Depression among Adolescents during the Antenatal Period in the DRC
How do sociocultural and economic factors influence depression among adolescents during the antenatal period in Kinshasa, Democratic Republic of Congo?
- 🖊️ Author: Leah Caragol
- 📆 Publish Date: February 23, 2023
- 🗒️ Type: Academic Proposal Research Paper
- 🏫 Association: Kings College London
Background
The Democratic Republic of Congo (DRC), with a population of 95.9 million, is among the world’s most populous and poorest countries, ranking 179 out of 191 countries on the Human Development Index (Worldbank.org, 2017). It has the third-highest total fertility rate in the world, with 6.2 births per woman (Mbadu Muanda et al., 2018). Like other high-fertility countries, the population is young, with 52% under 15 years old, with early sexual behaviours and childbearing contributing to high fertility rates (Mbadu Muanda et al., 2018). Among adolescents in the DRC, 119 per 1,000 women are aged 15 -19 years, a higher rate than in West and Central Africa (107 per 1,0000) (Fatusi et al., 2021).
Adolescence, defined as people between 10 and 19 years, is a time of significant life transition (World Health Organization, 2022). Multiple biological, physical, and emotional changes occur in a short period. This transition to adulthood is gradual and extended for many adolescents in high- or middle-income countries. However, the demand to “grow up” is more abrupt and dramatic for youth in poorer countries and communities. This period is often marked by a rise in risky behaviour, including substance use, unprotected sex and other rule-breaking behaviours (Pozuelo et al., 2021). During this phase, adolescents need information-supportive environments, which include comprehensive sexual education and access to mental health care (World Health Organization, 2022).
Multiple factors can affect an adolescent’s mental health, with the vulnerability of poverty and gender as significant risk factors. Worldwide, it is estimated that 1 in 7 10-19-year old’s experience mental health conditions (World Health Organization, 2022). Low social economic status is associated with the development of mental health disorders in children and adolescents due to often being exposed to stressful circumstances such as inadequate housing, neglect, domestic violence and conflict (Corcoran, 2016). For young women, depression is more than twice as prevalent than men due to a unique combination of hormonal changes and life stressors related to relationship dynamics, school, and societal norms (Albert, 2015; Mutahi et al., 2022; Lambani, 2015). Major depression is one of the most pervasive mental health illnesses affecting women during childbearing years, and prevalence rates among teens are estimated between 16% and 44% globally (Hodgkinson et al., 2014). Depression is associated with poor school performance, loss of relationships and worsened decision-making (Corcoran, 2016). Several studies have found risky sexual behaviours, including unprotected sex and adolescent pregnancy, are associated with the feeling of depression (Pozuelo et al., 2021); however, few studies have examined depression among pregnant adolescents in LMICs, despite 95% of adolescent births occurring outside high-income settings (Hodgkinson et al., 2014).
Being an adolescent is a risk factor for both perinatal health and depression. Globally, an estimated 14% of women reported giving birth before age 18 from 2015-2021 (UNICEF DATA, 2022). West and Central Africa, for example, had the highest regional adolescent birth rate at ten birth per 1,000 girls aged 10-14 and 107 births per 1,000 girls and young women aged 15-19 (UNICEF DATA, 2022). Conversely, Western Europe, Eastern Europe, Central Asia and North America had birth rates close to 0 per 1,000 aged 10-14 and between 8-9 births per 1,000 for girls and women aged 15-19 (UNICEF DATA, 2022). Research shows an association between maternal depression and high birth rates; however, there is no available literature on depression prevalence among adolescent girls in the Democratic Republic of Congo (Eboreime et al., 2022). Since being a teenager is a risk factor for both depression and adolescent pregnancy, these figures are imperative to know. Among non-pregnant teenagers, research in Uganda reported a severe depression prevalence of 16.35% and moderate depression of 29.68% among adolescent high school girls (Nabunya et al., 2020).
Adolescent pregnancy poses a profound public health concern (Eboreime et al., 2022). Pregnancy in adolescent girls and young women (AGYW) is associated with poor health outcomes, including maternal mortality and low infant birth weight (Liran et al., 2012). Research shows that unplanned and early pregnancies increase adolescents’ risk for STIs and HIV, and AGYW experiencing unintended pregnancy are more likely to resort to an abortion, which can lead to mortality and pregnancy and birth-related complications (Liran et al., 2012). Children born to AGYW mothers are more likely to have higher rates of health problems (low birth rate, preterm birth, neonatal death), cognitive problems and physical injury during birth compared to children born to adult mothers (Hodgkinson et al., 2010; Kaphagawani & Kalipeni, 2016; Sagalova et al., 2021). Family planning programs and the availability of contraceptives to prevent adolescent pregnancies in DRC have been scaled up in recent decades; however, little progress has been made in using these services due to poorly understood factors.
An analysis of culturally determined risk factors for postnatal depression in Sub-Saharan Africa found that some cultural practices, such as families preferring a male to a female child, are risk factors for maternal depression (Wittkowski et al., 2014). In contrast, social support and strong community togetherness were protective factors (Wittkowski et al., 2014).
Despite the disproportionate impact of mental health among AGYW, research and implementation specifically on this group are scarce in the African context. Understanding the mental health problems experienced by pregnant young women, sociocultural and economic factors that may influence perinatal depression and the specific gaps in mental health services is necessary to inform effective interventions tailored to this vulnerable population. With the early fertility rate in DRCs still high, the association between maternal depression and outcomes, and the risk factors of depression during adolescences; this study will address the research gap.
Research Design
Methods
This quantitative study scrutinises the sociocultural and economic factors influencing depression among adolescent mothers at CPK Clinics in Kinshasa, Democratic Republic of the Congo. The study findings could later be used to propose recommendations to support adolescent mental health and pregnancy.
Objectives:
The following objectives have been identified to address the aims of the study:
- Identify self-reported prevalence of symptoms of depression among young women and adolescent mothers aged 10-19 during their first antenatal visit.
- Identify social, cultural and economic factors associated with adolescent mothers experiencing depression during their first antenatal appointment.
- Explore culturally acceptable available mental health services for adolescents.
A quantitative survey study design has been chosen for this study because it is relatively quick to conduct, I can understand present conditions, and generalise the results to pregnant adolescents in urban Kinshasa, DRC.
Setting
The study will be conducted at seven Presbyterian Community of Kinshasa (CPK) clinics in the capital of the Democratic Republic of Congo, Kinshasa. More than 70% of DRC’s 60 million population live on less than $2.15 a day (Worldbank.org, 2017). The total population in Kinshasa is 15 million (MBF, 2020). Currently, more than 50% of the Kinshasa population is under 20 years old (Ahinkorah et al., 2021).
The Demographic and Health Survey (DHS), a nationwide survey with the most recent data in 2013-14 for DRC, reported 3,980 adolescent births and adolescent fertility of 13% among all adolescents in Kinshasa (Ahinkorah et al., 2021). The health centres operate in the poorest urban populations, providing maternal and primary health care services. In 2020, there were approximately 2,019 prenatal visits and 2,520 maternal deliveries across the seven centres, with more than 50% among adolescents (MBF, 2020).
This setting was chosen because there is a relationship between all seven clinics and the Presbyterian Community, which works to address quality education challenges and promote the well-being of women (MBF, 2020). These clinics are considered to provide quality care to the mothers of their communities, including mental health care (MBF, 2020).
Ethical Considerations
Approval
The study will be submitted for ethical approval to King’s College London, the Democratic Republic of Congo Ministry of Health, and the Presbyterian Community of Kinshasa. A quick Google search did not produce results on if there is an ethics committee for the CPK Clinics. However, this study would collaborate with the clinics to make them aware and consent to the offered study.
Implications
Participation is 100% voluntary, and the study interest will be disclosed to participants before receiving written informed consent to be collected from all respondents. Research in Accra, Ghana concluded that adolescent pregnant women are less supported by parents than non-pregnant peers; however, it is unclear whether an adult would be present at an antenatal visit in CPK clinics (Ahorlu, Pfeiffer and Obrist, 2015). Further ethical considerations would need to include consent from an adult if this was found faithful at the seven clinics during preliminary research since the study population includes those under age 18. The surveys will be given anonymously with no personally identifiable information to ensure confidentiality. All surveys will be copied to an encrypted computer, and paper copies will be stored in a locked cabinet.
Recruit Participants / Sample / Subjects
Adolescent women, aged 15-19, will be recruited through convenience sampling when they present at antenatal visits within the seven health centres. This sampling technique involves sampling a population close to the researcher’s hand, allowing for a more feasible data collection in a shorter period (Dudovskiy, 2012). Each excepting mother will be given a sheet with information about the study objectives and a consent form in French and Lingala, the most commonly spoken languages in Kinshasa (Worldbank.org, 2017). As statically calculated with a 95% CI and 5% margin of error, an ideal sample size is a minimum of 323 participants based on the approximate population of prenatal visits across the seven clinics annually. However, these recruitment numbers are likely not feasible for this study; in consequence, the aim of the sample size is 10% of the monthly clinic visits, which requires additional unpublished data from the seven clinics. Willing adolescent mothers aged 15-19 and in their prenatal period, able to understand the study and provide consent, and who live in the region near a clinic will be included. There will be no exclusions unless they do not fit the stated criteria. The survey will take a maximum of 20 minutes and will be administered privately at the seven clinics. The survey will have four sections with age-appropriate questions; social, economic and demographic characteristics, questions to assess symptoms associated with depression and sexual health behaviours; and questions related to knowledge and cultural practice of mental health.
Measures
Section A, social, economic and demographic characteristics of the survey will include questions that adolescents can answer. Their socioeconomic status, as they know it, will be recorded through questions on the World Bank wealth index tool, such as if there is a presence of a stove, toilet, electricity, etc. Demographics collected will include information such as educational level, religion, mother and father’s educational status, peers’ influence to engage in sexual intercourse, parents/sibling/peers’ reaction to pregnancy; modelling after a study examining pregnancy-related socio-cultural factors among adolescent girls in Ghana (Ahinkorah et al., 2019).
Section B, questions to assess symptoms associated with depression, will use the PHQ-9: Modified for Adolescents from Dartmouth-Hitchcock Medical Center (n.d.). The PQ-9 tool is a widely used and reliable instrument in diagnosing and determining the severity of depression (Ford et al., 2020). This self-report tool is free to use and asks the adolescent to rate on a four-point scale ranging from “not at all” to “nearly every day”, the frequency of which they have felt specific depressive symptoms in the two weeks prior (see Figure 1). Researchers have confirmed the validity of this tool across many settings (Ford et al., 2020). The specific survey for this study has been adapted for adolescents and will be used as a self-reported tool. We could potentially use the healthcare workers to ask these questions to the young women participating; however, there are concerns that the participants may not respond truthfully due to the stigma of mental health in DRC. The purpose of this section is not to diagnose women with depression but to use it as a data point in connection with the complementary survey sections to determine any relationships or patterns between depressive symptoms and other factors.
Section C, sexual health behaviours, is to be designed to ask young women to recall the age they first had sexual intercourse; remember the last time they had sex or missed their period; if they have been sexually assaulted in the past or if the sex was consensual; if any method was used to prevent pregnancy including condoms, withdrawal, some other method or not sure; and in an optional open-ended question, if the pregnancy was planned and if they intend to carry to term or abort the pregnancy. These questions can help provide a reasonable estimation of sexual behaviours and influencing factors in society. It will also inform the researcher if the pregnancy was planned and if they intend on keeping the pregnancy, which will provide valuable data in support of, or not, of completed research which estimated 49% of unintended adolescent pregnancies ending in abortion and can provide an understanding of how depression may impact their decision (Fatusi et al., 2021).
Section D, questions related to knowledge, cultural practice and attitude will include “yes” or “no” and open-ended questions. Questions will be designed with responses in mind from a study conducted in rural and urban populations of DRC exploring attitudes toward sexual and reproductive adolescents and young people (Mbadu Muanda et al., 2018). Mbadu Muanda et al. findings reported fear of pregnancy, judgmental attitude of health providers, and fear of side effects of contraceptives (2018). In consequence, the questions will be centered around these topics. Open-ended questions will explore the mental health challenges of adolescence and pregnancy and how young women are supported or would like to be. This section will allow the participant to share more in-depth any additional factors they would like to raise about pregnancy and explore how the Mbadu Muanda results may apply to this population (2018).
Data Analysis
Survey data will be analysed using IMB SPSS statistical software. I have chosen this software because it is free and can offer the necessary tests; chi-square and t-tests. General characteristics of the study participants plan to include age, socioeconomic status, education level, mental illness, fear, (un)planned pregnancy, age at first intercourse, and support. These groups are subject to change based on sample size. SPSS will calculate the mean and standard deviation of these subgroups. The differences between categorical (ex: age) and continuous variables (ex: occurrence of depression) will be analysed with chi-square and t-tests. Multiple linear regression can be used to review the relationship between cultural and social factors influencing pregnant adolescent mental health with multiple predicting factors. The results of the regression models will be reported with 95% confidence intervals, and statistical significance will be set at 0.05. If the p-value is equal to or lower than 0.05, it will have moderate statistical significance.
Critique and Complementary Method
Critique
Although this study will provide valuable data for informing on cultural, social and economic factors affecting adolescent pregnancy and mental health, there are some limitations where a complementary study might be helpful.
Surveys are completed at one point in time, and in addition to issues regarding recruitment, there can be response bias. There may be a lower priority for the survey on first antenatal visits, resulting in low sample sizes and potential answers not reflective of the individual’s experience. Additionally, the study population is adolescents who may be uncomfortable answering questions regarding sexual behaviours and mental health for fear of being judged. The findings of this study may not be generalisable to all poor adolescent pregnancies in DRC as the study is in Kinshasa, an urban setting, and factors may contribute differently in rural settings of the country. As mentioned, self-reported information may be liable to desirability and response bias, particularly among adolescents reporting their pregnancy as indented if there is a stigma.
Though this study is likely feasible for a master’s student to undertake, recruitment would be one of the most considerable challenges. When designing this study, I considered this a potential issue due to the limited online data for CPK clinics. Small sample sizes would result in less statistically significant data to conclude any patterns. Therefore, preliminary data needs to be collected on how many maternal visits per day at the clinic and any specific demographics to help determine if this is the right setting for this study. This research question could be applied to many LMICs, due to most mental health adolescent data and pregnancy materialising in high-income countries.
Complementary Method
To address these limitations, a complementary qualitative study could be executed. This study would analyse community-based informal healthcare workers (e.g., church leaders, traditional healers, traditional birth attendants) and healthcare workers’ knowledge, perceptions and practice towards the mental health of pregnant adolescents. To achieve this, focus group discussions would be the most advantageous method to provide rich and culturally relevant information about adolescent pregnancy and social factors affecting mental health in their communities.
In the same setting, seven focus group discussions (one per community surrounding clinics) will be carried out. A convenience sampling procedure will be conducted to recruit informal and formal healthcare workers. Participants will be made aware of the study objectives, they can leave at any time during the FGs, and that data is securely stored before being required to present written consent. The inclusion criteria will be providing some healthcare to adolescent girls residing in one of the seven communities. Any parents of currently pregnant adolescents will be excluded to limit cognitive bias from their own experience and allow for a productive discussion. A local researcher will lead focus groups in Lingala which will last approximately 90 minutes. Questions will be adapted from Fatusi et al. (2021) exploring unintended pregnancy, induced abortion and experiences among adolescents in Kinshasa. The findings indicated cultural perspectives and norms against pre-marital sex, low contraceptive use, and varied reported barriers to access to care (Fatusi et al., 2021). At the end of the session, the local researcher and King’s researcher will manually translate and transcribe the recorded data to be analysed through thematic analysis.
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