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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 36  |  Issue : 3  |  Page : 391-397

Suicidality among Nigerian postpartum women: Prevalence and correlates


1 Department of Mental Health, State Specialist Hospital, Osogbo, Osun State, Nigeria
2 Department of Mental Health, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria
3 Department of Community Medicine, Ladoke Akintola University of Technology Teaching Hospital, Osogbo, Osun State, Nigeria

Date of Submission17-May-2019
Date of Decision23-Aug-2019
Date of Acceptance07-Nov-2019
Date of Web Publication22-Jan-2020

Correspondence Address:
Dr. T Opakunle
State Specialist Hospital, Osogbo, Osun State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TJOG.TJOG_43_19

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  Abstract 


Background: Postpartum suicidality is a major public health concern that has been identified as one of the major contributors to the global mortality burden. It poses a profound risk to women in the postpartum and the community in general.
Aim: To determine the prevalence and correlates of suicidality among Nigerian postpartum women.
Subjects and Methods: This is a cross-sectional descriptive study involving 347 Nigerian women recruited during the postpartum period. They completed a study-specific sociodemographic and pregnancy-related questionnaire, the Edinburgh Postpartum Depression Scale, Suicidal Behaviors Questionnaire-Revised, and the Brief version of the World Health Organization Quality of Life Questionnaire.
Results: The prevalence of lifetime suicidal ideation, plans, and attempts was 10.4%, 2.9%, and 1.7% respectively. In addition, 5.2% of the respondents reported suicidal ideation in the past year, while 4.0% of the respondents indicated the likelihood of suicide attempts in the future. Depression, lower quality of life, preterm delivery, complications during pregnancy, poor support from the husband and the in-laws, stressful infant care, and baby's hospitalization were significantly associated with suicidality.
Conclusion: Suicidality is relatively common among Nigerian postpartum women. Therefore, postpartum women should be routinely screened for suicidal behaviors.

Keywords: Nigerian postpartum women; prevalence; correlates; suicidality.


How to cite this article:
Opakunle T, Aloba O, Opakunle O. Suicidality among Nigerian postpartum women: Prevalence and correlates. Trop J Obstet Gynaecol 2019;36:391-7

How to cite this URL:
Opakunle T, Aloba O, Opakunle O. Suicidality among Nigerian postpartum women: Prevalence and correlates. Trop J Obstet Gynaecol [serial online] 2019 [cited 2020 Feb 19];36:391-7. Available from: http://www.tjogonline.com/text.asp?2019/36/3/391/276441




  Introduction Top


In the developed countries, suicide accounts for up to 28% of all deaths in women within the first year of giving birth and has become one of the three leading contributors to maternal mortality in these countries.[1] Suicidality is a behavioral and cognitive spectrum that ranges from suicidal ideation, making suicide-related plans to the act of committing suicide. It is a major public health concern that has been identified as one of the major contributors to the global mortality burden.[2],[3] Suicidality is now recognized as a serious problem in women during the postpartum period due to the profoundness of the risk posed to the woman's life, the deleterious effects on the growth and development of the baby, its adverse effects on the functions of the family, and possibly the burden on the community as a whole.[4] Suicidal ideation includes thoughts and feelings that are often associated with suicidal behaviors.[5] On the other hand, suicidal behaviors include suicidal plans, preoccupation with thoughts of death, and actual attempts.[5]

According to various studies from European, North and South American, and African countries (excluding Nigeria), the prevalence of suicidal behaviors among postpartum women ranges from 3.2% to 21.6%.[5],[6],[7],[8],[9] Relatively, there are more studies from developing countries regarding suicide-related behaviors in the postpartum period.[9],[10] However, certain factors such as previous suicide attempts, unmarried status, and postpartum depression have been identified as crucial risk factors for an increased likelihood of suicide-related behaviors during the postpartum period from studies in developed countries.[11],[12] In addition, the women who had delivery via cesarean section also have an increased risk of suicidality.[10] Women with unplanned pregnancies, those with retrospective exposure to intimate partner violence, and those with high parity have all been statistically reported to have higher odds of engaging in suicidal behaviors in the postpartum period.[13],[14] Suicidality has also been found to be significantly associated with lower quality of life (QOL).[15]

It has been reported that postpartum women who are at the risk of suicidal behavior feel less prepared for motherhood and experience impaired mother-infant bonding.[16] In addition, the children of women with increased suicidality in the postpartum period prospectively have a higher risk for suicidal ideations and attempts.[17] Suicidality especially suicidal ideation in the postpartum period is also associated with functional impairment, psychiatric comorbidity, increased health service use, and subjective distress.[18],[19]

Despite the observation that studies in developed countries have reported that suicide-related behaviors and the associated burden are not uncommon in the postpartum period,[5],[6],[7],[8] an extensive electronic literature search revealed that suicidal behaviors in terms of their prevalence and correlates have not been examined among Nigerian women in the postpartum period. Hence, the objectives in this study were, first, to determine the prevalence of suicidal behaviors, and, second, to explore some of the correlates of such behaviors in a cross-sectional sample of Nigerian women in the postpartum period. The findings from this study may help in planning health services for women, especially those in the postpartum period. Our findings could also serve as a baseline for further studies related to suicidality among postpartum women in Nigeria.


  Subjects and Methods Top


Study setting

This study was conducted in Osogbo, the capital city of Osun State in Southwestern Nigeria. The city is divided into three local government areas (LGAs). Most of the city residents are either public civil service workers or involved in farming, commercial services, or various artisanship. The study participants consisted of 347 women in their 1st-year post-delivery. They were recruited consecutively over a period of 4 months (December 2018 to March 2019), from the 12 primary health care centers (PHC) distributed across the three LGAs.

Study design

This is a descriptive cross-sectional study.

Procedure

The approval for the study protocol was obtained from the ethics committee of the Osun State Ministry of Health, Osogbo, Osun State. Inclusion criteria included those who are aged 18 years and above who delivered a live baby within the preceding 12 months and can communicate in either the local dialect (Yoruba language) or the English language. Those mothers who indicated that they have a preexisting psychiatric disorder, those who refused to give consent, and those who were too ill to complete the study measures during their presentation in the postnatal clinic were excluded. We also excluded those who were receiving treatment for chronic medical disorders such as hypertension or diabetes mellitus.

Study instruments

The sociodemographic and pregnancy-related questionnaire

This questionnaire consisted of variables such as age, educational status, parity, mode of delivery, illness in pregnancy, etc.

The Edinburgh Postpartum Depression Scale

The Edinburgh Postpartum Depression Scale (EPDS) was used to quantitatively evaluate the severity of depressive symptoms. It has a total of 10 questions which are rated on a 4-point Likert scale (0–3) according to the severity of symptoms.[20] Higher cumulative scores reflect greater severity of subjective depressive symptoms. Cut-off scores range from 9 to 13 points.[20] Its psychometric properties in terms of its reliability, validity, and screening characteristics in identifying Nigerian postpartum women with depressive disorders have been reported to be satisfactory.[21]

Suicidal Behaviors Questionnaire-Revised (SBQ-R)

The suicidal behaviors questionnaire-revised (SBQ-R) consists of 4 items.[22] Item 1 taps into lifetime suicide ideation and/or attempt while item 2 assesses the frequency of suicidal ideation over the preceding 12 months. Item 3 assesses the threat of suicide attempt, while item 4 evaluates the futuristic likelihood of subjectively reporting suicidal behavior.[22] The aggregate score on the SBQ-R ranges from 3 to 18, with higher scores reflecting the greater risk for suicidal behaviors.[22] The SBQ-R in terms of its psychometric and suicide risk screening characteristics have been recently described among Nigerians.[23]

The brief version of the World Health Organization Quality of Life Questionnaire (WHOQoL-Bref)

The brief version of the World Health Organization Quality of Life Questionnaire (WHOQoL-Bref) is a 26-item self-administered generic questionnaire which is a shorter version of the WHOQoL-100 scale.[24] The WHOQoL-Bref quantitatively evaluates four QOL domains: Physical health (seven items), psychological health (six items), social relationships (three items), and Environmental domain (eight items). It also included two separately scored items about individuals' perception of their QOL (Q1) and overall health (Q2). The Q1 and Q2 items and the items in the four domains are scored according to a 5-point Likert format (1–5). The total scores on the physical health, psychological health, social relationships, and environment domains ranges from 7 to 35, 6–30, 3–15, and 8–40, respectively. The lower the score in a domain, the poorer the QOL with respect to that domain. Likewise, poorer QOL is indicated by lower scores on the Q1 and Q2 items. Satisfactory psychometric properties of the WHOQoL-Bref have been reported across different cultures including Nigeria.[25]

Data analysis

All statistical analyses were performed with the Statistical Product and Service Solutions (SPSS) software, 21st version. Descriptive statistics such as the mean (standard deviation) and frequency (percentages) were utilized in depicting the sociodemographic and pregnancy-related variables as well as the scores on the study measures. The dependent variable was suicidality which was measured by the SBQ-R. The directions and strengths of the relationship between the SBQ-R and the other study measures were evaluated by applying correlational analyses. Regression analysis was conducted to identify the variables that were significantly associated with the total SBQ-R scores. The level of statistical significance was set at a P value less than 0.05 and all tests were 2-tailed.


  Results Top


A total of 386 postpartum women who fulfilled the inclusion criteria were given the study measures, out of which 39 returned incompletely filled study measures. Therefore, only 347 were available for the analysis, giving a response rate of 89.9%. [Table 1] shows that the mean age of the respondents was 26.54 (SD 5.06) years. Only 1.2% of them were not formally educated. The majority (83.3%) did not experience significant ill health during pregnancy and almost all (92.2%) had term deliveries. The total EPDS mean score was 7.32 (SD 6.23) while the total SBQ-R mean score was 4.54 (SD 2.48). The physical health, psychological health, social relationships, and environment domain mean scores were 22.33 (SD 2.89), 20.12 (SD 3.01), 10.63 (SD 2.10), and 24.77 (SD 4.32), respectively.
Table 1: Respondents (n=347) characteristics

Click here to view


[Table 2] depicts the prevalence of suicide-related behaviors among the respondents according to the four items of the SBQ-R. Among the respondents, 10.4%, 2.9%, and 1.7% had lifetime suicidal ideations, plans, and attempts, respectively. In addition, 5.2% reported suicidal ideation in the previous year, while 4.0% of the respondents indicated that they are likely to attempt suicide in the future.
Table 2: Prevalence of suicidal behaviors among the respondents (n=347)

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[Table 3] shows the correlational analysis between the SBQ-R and the other study measures. There was a statistically significant modest positive correlation between SBQ-R and EPDS (rp = 0.495, P < 0.001). SBQ-R also had a statistically significant modest negative correlation with all the QOL domains (physical health: rp= −0.355, P < 0.001; psychological health: rp= −0.325, P < 0.001; social relationships: rp= −0.272, P < 0.001; environment: rp= −0.241, P < 0.001).
Table 3: Correlational analyses between SBQ-R and other study measures

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[Table 4] shows the mean differences in SBQ-R in relation to the categorical postpartum-related variables. There was a statistically significant relationship between preterm delivery and postpartum suicidality. The other variables that had statistically significant relationships with postpartum suicidality were complications during pregnancy, poor support from the husband and the in-laws, stressful infant care, and baby's hospitalization.
Table 4: Mean difference in SBQ-R in relation to categorical postpartum variables

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[Table 5] shows that the SBQ-R score was significantly predicted by the EPDS score. This accounted for approximately 26% of the total variance in the SBQ-R score.
Table 5: Multiple linear regression analysis showing variables that significantly predicted the SBQ-R score among the respondents

Click here to view



  Discussion Top


In this study, we reported the prevalence as well as the correlates of suicidality among postpartum women in Southwestern Nigeria. The 12-month prevalence of suicidal ideation in our study (5.2%) is within the range of 5%–14% reported from developed countries.[26] However, an American study reported a lower prevalence rate of 3.2%.[7] On the other hand, the lifetime prevalence of suicidal ideation among the postpartum women in our study was 10.4%. This is lower than the prevalence of 17.1% reported by a Brazilian study.[27] There is still a paucity of literature on the lifetime prevalence rate of suicidal ideation among postpartum women, especially in Africa. Suicidal plans were reported by 2.9% of our respondents, a figure that is much lower than what was reported in a previous study in the United States of America, where a higher finding of 8% was reported.[28] In addition, a Zimbabwean study across six postnatal clinics reported a prevalence rate of suicidal attempt among postpartum women as 4%.[9] This is much higher than what we observed among our respondents (1.7%).

The wide margin of differences in the various facets of suicidality in our study compared to the previous ones could possibly be attributed to cultural and reporting differences as well as due to methodological differences resulting from the study measures adopted in these studies.[29] Suicide attempt is considered a criminal offense in Nigeria, therefore it is plausible that some of our respondents may not voluntarily agree to their suicidal behaviors as evaluated with the SBQ-R items.

Conversely, the prevalence of suicide risk in our study was 4%, which is within the range of 4%–15% reported in several studies across different countries and cultures.[5],[8],[26] Some of the factors that are associated with increased suicide risk among postpartum women include preterm pregnancy, intimate partner violence, lack of social support, and stressful infant care.[5],[9],[16],[30]

As observed among our respondents, previous studies have reported that suicidality during pregnancy and the postpartum period is associated with depression.[16],[30],[31],[32] In a review of perinatal suicide, it was reported that suicidality in the postpartum period is associated with mood disorders, most especially depression.[30] The negative correlation we noted between suicidality and QOL among the Nigerian postpartum women has also been previously reported.[15] Suicidal behaviors lower the QOL in all its domains.[15] In addition, suicidality has been found to be related to violence, conflicts, and other types of relationship problems.[33] In our study, poor support from the husband and the in-laws, stressful infant care, preterm pregnancy, occurrence of pregnancy-related complications, and baby's hospitalization were significantly associated with suicidality. These same correlates have been reported in previous studies that examined suicidality in postpartum women.[5],[9],[16],[28],[30],[34]

In our study, multivariate analysis identified depression as contributing approximately 26% of the total variance in the suicidality score among our respondents. Similar observations have been reported in previous studies from developed countries.[16],[32],[35] The small variance contributed by depression to suicidality in this study is an indication that there is a need for additional studies that will identify other factors that may significantly contribute to suicidality among Nigerian women in the postpartum. It has been established that women who indicated having suicidal ideations in the early phase of the postpartum period have an increased likelihood of developing severe depressive episodes during the latter phases.[36]

The presence of suicidal ideation longitudinally predicts suicidal behavior including suicidal attempt.[36] Suicidal ideation is rarely explored among women presenting during the postpartum period.[37] It has therefore been advocated that suicidal ideation should be specifically screened for among postpartum women.[36] Screening for suicidal ideations among postpartum women may prospectively reduce their risk for suicidal behaviors, in that those identified as having such ideations can be referred to mental health specialists for further evaluations. In our study, depression was the largest contributor to the variance in suicidality, an observation that further lends credence to what has been previously suggested; that health care providers for postpartum women need to carefully monitor women during this period specifically screening for suicidal ideations or thoughts and plans of self-harm as well as symptoms of depression.[6]

This study is not without a number of limitations. First, the participants were selected from PHCs in Southwestern Nigeria (one of six geopolitical regions); therefore, caution must be exercised in generalizing our results to postpartum women in other parts of the country. Second, this study is cross-sectional in nature, thus, the direction of the causality between our dependent variable and the other study measures cannot be categorically established. Third, in this study, almost all the participants had term deliveries (92.2%). This to some extent is a reflection of selection bias, since the participants were recruited from only the PHC postnatal clinics. More studies regarding suicidality are needed among Nigerian women receiving postpartum care in the higher tiers of the healthcare system such as those in the secondary (i.e., general hospitals) and tertiary (i.e., teaching hospitals) facilities. Despite these limitations, the strength of this study is that to the best of the authors' knowledge, no study has previously examined the prevalence and correlates of suicidality specifically among Nigerian women in the postpartum. Further studies are needed in other parts of Nigeria for comparison with our data. In conclusion, this study has shown that the different components of suicidality are relatively common among Nigerian postpartum women.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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