finding assumed on a score of 13 is commonly employed; although its
sensitivity and specificity may be influenced by culture and language This is because
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Cultural
Empowerment
Positive
Existential
Negative
Relationships and
Expectations
Perceptions
Enablers
Nurturers
Cultural Identity
Person
Extended Family
Neighborhood

when people follow different culture then their value and ethics changes. Also, when
they do not understand language so it also influence it. (Fitelson et al., 2011). In
addition to this, Postpartum Depression Screening Scale, a 35-point self-screening
tool of Likert type with 7 subcategories (Vogeli et al., 2018) and 9-item Physicians
Health Questionnaire (PHQ-9) a self-administered type questionnaire which has
been culturally adapted (Urtasun, 2019), have been utilised. Systematic reviews in
Africa (Wittkosky et al. (2014), identified the effective use of questionnaire scales in
identifying risk of PPD. This can suggest that a viable way to identify PPD culturally,
would involve individualised comparison of symptoms using commonly known
presentation. The hierarchy of resort is called an acculturative hierarchy of resort. In
this sequence, allopathic therapy is the first resort. Similarly, in PPD as well this
trend is influenced due to cultural and traditional treatment methods. The main focus
is on treating depression with allopathy medicine. But the choice of medicine
depends on various factors such as age, gender, etc.
1.4 Rationale and significance of study
Although PPD as a public health problem has been identified by author and explored
in the contexts such as culture, risks and mother-child relationships there have been
challenges in middle and low- income countries surrounding PPD culturally. In Benin,
although some studies (Fottrell et al., 2010) have explored the risk of having
psychological distress from obstetric complications, there is a limited exploration of
this entity even though the challenges that influence the identification, management,
and prevention of PPD occurrence are identifiable in Benin cultures (Tuffour, 2017).
So far, the views and perspective of women in Benin cultures about PPD is less
analysed. This study will explore PPD and its concept from the perspective of the
women in Benin culture to explore and understand their narratives, views and
perception of PPD. Findings from this study will in addition to creating a foundation
for further research in Benin, form a basis for local policy and intervention planning
about PPD. There can be barriers in it such as cultural and social issues.
2.0 Aim: To critically explore the understanding and perception of post-partum
depression among Beninese women in the reproductive age through their religious
and cultural domains.
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2.1 Objectives:
 To explore the understanding, views and perceptions of women of pregnancy
age in Benin towards PPD with experienced women in Benin
 To explore what experiences women who have children of Benin have about
PPD.
 To explore the perceptions of Beninese women who had children about the
factors which predispose women to PPD in Benin.
 To explore what barriers exist during healthcare given to women in the
context of PPD.
 To explore the coping measures to PPD among women who had children in
Benin.
 To explore the management of PPD among women who had children in
Benin.
The research question was formed by using PICO framework. In this the problem
was identified and then intervention for it. then, comparison and outcome of topic
was analysed to form research question.
Search strategy- in this the strategy used was phrase strategy. Here, words that is
PPD and women was used together.
Database used- There were different database which was used. It is as below :
Database Why it was used
Pubmed It consists of authentic and large
number of articles, journals, etc.
Cinahl This data base is mostly used by
authors, scholar, etc. to gather data.
Medline It contains reliable and valid articles,
journals, etc. from where info can be
collected.
Search terms-
Words Synonyms
Post partum depression, Post natal depression
Women Female
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Pregnancy Prenatal period
Perception Views
,
PICO question
Problem = women who had children with PPD
Intervention- religious and cultural domain
Control – No religious and cultural domain
Outcome – treatment of PPD
Inclusion criteria Exclusion criteria
PPD women who have children No PPD women
Sub African studies and women The studies from other countries such
as UK, US, Asia, etc.
Studied which is conducted in English
language
Studied conducted in other language
such as French, etc.
Quality assessment of criteria – for this CIPD was used which enabled in maintaining
quality of data.
Data extraction- the data was extracted by selecting the articles which was relevant.
Thus, for that certain criteria were made and then data was extracted.
3.0 Literature review:
A literature review is summary of various studies of a subject area, explores the
interpretable trends and patterns, aggregates findings as a basis to support evidence
for specific research question, forming frameworks and theories and hence helps to
the research question which requires investigation (Pare and Kitsiou, 2017). The that
influence the occurrence of disease in LMIC, several factors including obstetric
problems, poverty, domestic violence and physical health problems including human
immunodeficiency virus. Fottrell et al., 2010; Skeen et al., 2010) have been noted by
Skeen et.al., 2010 to influence the mental well-being of people in Sub-Saharan
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Africa. This section will explore existing studies which investigated post-partum
depression in the various culture which is a public health problem.
Maimburg and Væth (2015), said that regarding the risk factors a parallel
randomized controlled trial (RCT) which explored the effect of short antenatal
sessions in reducing post-partum depression and to identify the obstetric
characteristics of women who have a risk of developing PPD with the aim of
improving early intervention and treatment. Following the educational intervention
and assessment of the participants using questionnaires administered at 24 weeks
and 34 weeks antepartum and 6 weeks post-partum and screening using the
Edinburg Postnatal Depression Scale (EPDS) tool, found that the risk of developing
postpartum depression was associated with both scheduling a caesarean section,
preterm delivery before 30 weeks, low APGAR score of babies, poor pain relief and
poor knowledge of pain relief, less presence of midwives in the labour room, lack of
preparation for hospital discharge, poor or no breastfeeding during puerperium
including insufficient knowledge of breastfeeding, poor mental status and poor
attachment to child within the 6 week period. Although Maimburg and Væth (2015)
focused with a risk of developing PPD, there was a limited indication to emphasize
that the participants all truly had the risk of developing PPD as first-time mothers
were included and the intervention was only limited to the antenatal period with no
consideration for the post-partum hence a chance of influencing the outcome.
It is evaluated that between the 1920s and 1950s, French colonial governments
undertook extensive medical campaigns in sub‐Saharan Africa aimed at managing
tropical disease. There were many campaigns organised by government this was
regarding disease such as leprosy, yaws malaria, etc. however, many people were
forced to taken injections of medications. This led to side effective and death as well.
The campaigns may have affected trust in medicine because villagers were forced to
receive injections, many of the medications had serious negative side effects, and
the medications were ineffective. The digitization and compilation of this historical
data is itself a unique and valuable contribution to understanding the history of sub‐
Saharan Africa.
y
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