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The Prevalence of Depression and other Common Psychiatric Disorders in women who have experienced pre-natal foetal loss at QECH. Dr Kazione Kulisewa Medical Officer- Zomba Mental Hospital/ Mmed (Mw) trainee. Abortion: The Situation in Malawi.

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Dr Kazione Kulisewa Medical Officer- Zomba Mental Hospital/ Mmed (Mw) trainee

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Dr kazione kulisewa medical officer zomba mental hospital mmed mw trainee

The Prevalence of Depression and other Common Psychiatric Disorders in women who have experienced pre-natal foetal loss at QECH

Dr KazioneKulisewa

Medical Officer- Zomba Mental Hospital/ Mmed (Mw) trainee


Abortion the situation in malawi

Abortion: The Situation in Malawi

  • ‘In Malawi, abortion is restricted by law to circumstances where it is performed to preserve the pregnant woman’s life.’ B.A Levandowski et al 2011

  • Prevalence of Abortion in Malawi (2009)

    • 24.0 /1000 women (15-44yrs) B.A Levandowski et al

    • →70,194 induced abortions (range 50,696-89,692)

    • Under-estimated ? 38/1000 women (1995 to 2008) Dr Gilda Sedgh et al 2012


Global incidence of induced abortion 1995 2008 dr gilda sedgh et al

Global incidence of induced abortion (1995-2008) Dr Gilda Sedgh et al


Dr kazione kulisewa medical officer zomba mental hospital mmed mw trainee

  • ‘In legally restrictive settings, women turn to unsafe abortion to manage unwanted pregnancy. Many suffer long-term health consequences…’ B.A Levandowski et al


Dr kazione kulisewa medical officer zomba mental hospital mmed mw trainee

  • Post Abortion Care (PAC) in Malawi

    • ‘1.emergency treatment of incomplete abortion (uterine evacuation) and potentially life threatening complications;

    • 2.provision of Family Planning counselling and services;

    • 3. and links between emergency care and other Reproductive Health services’ . Malawi Ministry of Health and Population, Reproductive Health Unit, National Post-Abortion Care Strategy

  • Impact on Mental Health?

    • no protocols for management or mention of the psychological impact/ psychiatric morbidity


Abortion and mental health is there an association

Abortion and Mental Health- is there an association?

  • significant body of literature:

  • ABORTION→ MENTAL ILLNESS (MI)

    • ‘…having an abortion, independent of other life circumstances, is a traumatic experience with consequences similar to other traumatic experiences, such as rape or war.’ J.R Steinberg et al 2011

  • MORBID PREDISPOSITION + STRESSOR (Abortion)→MI

    • ‘Women likely to have negative psychological outcomes following an abortion are those least apt to cope with any stressful life event…’ J.R Steinberg et al


Dr kazione kulisewa medical officer zomba mental hospital mmed mw trainee

  • PSYCHOSOCIAL STRESSORS→ ABORTION + MI

  • Psychiatric Morbidity associated with Abortion

    • Post Abortion Syndrome M.Boulind et al 2008

    • ‘ … women who have aborted are at a higher risk for a variety of mental health problems including anxiety (panic attacks, panic disorder, agora-phobia, PTSD), mood (bipolar disorder, major depression’ J.R Steinberg et al 2011, E .Robertson Blackmore et al 2011 [8]

    • ‘Numerous studies have demonstrated statistically significant associations between abortion and subsequent substance misuse, a widely recognised and prevalent mental health problem.’ P. Coleman 2011

    • ‘analysis of the largest and strongest studies available resulted in the conclusion that abortion is associated with an increased risk of depression that may lead to self-harm.’ P. Coleman


Dr kazione kulisewa medical officer zomba mental hospital mmed mw trainee

  • Dissenting views: abortion does not pose serious risks above those associated with unintended pregnancy that are carried to term . American Psychological Association Task Force on Mental Health and Abortion. Report of the American Psychological Association Task Force on Mental Health and Abortion.APA, 2008; VE Charles et al 2009; GE Robinson et al 2008

  • The general consensus across literature = prenatal foetal loss (induced abortions or spontaneous miscarriages) put women at an ↑ risk of poor mental health (P. Coleman)possibly due to the psychological factors that preceded and led to the event or directly as a result of the abortion itself.


Rationale

Rationale

  • Lack of local literature describing association in a local Malawian context

    • NEED for clarifying the extent of psychiatric morbidity associated with prenatal foetal loss and using this data to critically inform our post-abortion policies.


Broad objective

Broad Objective

  • To describe the prevalence of common mental disorders CMD) in women presenting at Queen Elizabeth Central Hospital for Post Abortion Care


Specific objectives

Specific Objectives

  • 1) To describe demographic details of women with prenatal foetal loss at QECH

  • 2) To describe the prevalence of Depressive disorders among these women

  • 3) To describe the prevalence of other probable CMD among these women

  • 4) To describe the obstetric/gynaecologic, social and demographic factors associated with CMD in women with prenatal foetal loss

  • 5) To determine the detection rate of probable CMD or Depression associated with prenatal foetal loss by gynaecological staff at QECH


Study design

Study Design

  • Cross sectional quantitative study at QECH

  • Study population

    • Gynaecological admissions; attendees at Gynaecological clinics seeking PAC

  • Sample size: 130 participants (65 cases, 65 controls)


Cases

Cases

  • Inclusion criteria

    • Admissions or outpatient clinic attendees seeking PAC following an abortion, miscarriage or termination of pregnancy

  • Exclusion criteria

    • Women with prior and pre-existing CMD not related to index pregnancy

    • Women who don’t consent

    • Women under 18yrs lacking a guardian


Controls

Controls

  • Inclusion criteria

    • Gynaecology admissions being managed for conditions other than miscarriages or abortions

  • Exclusion criteria

    • Women with a prior and pre-existing CMD

    • Women who don’t consent

    • Women under 18yrs lacking a guardian


Data collection

Data Collection

  • Identification of possible participants from registers

  • Provision of Informed Consent

  • Initial 2 part questionnaire

    • Part 1: Demographic, Gynaecological and Social Details

    • Part 2: Chichewa Self Reporting Questionnaire (SRQ)20

  • Probable CMD (cut-off scores ≥ 9/20)→ Chichewa Structured Clinical Interview for DSM-IV Major/Minor Depressive Episode (SCID-MDE)

  • Case notes/health passports of women with probable CMD read to determine if CMD detected


Ethical considerations

Ethical Considerations

  • Participants who score highly on the SRQ-20 will subsequently be referred to the QECH Psychiatric Unit for further and comprehensive assessment following the SCID

  • Voluntary participation

  • Informed consent


Discussion and questions

Discussion and questions


References

References

  • The estimated incidence of abortion in Malawi. Brooke A. Levandowski, Edgar Kuchingale, Linda Kalilani-Phiri, Hans Katengeza, YirguGebrehiwot, HailemichaelGebreselassie, Juliana Lunguzi, Fanny Kachale, Godfrey Kangaude, ChisaleMhango

  • Induced abortion: incidence and trends worldwide from 1995 to 2008, Dr Gilda Sedgh et al The Lancet , Vol 179, Issue 9816, pg625-632, 18 Feb 2012

  • Malawi Ministry of Health and Population, Reproductive Health Unit, National Post-Abortion Care Strategy

  • Examining the association of abortion history and current mental health: A reanalysis of the National Comorbidity Survey using a common-risk-factors model Julia R. Steinberg, Lawrence B. Finer Soc Sci Med 2011 Jan;72(1):72-82: doi:10.1016


Dr kazione kulisewa medical officer zomba mental hospital mmed mw trainee

  • The Assessment and Treatment of Post-Abortion Syndrome: A Systematic Case Study From Southern Africa, Boulind M, Edwards DJA Journal of Psychology in Africa, 2008 18 (4).pp. 539-548. ISSN 1433-0237

  • Previous prenatal loss as a predictor of perinatal depression and anxiety, Emma Robertson Blackmore, Denise Côté-Arsenault et al) BJP 2011 May;198(5):373-8. doi: 10.1192

  • Abortion and mental health; quantitative synthesis and analysis of research published 1995-2009, Priscilla Coleman BJP Sept 2011

  • American Psychological Association Task Force on Mental Health and Abortion. Report of the American Psychological Association Task Force on Mental Health and Abortion.APA, 2008.

  • Abortion and long-term mental health outcomes: a systematic review of the evidence.Contraception2008; 78: 436–50.Charles VE, Polis CB, Sridhara SK, Blum RW

  • Is there an ‘abortion trauma syndrome’? Critiquing the evidence. Harv Rev Psychiatry 2009;17: 268–90Robinson GE, Stotland NL, Russo NF, Lang JA, Occhiogrosso M


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