Mrs Caroline Ajetunmobi, a full-time housewife, lives in Ejigbo area of Lagos. Each time the woman delivers a baby, she always loses her sanity for about one year. The three times she had delivered babies, the same fate had befallen her. Now, she has stopped having new babies because her husband is afraid she may suffer the same depression again.

If Caroline’s challenge is insanity, Mrs. Nkechi Apama can be said to have been lucky to an extent. Her own experience is weight gain. She has added so much weight that many who knew her as a thin lady now call her ‘Biggie’, a derogatory manner of alluding to her fatness.

It is becoming obvious that there is poor knowledge of postpartum depression among postnatal women, and poor recognition of its symptoms by health practitioners in Nigeria, a situation that has resulted in poor diagnosis of the illness. It does not necessarily keep mothers in hospital but it creeps into the child-nursing stage from the first six weeks, and torments the very existence of not only their womanhood but also motherhood, endangering the lives of the affected mother and that of the child.

Postpartum Depression (PPD) is one of the most common but obscure complications of childbirth in Nigeria and some other parts of Africa. It is a mental health disorder that affects postnatal women globally. The condition is on the rise and many women are facing the challenge.

This perceived depression is said to be the reason a mother, Chidima Arinze, murdered her three-month-old baby boy, Chibusoma Arinze, and a four-year-old daughter, Esther Arinze, at the same time in Enugu State recently. The police reported that both victims bore marks of violence suspected to have been inflicted with a sharp object. The mother of the two children has been arrested and taken into custody while the case is still being investigated.

Narrating her experience as a first-time mother to The Guardian, Chioma Eze said: “Keeping shape has always been a big deal for me especially, because of my career. My profession does not give room for unnecessary body fat or weight that slows you down physically and makes you look tacky. So, when I got pregnant, I was very conscious of my weight, I didn’t want to add so much weight despite the fact that a protruding tummy was inevitable. But after I gave birth, I suddenly started adding so much weight. I think it came from eating so much because I lost a lot of blood during childbirth and the doctor advised recuperating by eating properly without skipping meal time as I used to do before pregnancy. So, I did breakfast, lunch and dinner. I even did in-between meals. And one morning, I woke up to the mirror and saw that I didn’t recognise myself, as every part of my body started looking plum, despite everything I did to stop it, including food reduction, eating more of vegetables and fruits, and doing daily exercise, it did not stop.

“Later I started feeling so empty and withdrawn. My husband did everything to talk me out of it but that feeling of emptiness lingered, I can’t even explain why I felt so unhappy about my look. However, my husband kept encouraging me. One day, he said something that clicked for a minute – he said a little bit of flesh here and there is what gives the proper woman-look and that is what motherhood has blessed me with. I smiled, and surprisingly I felt good. So, the next day I took pictures of myself and posted them on social media, and a lady commented on the post, saying: ‘You are now looking so big. You are fat.’’ The next person called me ‘Orobo’, meaning very fat. In one of the pictures, part of my backside was showing due to the posture, and someone else said: ‘Your backside is now massive.’ I didn’t feel good about all these comments, I felt horrible.

“I lost my mind, I cried, I broke down, I couldn’t even attend to my baby. When my husband called and heard me crying, he rushed home, and by the time he got home, I was already running temperature. He didn’t know what was wrong, I didn’t tell him about the social media thing because I took down all the pictures immediately. When we got to the hospital, after speaking with the doctor alone, he diagnosed postpartum depression and got me into a counseling session in the hospital. I went for a couple sessions but it was not helping, so I stopped.”

Eze said she wanted to lose weight, believing that it is the only way she can get better. ‘’I want to look good, I love looking good, I want to wear a dress and have it fit me perfectly and I am all happy about my body and feel good in my own skin without feeling uneasy about excessive fat here and there. A friend of mine who had a baby a year ago and also added weight came to visit me and she looked slim and perfectly shaped. I asked her what she did and she said ‘intermediate fasting’ but I am a breastfeeding mum, I can’t even do that now.”

Another woman, Jennifer Chinenye Emelife, who spoke on her experience, said: “It took two years to start loving my body again after childbirth. I’d go to my best friend and we discuss about how different I felt in my skin and how terribly sad that has made me. And she’d say, ‘First of all, Jenny, you look great and your body has gone through something remarkable. Give it time and give yourself some grace. However, time and grace are two things new moms struggle with. There are still things about my pre-pregnancy body that I miss, but I’ve learned to be kinder to myself. So, to every struggling mama I say that body of yours grew a human being, brought it into the world, and fed it. That’s a big deal. Be gracious to yourself,” Jennifer said.

On her part, Christiana Iko-Ojo Amodu, a mother, said: ‘It’s so hard to make sense of it and it’s so saddening thinking about the changes. Postpartum depression is traumatic. Some people get over it easier than others. Some just accept the changes and roll with it, while others get stuck in it.”

Chisom Agha said: “I am going through postpartum depression at the moment. My weight gain is my biggest challenge. I do not like the outcome of my body after childbirth. Honestly, I don’t find it funny at all. There’s nothing I haven’t tried on my skin, yet it just wouldn’t work. My greatest joy lies in the fact that my baby came out so flawless and beautiful. At least seeing her gives me consolation.”

Oluwafunmilayo Babatunde, who is also experiencing postpartum weight gain, said: “I am in this phase and it’s been truly a struggle. I will learn to be gracious to myself going forward.”

According to experts, this disorder sets in immediately or about two to six weeks after delivery and may last for over a year. It is characterised by symptoms such as tearfulness, a feeling of complete hopelessness and helplessness, emotional liability, self-dislike, frustration, feelings of guilt, sleep problems and zero will to run daily life activities.

In a 2020 journal of the National Institutes of Health (NIH) on the prevalence and predictors of postpartum depression, it is stated that about 10 to 15 per cent of postnatal women are affected globally on a yearly basis.

Factors Responsible For PPD
SOME of the major factors spiral from sociodemographic causes such as: religion, age, socio-economic status, education and unemployment.

Also, obstetric and infant care factors such as unplanned pregnancy, complications in pregnancy, an unhealthy baby, death of an infant, parity, and history of abortion, have been reported as risk factors. Lack of antenatal care, history of psychiatric illness, stress, marital problems, and lack of emotional or social support have also been identified.

The most stable risk factors/predictors reported over time include a prior history of depression, inadequate social support, lack of cordial mother’s relationship with her partner, and stress.

Hence, as exciting as the birth of a baby can be to a mother, it can also be emotionally draining, tasking, and stressful, leading to a depressed mood, which affects a woman’s quality of life, social functioning and economic productivity.

A study on postpartum depression by NIH revealed that it has significant effect on the mother and long-term consequences on the cognitive and emotional development of most children whose mothers are affected. While PPD can progress into major depression, and carries a great risk of ill health and death, it remains an under-diagnosed and underrated illness in many countries.

According to reports, incidence of PPD is three times higher in developing countries compared to developed nations. There are various factors accounting for the high burden of the illness. The estimated prevalence of PPD in Africa is 18.4 per cent. However, various countries have reported higher rates. Among them are Uganda (43 per cent) and Cameroon (23.4 per cent) when compared with Ethiopia (13.1 per cent), Ghana (3.8 per cent) and Morocco (11.6 per cent).

In Nigeria, various studies have been conducted to determine the prevalence of PPD, using the Edinburgh Postnatal Depression Scale (EPDS). In western Nigeria, the lowest and highest prevalence of PPD reported were 14.6 per cent and 23 per cent in that order.

Two different studies conducted in Southeast Nigeria reported a low prevalence of 10.7 per cent in one and a high prevalence of 30 per cent in the other. In Northern Nigeria, high prevalence rates of 44.5 per cent and 21.8 per cent were reported.

Speaking to The Guardian on postpartum depression, the Managing Director of White Clinics & Fertility Centre, Ota, Dr Nwachukwu Paul Malcolm, described the health situation as a mood disorder, which may affect certain females of child-bearing age after childbirth. And this can occur within 48hours to one year post-childbirth.

“The Medical angle (public health) to this is the prevalence of the occurrences, as it is known that 85 per cent of women experience puerperal blues. An estimated 400,000 babies are born by depressed mothers yearly. This information is according to the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics,” Malcolm noted.

He said: “I believe that Nigeria’s local national statistics would be way higher based on risk factors that are peculiar to our people such as adolescent marriages. It is a known fact that some adolescent females are forcefully given out in marriage and this in turn creates bitterness and sadness in their hearts, leaving them soaked up in grief and pregnancy by rape. Homeless females made pregnant, drug addicted females made pregnant, among others, could develop into postpartum depression.

“The clinical presentation of postpartum depression includes expression of sadness, mood disturbance, tearfulness, fatigue, poor appetite, poor sleep, lack of interest in anything, anhedonia, anxiety, suicidal thoughts, recurrent persistent thoughts of death, and despairing.”

When asked what causes postpartum depression, Malcolm said: “Hormonal factors such as decrease in the level of certain hormones like oestrogens, progesterone, cortisol, and prolactin after childbirth has been discovered. A study carried out by Metha et al revealed that differently expressed estrogen transcripts could be responsible for this depression. Also, there are psychosocial factors: Woolhouse et al found that domestic violence, loss of breadwinner, loss of job, accommodation, support system, poor sleep, dysmorphic bodily changes are implicated. Zacher Kjeldsen et al carried out a study to show that family factors/biological factors lead to depression as linked to family history. Silverman et al proved that past depression can lead to postpartum depression.”

On the diagnostic tools used for picking up perinatal and postpartum depression by caregivers, the medical practitioner mentioned Edinburgh Postpartum Depression Scale (EPDS), which is a 10-question template, Montgomery -Asberg Depression Scale (MADRS) and Postpartum Depression Screening Scale (PDSS).

Malcolm noted that postpartum depression can be managed in two dimensions. ‘’There is non- pharmacological, which involves the use of cognitive behavioural therapy and interpersonal therapy, taking balanced diet, regular exercises, adequate sleep, selfcare and open communications with support teams. There is also the pharmacological, which includes the use of Selective Serotonin Reuptake Inhibitors (SSRIs), Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs), and Tricyclic Antidepressants (TCAs), among others.” Malcolm explained.

The prevalence of postpartum depression among postnatal women in Nigeria has increased in recent times as more women are now in the know of the illness.

The NIH study examined the prevalence of postpartum depression among postnatal women in Lagos where chi-square and logistic regression analysis were used to determine association and predictive relationships between various factors and the presence of postpartum depression. The result showed that the prevalence of postpartum depression amongst postnatal women in Lagos was 35.6 per cent as at the time of the research. Multiparity, delivery by cesarean section, mother being unwell after delivery, and not exclusively breastfeeding the baby were the factors linked with postpartum depression.

The study further revealed that having postpartum blues, not getting help with caring for the baby, experiencing intimate partner violence and having an unsupportive partner, were identified as predictors of postpartum depression.

Curbing Postpartum Depression.
TO curb this postnatal menace, social support for women both in the pre-and-postnatal periods, and routine screening of women for postpartum depression should be encouraged for early detection and immediate intervention.

Certain factors help reduce PPD in some parts of Nigeria: communal-living lifestyle found especially in rural settings enables social support and companionship from members within the community. This gives a sense of comfort and relief to women, from the challenges of pregnancy to delivery. In addition, the traditional naming ceremony that is typically celebrated on the baby’s eighth day of life in some African cultures enables mothers to maintain high spirits in the first few days after delivery.

Furthermore, the cultural practice of ‘omugwo/ olojojoomo’ where a woman’s mother or her mother in-law takes residence with her after her delivery for periods up to six months or more to care for both the mother and the baby helps the newly delivered woman to quickly adjust to life after childbirth. This and similar practices reduce the stress and anxiety that come with motherhood and hence reduce the risk of developing PPD.

Postpartum Depression Enabler
A lot of women during postnatal visits to the clinic conceal their emotions and view PPD as normal rather than as an illness of concern, thus keeping their feelings to themselves, bottling up in silence. It is also a fact that many women are unaware of the signs and symptoms of the illness, and those that are aware that they have a problem, tend to keep quiet about it for fear of being stigmatised or considered weak.

A descriptive cross-sectional study was carried out in a number of primary healthcare centres in Lagos, Nigeria among women attending infant immunisation clinics and the result shows 57.6 per cent was within the age group 21 to 30 years. A greater proportion of the respondents were Christians (62.4 per cent), majority (91.6 per cent) married or in-union, 85.2 per cent of them being in monogamous marriages.

Yoruba made up 40.4 per cent, Igbo were 23.2 per cent, Hausa 7.6 per cent, and other tribes (Tiv, Ibira, Efik) made up 28.8 per cent of the respondents. Noteworthy is the fact that the majority (74 per cent) of the respondents did not experience any complications during pregnancy. More than half (61.2 per cent) had two to four children. Vaginal delivery was the most common mode of delivery among respondents. Almost a third (26.6 per cent) of the respondents had been unwell since their delivery. As high as 67.2 per cent of the respondents had experienced postpartum blues, attributed to lack of support in caring for the baby and themselves (38.1 per cent), followed by having insufficient funds (30.4 per cent).

The study showed that male children were the desire of 42 per cent of the respondents, though 47.6 per cent eventually had male babies. An optimal birth weight (2.5kg – 4.0kg) was found with 87.6 per cent of the babies, while 69.6 per cent had optimal weights of 4kg to 6kg at six weeks of life. Majority of the babies were exclusively breastfed (68.8 per cent).

A gynaecologist in Nigeria, Dr. David (surname withheld) said genetics, depression, stress, anxiety, pregnancy, childbirth, certain medications, hormonal imbalance such as Polycystic Ovary Syndrome (PCOS), Cushing’s syndrome, hypothyroidism, medical issues related to kidney, heart, as well as psychological factor, lifestyle, among others, are some of the reasons women experience weight gain.

According to the expert, while a few of these factors can be managed through optimum and dedicated preventive measures, a number of them can’t be controlled.

“Postpartum depression doesn’t affect only mother that gave birth, it can also affect surrogates and adoptive parents. However, what we tell postnatal women who have been diagnosed of postpartum depression is that, it is common to experience hormonal, physical, emotional, financial and social changes after having a baby. So time, positive mindset and the needed help from loved ones make it better.”