Effect of maternal mental health on infant growth in low income countries: new evidence from South Asia
http://www.100md.com
《英国医生杂志》
1 London School of Hygiene and Tropical Medicine, and Sangath, Goa, India, 2 School of Psychiatry and Behavioural Sciences, University of Manchester, 3 Christian Medical College, Vellore 632002, India, 4 Institute of Psychiatry, London
Correspondence to: V Patel, Sangath, 841/1 Alto Porvorim, Goa, India 403521 vikpat_goa@sancharnet.in
Impaired infant growth, a major problem in South Asia, may require interventions to improve maternal mental health in addition to current interventions targeting infant nutrition
Unicef estimates that over 220 million children aged less than 5 years in the developing world have significantly impaired growth.1 The South Asian region is perhaps worst affected, being home to more than half of all the underweight children in the world.2 This article considers the relevance of new evidence on the epidemiology and impact of postnatal depression in South Asia on poor infant growth in low income countries. This evidence shows, for the first time, that a common and potentially treatable mental health problem in mothers is one of the causes of infant failure to thrive. We use this evidence to present a case that child focused interventions, largely aiming to provide supplementary nutrition, may need to be combined with mother focused interventions that target maternal mental health.
Prevalence and risk factors for postnatal depression
Postnatal depression is depressive disorder occurring in the postnatal period and is typically diagnosed about 4-12 weeks after childbirth (see box).
Several recent studies from South Asia have documented substantial rates of postnatal depression.3-6 Patel et al's cohort study of women attending a district hospital antenatal clinic in Goa, India, reported a prevalence of 23%.4 Chandran et al's community cohort study from Tamil Nadu, India, documented prevalence and incidence of 19.8% and 11%, respectively.3 Rahman et al's community cohort study from Pakistan reported a prevalence of 28%.6 These studies also showed that depressed mothers had significantly higher levels of disability, and that more than half remained ill for at least six months.
Consistent risk factors for postnatal depression were antenatal psychiatric morbidity, economic deprivation, low education, and marital disharmony. Education, support from extended family members, and employment were protective factors. While most of these risk factors have also been demonstrated in developed countries,7 the three South Asian studies have also shown the importance of the sex of the newborn infant as a determinant of postnatal depression. The preference for male children is deeply rooted in South Asia. Women are often blamed for the birth of girls, especially if the woman already has a girl child. Such bias and the limited ability of women to control their reproductive health can make pregnancy and the birth of a daughter extremely stressful, contributing to the risk of postnatal depression.
Postnatal depression among mothers in low income countries can substantially impair children's growth and development
Credit: HELDUR NECTONY/PANOS
Link between postnatal depression and infant growth
Providing continuous care and attention of children is a demanding task, and poor mental health in mothers might be expected to have adverse consequences on their children's health and development. Several studies in wealthy countries provide compelling evidence that postnatal depression is associated with long term emotional, cognitive, and behavioural problems in children.8 The impact on physical development of children has, however, received less attention. In low income countries, maternal competence in child care is likely to have a greater role in a child's physical wellbeing and survival, especially in the first year of life, as the environment is often more hostile than in wealthy countries. Poverty, overcrowding, and poor sanitation are common, with suboptimal maternal care potentially resulting in a greater risk to a child's physical health.9 Three recent studies have provided new evidence of this (table).
Studies from South Asia examining association between maternal mental health and child growth
Diagnostic criteria for postnatal depression (ICD-10)
At least two of the following features must be present for at least two weeks:
A depressed mood for most of the day
Loss of interest or pleasure in activities that are normally pleasurable, such as playing with the baby
Tiredness, decreased energy, and fatigue
Additionally, any four of the following should be present:
Loss of confidence and self esteem
Feelings of guilt and blaming oneself
Recurrent thoughts of suicide or death, including that of the child
Difficulty in concentration
Agitation or lethargy
Sleep disturbance
Appetite disturbance
In a cohort study of babies born in a district general hospital in Goa, India, babies who were under the fifth centile for weight at 6 months were 2.3 times more likely to have a mother who was postnatally depressed at six weeks (P < 0.01). This association remained significant after adjustment for variables such as birth weight, infant physical health, paternal and maternal education, and breast feeding practices.10 In a community based case-control study of risk factors for malnutrition in children aged 6-12 months in Tamil Nadu, India, the odds ratio for postnatal depression was 7.4 (P = 0.01). This association remained significant after adjustment for maternal intelligence, birth weight, breast feeding, immunisation, and economic status.11 In an immunisation clinic based case-control study of undernutrition (below third centile of weight for age) in infants aged 9 months from Rawalpindi, Pakistan, the odds ratio for high levels of maternal mental distress was 3.9 (P < 0.01). The association remained significant after adjustment for birth weight, economic status, maternal age and literacy, infant's sex, and family structure.12
Mechanisms linking postnatal depression and failure to thrive
Several possible mechanisms could link maternal depression with their young children's failure to thrive.9 The first is through the risks that antepartum depression, a common precursor to postnatal depression, could pose to the unborn infant. Studies suggest that depressed mood during pregnancy is associated with poor attendance at antenatal clinics, low birth weight, and preterm delivery.13 14 In wealthy countries it has been shown that depressed women are more likely than non-depressed women to obtain inadequate antenatal care and have increased rates of premature births and lower birth weight infants.15 In low income countries, where antenatal care is more difficult to access, depression in mothers could influence the level of care received, increasing the incidence of low birth weight, and subsequent infant morbidity and mortality. Depression is also associated with risk taking behaviours such as smoking and unhealthy eating, which could further increase the risks to the fetus.16
The second set of mechanisms involves the direct impact that depressive symptoms have on the emotional quality of parenting. In developed countries, depressed mothers have been seen to provide less quantity and poorer quality of stimulation for their infants17 and to be slower in responding and less responsive to them.18 Depressed mothers are also more likely to have negative views of themselves as parents, seeing themselves as having less personal control over their child's development, and less able to influence their children positively.19 Similar findings have been reported in a disadvantaged South African community, where maternal sensitivity in engagement with the infant was found to be significantly poorer in depressed women than non-depressed women.20 Recent evidence from Jamaica suggests that such maternal characteristics as depressed mood, poor parenting, low self esteem, and inability to provide a stimulating environment are associated with undernutrition in children aged 9-30 months.21 The emotional quality of parenting may therefore be an important mediator of the effect of postnatal depression on infant growth.
A third potential mechanism linking maternal depression to physical morbidity in children is through its links with negative life events and chronic psychosocial difficulties. Psychosocial adversity in infancy has been associated with poor growth, particularly stunting.22
Implications for research and policy
Among the many health problems facing families rearing children in low income countries are two common conditions—postnatal depression and infant failure to thrive. Recent research from South Asia provides compelling evidence that failure to thrive is more common in infants whose mothers have postnatal depression. These findings add to the body of evidence indicating that both postnatal depression and failure to thrive may lead to further damaging effects on infants' development.23-25 The hope raised by the new evidence is that the epidemiological overlap might indicate an opportunity for improved intervention, by integrating a stronger psychosocial component into infant health initiatives, targeting mothers and key members of their families.
The prospect for improved interventions can be informed to some extent by the existing literature. Evidence from low income countries shows that postnatal depression can be detected with good sensitivity and specificity using a short screening questionnaire such as the Edinburgh postnatal depression scale.4 5 Recent randomised clinical trials from developing countries have shown the efficacy of antidepressants and group psychotherapy for non-puerperal depression.26-28 There are few studies of interventions specifically for postnatal depression in low income countries, though there is good evidence for affordable community based treatment for postnatal depression from wealthy countries.29 30 However, attempts to show the efficacy of a preventive intervention have so far either failed or been only partially successful.31 32
Public health programmes on child development in low income countries are starting to focus on interventions that promote maternal mental health and appropriate parenting as a means to improve child outcomes. There is some evidence that support and counselling in the antenatal period improve maternal and child health outcomes: for example, a trial from Zambia showed that mothers who received such support took more action to solve infant health problems, an indirect measure of maternal empowerment and problem solving abilities.33
"Women to women" programmes have increased maternal self esteem and empowerment in Peru.34 A recent pilot study examined the effectiveness of a mother-infant intervention on maternal mental health in an indigent shanty town in South Africa.35 The intervention, which was delivered by locally recruited community health workers, aimed to provide emotional support and to encourage mothers in sensitive responsive interactions with their infant. Preliminary evidence indicates that the intervention could improve mother-infant interaction and infant growth. A randomised controlled trial is currently in progress in Goa, India, to evaluate the effectiveness of community counselling in preventing maternal depression among high risk women; pilot studies have shown marked improvements in mental health status, and early evidence from the main trial suggests a high compliance rate with the intervention (Marcus Hughes, personal communication).
In view of the enormous scale of the problem of childhood failure to thrive in poor countries, and in South Asia in particular, it is evident that nutritional programmes will need to be strengthened to ensure that poor children and their mothers have access to an adequate diet. But, in addition to this, we propose that interventions for preventing and treating postnatal depression may be required, targeted according to known risk factors and delivered as part of a package of services provided during the antenatal and early postnatal period. Above all, the new evidence we have reviewed emphatically shows that maternal mental health is a critical, and previously ignored, factor in the association between social adversity and infant failure to thrive in low income countries.
Summary points
Rates of childhood undernutrition are high in South Asia
Postnatal depression is a common cause of disability among mothers in south Asia
Antenatal psychiatric morbidity, economic difficulties, marital disharmony, and the sex of the newborn child are determinants of postnatal depression
Infants of mothers who are depressed show poorer growth outcomes than infants whose mothers are not depressed
Ongoing clinical trials will provide information on whether interventions targeted to the prevention or treatment of postnatal depression help improve infant growth outcomes
We acknowledge the support of the Wellcome Trust and MacArthur Foundation for funding the research on maternal and child health in South Asia.
Contributors and sources: The authors are all psychiatrists, working in South Asia on the epidemiology and treatment of postnatal depression. This article was based on the findings of their independent studies, and supplemented by a review of the research on postnatal depression and child outcomes in developing countries.
Funding: VP and AR are supported by Wellcome Trust career development fellowships in clinical tropical medicine; MH is supported by a Wellcome Trust training fellowship in tropical clinical epidemiology.
Competing interests: None declared.
References
Unicef. Panel 3: Stunting linked to impaired intellectual development. In: The state of the world's children 1998: focus on nutrition. Oxford: Oxford University Press, 1998:16-9. (www.unicef.org/sowc98/panel3.htm, accessed 29 Oct 2003.)
Bhutta ZA. Why has so little changed in maternal and child health in South Asia. BMJ 2000;321: 809-12.
Chandran M., Tharyan P, Muliyil J, Abraham S. Post-partum depression in a cohort of women from a rural area of Tamil Nadu, India. Incidence and risk factors. Br J Psychiatry 2002;181: 499-504.
Patel V, Rodrigues M, De Souza N. Gender, poverty and post-natal depression: a cohort study from Goa, India. Am J Psychiatr 2002;159: 43-7.
Regmi S, Sligl W, Carter D, Grut W, Seear M. A controlled study of post-partum depression among Nepalese women: validation of the Edinburgh postpartum depression scale in Kathmandu. Trop Med Int Health 2002;7: 378-82.
Rahman A, Iqbal Z, Harrington R. Life events, social support and depression in childbirth: perspectives from a rural community in the developing world. Psychol Med 2003;33: 1161-7.
O'Hara M, Swain A. Rates and risk of postpartum depression—a metaanalysis. Int Rev Psychiatry 1996;8: 37-54.
Murray L, Cooper P. Effects of postnatal depression on infant development. Arch Dis Child 1997;77: 99-101.
Rahman A, Harrington R, Bunn J. Can maternal depression increase infant risk of illness and growth impairment in developing countries? Child Care Health Dev 2002;28: 51-6.
Patel V, De Souza N, Rodrigues M. Postnatal depression and infant growth and development in low-income countries: a cohort study from Goa, India. Arch Dis Child 2003;88: 34-7.
Anoop S, Saravanan B, Joseph A, Cherian A, Jacob K. Maternal depression and low maternal intelligence as risk factors for malnutrition in children: a community based case-control study from South India. Arch Dis Child (in press).
Rahman A, Lovel H, Bunn J, Iqbal Z, Harrington R. Mothers' mental health and infant growth: a case-control study from Rawalpindi, Pakistan. Child Care Health Dev 2004;30: 21-7.
Hedegaard M, Henriksen TB, Sabroe S, Secher NJ. Psychological distress in pregnancy and preterm delivery. BMJ 1993;307: 234-9.
Pagel MD, Smilkstein G, Regen H, Montano D. Psychosocial influences on newborn outcomes: a controlled prospective study. Soc Sci Med 1990;30: 597-604.
Copper RL, Goldenberg RL, Das A, Elder N, Swain M, Norman G, et al. The preterm prediction study: maternal stress is associated with spontaneous preterm birth at less than thirty-five weeks' gestation. Am J Obstet Gynecol 1996;175: 1286-92
Milberger S, Biederman J, Faraone SV, Chen L, Jones J. Is maternal smoking during pregnancy a risk factor for attention deficit hyperactivity disorder in children? Am J Psychiatry 1996;153: 1138-42.
Bettes BA. Maternal depression and motherese: temporal and intonational features. Child Dev 1988:59: 1089-96.
Livingood AB, Daen P, Smith BD. The depressed mother as a source of stimulation for her infant. J Clin Psychol 1983;39: 369-75.
Kochanska G, Radke-Yarrow M, Kuczynski L, Friedman S. Normal and affectively ill mothers' beliefs about their children. Am J Orthopsychiatr 1987;57: 345-50.
Cooper P, Tomlinson M, Swartz L, Woolgar M, Murray L, Molteno C. Post-partum depression and the mother-infant relationship in a South African peri-urban settlement. Br J Psychiatry 1999;175: 554-8.
Baker-Henningham H, Powell C, Walker S, Grantham-McGregor S. Mothers of undernourished Jamaican children have poorer psychosocial functioning and this is associated with stimulation provided in the home. Eur J Clin Nutr 2003;57: 786-92.
Montgomery SM, Bartley MJ, Wilkinson RG. Family conflict and slow growth. Arch Dis Child 1997;77: 326-30.
Hay D, Pawlby S, Sharp D, Asten P, Mills A, Kumar R. Intellectual problems shown by 11-year old children whose mothers had postnatal depression. J Child Psychol Psychiatry 2001;42: 871-89.
Wilensky DS, Ginsberg G, Altman M, Tulchinsky TH, Ben Yishay F, Auerbach J. A community based study of failure to thrive in Israel. Arch Dis Child 1996;75: 145-8.
Wright CM. Identification and management of failure to thrive: a community perspective. Arch Dis Child 2000;82: 5-9.
Patel V, Chisholm D, Rabe-Hesketh S, Dias-Saxena F, Andrew G, Mann A. The efficacy and cost-effectiveness of a drug and psychological treatment for common mental disorders in general health care in Goa, India: a randomised controlled trial. Lancet 2003;361: 33-9.
Araya R, Rojas G, Fritsch R, Gaete J, Simon G, Peters TJ. Treating depression in primary care among low-income women in Santiago, Chile: a randomised controlled trial. Lancet 2003;361: 995-1000.
Bolton P, Bass J, Neugebauer R, Verdeli H, Clougherty K, Wickramaratne P, et al. Group interpersonal psychotherapy for depression in rural Uganda. JAMA 2003;289: 3117-24.
Holden JM, Sagovsky R, Cox J. Counselling in a general practice setting: controlled study of health visitor intervention in treatment of postnatal depression. BMJ 1989;298: 223-6.
Wickberg B, Hwang CP. Counselling of postnatal depression: a controlled study on a population based Swedish sample. J Affect Disord 1996;39: 209-16.
Brugha TS, Wheatley S, Taub NA, Culverwell A, Friedman T, Kirwan P, et al. Pragmatic randomized trial of antenatal intervention to prevent post-natal depression by reducing psychosocial risk factors. Psychol Med 2000;30: 1273-81.
Elliott SA, Leverton TJ, Sanjack M, Turner H, Cowmeadow P, Hopkins J, et al. Promoting mental health after childbirth: a controlled trial of primary prevention of postnatal depression. Br J Clin Psychol 2000;39: 223-41.
Ransjo-Arvidson AB, Chintu K, Ng'andu N, Eriksson B, Susu B, Christensson K, et al. Maternal and infant health problems after normal childbirth: a randomised controlled study in Zambia. J Epidemiol Community Health 1998;52: 385-91.
Lanata C. Children' health in developing countries: issues of coping, child neglect and marginalization. In: Leon D, Walt G, eds. Poverty, inequality and health. Oxford: Oxford University Press, 2001: 137-58.
Cooper P, Landman M, Tomlinson M, Molteno C, Swartz L, Murray L. The impact of a mother-infant intervention in an indigent peri-urban South African context: a pilot study. Br J Psychiatry 2002;180: 76-81.(Vikram Patel, chair1, Ati)
Correspondence to: V Patel, Sangath, 841/1 Alto Porvorim, Goa, India 403521 vikpat_goa@sancharnet.in
Impaired infant growth, a major problem in South Asia, may require interventions to improve maternal mental health in addition to current interventions targeting infant nutrition
Unicef estimates that over 220 million children aged less than 5 years in the developing world have significantly impaired growth.1 The South Asian region is perhaps worst affected, being home to more than half of all the underweight children in the world.2 This article considers the relevance of new evidence on the epidemiology and impact of postnatal depression in South Asia on poor infant growth in low income countries. This evidence shows, for the first time, that a common and potentially treatable mental health problem in mothers is one of the causes of infant failure to thrive. We use this evidence to present a case that child focused interventions, largely aiming to provide supplementary nutrition, may need to be combined with mother focused interventions that target maternal mental health.
Prevalence and risk factors for postnatal depression
Postnatal depression is depressive disorder occurring in the postnatal period and is typically diagnosed about 4-12 weeks after childbirth (see box).
Several recent studies from South Asia have documented substantial rates of postnatal depression.3-6 Patel et al's cohort study of women attending a district hospital antenatal clinic in Goa, India, reported a prevalence of 23%.4 Chandran et al's community cohort study from Tamil Nadu, India, documented prevalence and incidence of 19.8% and 11%, respectively.3 Rahman et al's community cohort study from Pakistan reported a prevalence of 28%.6 These studies also showed that depressed mothers had significantly higher levels of disability, and that more than half remained ill for at least six months.
Consistent risk factors for postnatal depression were antenatal psychiatric morbidity, economic deprivation, low education, and marital disharmony. Education, support from extended family members, and employment were protective factors. While most of these risk factors have also been demonstrated in developed countries,7 the three South Asian studies have also shown the importance of the sex of the newborn infant as a determinant of postnatal depression. The preference for male children is deeply rooted in South Asia. Women are often blamed for the birth of girls, especially if the woman already has a girl child. Such bias and the limited ability of women to control their reproductive health can make pregnancy and the birth of a daughter extremely stressful, contributing to the risk of postnatal depression.
Postnatal depression among mothers in low income countries can substantially impair children's growth and development
Credit: HELDUR NECTONY/PANOS
Link between postnatal depression and infant growth
Providing continuous care and attention of children is a demanding task, and poor mental health in mothers might be expected to have adverse consequences on their children's health and development. Several studies in wealthy countries provide compelling evidence that postnatal depression is associated with long term emotional, cognitive, and behavioural problems in children.8 The impact on physical development of children has, however, received less attention. In low income countries, maternal competence in child care is likely to have a greater role in a child's physical wellbeing and survival, especially in the first year of life, as the environment is often more hostile than in wealthy countries. Poverty, overcrowding, and poor sanitation are common, with suboptimal maternal care potentially resulting in a greater risk to a child's physical health.9 Three recent studies have provided new evidence of this (table).
Studies from South Asia examining association between maternal mental health and child growth
Diagnostic criteria for postnatal depression (ICD-10)
At least two of the following features must be present for at least two weeks:
A depressed mood for most of the day
Loss of interest or pleasure in activities that are normally pleasurable, such as playing with the baby
Tiredness, decreased energy, and fatigue
Additionally, any four of the following should be present:
Loss of confidence and self esteem
Feelings of guilt and blaming oneself
Recurrent thoughts of suicide or death, including that of the child
Difficulty in concentration
Agitation or lethargy
Sleep disturbance
Appetite disturbance
In a cohort study of babies born in a district general hospital in Goa, India, babies who were under the fifth centile for weight at 6 months were 2.3 times more likely to have a mother who was postnatally depressed at six weeks (P < 0.01). This association remained significant after adjustment for variables such as birth weight, infant physical health, paternal and maternal education, and breast feeding practices.10 In a community based case-control study of risk factors for malnutrition in children aged 6-12 months in Tamil Nadu, India, the odds ratio for postnatal depression was 7.4 (P = 0.01). This association remained significant after adjustment for maternal intelligence, birth weight, breast feeding, immunisation, and economic status.11 In an immunisation clinic based case-control study of undernutrition (below third centile of weight for age) in infants aged 9 months from Rawalpindi, Pakistan, the odds ratio for high levels of maternal mental distress was 3.9 (P < 0.01). The association remained significant after adjustment for birth weight, economic status, maternal age and literacy, infant's sex, and family structure.12
Mechanisms linking postnatal depression and failure to thrive
Several possible mechanisms could link maternal depression with their young children's failure to thrive.9 The first is through the risks that antepartum depression, a common precursor to postnatal depression, could pose to the unborn infant. Studies suggest that depressed mood during pregnancy is associated with poor attendance at antenatal clinics, low birth weight, and preterm delivery.13 14 In wealthy countries it has been shown that depressed women are more likely than non-depressed women to obtain inadequate antenatal care and have increased rates of premature births and lower birth weight infants.15 In low income countries, where antenatal care is more difficult to access, depression in mothers could influence the level of care received, increasing the incidence of low birth weight, and subsequent infant morbidity and mortality. Depression is also associated with risk taking behaviours such as smoking and unhealthy eating, which could further increase the risks to the fetus.16
The second set of mechanisms involves the direct impact that depressive symptoms have on the emotional quality of parenting. In developed countries, depressed mothers have been seen to provide less quantity and poorer quality of stimulation for their infants17 and to be slower in responding and less responsive to them.18 Depressed mothers are also more likely to have negative views of themselves as parents, seeing themselves as having less personal control over their child's development, and less able to influence their children positively.19 Similar findings have been reported in a disadvantaged South African community, where maternal sensitivity in engagement with the infant was found to be significantly poorer in depressed women than non-depressed women.20 Recent evidence from Jamaica suggests that such maternal characteristics as depressed mood, poor parenting, low self esteem, and inability to provide a stimulating environment are associated with undernutrition in children aged 9-30 months.21 The emotional quality of parenting may therefore be an important mediator of the effect of postnatal depression on infant growth.
A third potential mechanism linking maternal depression to physical morbidity in children is through its links with negative life events and chronic psychosocial difficulties. Psychosocial adversity in infancy has been associated with poor growth, particularly stunting.22
Implications for research and policy
Among the many health problems facing families rearing children in low income countries are two common conditions—postnatal depression and infant failure to thrive. Recent research from South Asia provides compelling evidence that failure to thrive is more common in infants whose mothers have postnatal depression. These findings add to the body of evidence indicating that both postnatal depression and failure to thrive may lead to further damaging effects on infants' development.23-25 The hope raised by the new evidence is that the epidemiological overlap might indicate an opportunity for improved intervention, by integrating a stronger psychosocial component into infant health initiatives, targeting mothers and key members of their families.
The prospect for improved interventions can be informed to some extent by the existing literature. Evidence from low income countries shows that postnatal depression can be detected with good sensitivity and specificity using a short screening questionnaire such as the Edinburgh postnatal depression scale.4 5 Recent randomised clinical trials from developing countries have shown the efficacy of antidepressants and group psychotherapy for non-puerperal depression.26-28 There are few studies of interventions specifically for postnatal depression in low income countries, though there is good evidence for affordable community based treatment for postnatal depression from wealthy countries.29 30 However, attempts to show the efficacy of a preventive intervention have so far either failed or been only partially successful.31 32
Public health programmes on child development in low income countries are starting to focus on interventions that promote maternal mental health and appropriate parenting as a means to improve child outcomes. There is some evidence that support and counselling in the antenatal period improve maternal and child health outcomes: for example, a trial from Zambia showed that mothers who received such support took more action to solve infant health problems, an indirect measure of maternal empowerment and problem solving abilities.33
"Women to women" programmes have increased maternal self esteem and empowerment in Peru.34 A recent pilot study examined the effectiveness of a mother-infant intervention on maternal mental health in an indigent shanty town in South Africa.35 The intervention, which was delivered by locally recruited community health workers, aimed to provide emotional support and to encourage mothers in sensitive responsive interactions with their infant. Preliminary evidence indicates that the intervention could improve mother-infant interaction and infant growth. A randomised controlled trial is currently in progress in Goa, India, to evaluate the effectiveness of community counselling in preventing maternal depression among high risk women; pilot studies have shown marked improvements in mental health status, and early evidence from the main trial suggests a high compliance rate with the intervention (Marcus Hughes, personal communication).
In view of the enormous scale of the problem of childhood failure to thrive in poor countries, and in South Asia in particular, it is evident that nutritional programmes will need to be strengthened to ensure that poor children and their mothers have access to an adequate diet. But, in addition to this, we propose that interventions for preventing and treating postnatal depression may be required, targeted according to known risk factors and delivered as part of a package of services provided during the antenatal and early postnatal period. Above all, the new evidence we have reviewed emphatically shows that maternal mental health is a critical, and previously ignored, factor in the association between social adversity and infant failure to thrive in low income countries.
Summary points
Rates of childhood undernutrition are high in South Asia
Postnatal depression is a common cause of disability among mothers in south Asia
Antenatal psychiatric morbidity, economic difficulties, marital disharmony, and the sex of the newborn child are determinants of postnatal depression
Infants of mothers who are depressed show poorer growth outcomes than infants whose mothers are not depressed
Ongoing clinical trials will provide information on whether interventions targeted to the prevention or treatment of postnatal depression help improve infant growth outcomes
We acknowledge the support of the Wellcome Trust and MacArthur Foundation for funding the research on maternal and child health in South Asia.
Contributors and sources: The authors are all psychiatrists, working in South Asia on the epidemiology and treatment of postnatal depression. This article was based on the findings of their independent studies, and supplemented by a review of the research on postnatal depression and child outcomes in developing countries.
Funding: VP and AR are supported by Wellcome Trust career development fellowships in clinical tropical medicine; MH is supported by a Wellcome Trust training fellowship in tropical clinical epidemiology.
Competing interests: None declared.
References
Unicef. Panel 3: Stunting linked to impaired intellectual development. In: The state of the world's children 1998: focus on nutrition. Oxford: Oxford University Press, 1998:16-9. (www.unicef.org/sowc98/panel3.htm, accessed 29 Oct 2003.)
Bhutta ZA. Why has so little changed in maternal and child health in South Asia. BMJ 2000;321: 809-12.
Chandran M., Tharyan P, Muliyil J, Abraham S. Post-partum depression in a cohort of women from a rural area of Tamil Nadu, India. Incidence and risk factors. Br J Psychiatry 2002;181: 499-504.
Patel V, Rodrigues M, De Souza N. Gender, poverty and post-natal depression: a cohort study from Goa, India. Am J Psychiatr 2002;159: 43-7.
Regmi S, Sligl W, Carter D, Grut W, Seear M. A controlled study of post-partum depression among Nepalese women: validation of the Edinburgh postpartum depression scale in Kathmandu. Trop Med Int Health 2002;7: 378-82.
Rahman A, Iqbal Z, Harrington R. Life events, social support and depression in childbirth: perspectives from a rural community in the developing world. Psychol Med 2003;33: 1161-7.
O'Hara M, Swain A. Rates and risk of postpartum depression—a metaanalysis. Int Rev Psychiatry 1996;8: 37-54.
Murray L, Cooper P. Effects of postnatal depression on infant development. Arch Dis Child 1997;77: 99-101.
Rahman A, Harrington R, Bunn J. Can maternal depression increase infant risk of illness and growth impairment in developing countries? Child Care Health Dev 2002;28: 51-6.
Patel V, De Souza N, Rodrigues M. Postnatal depression and infant growth and development in low-income countries: a cohort study from Goa, India. Arch Dis Child 2003;88: 34-7.
Anoop S, Saravanan B, Joseph A, Cherian A, Jacob K. Maternal depression and low maternal intelligence as risk factors for malnutrition in children: a community based case-control study from South India. Arch Dis Child (in press).
Rahman A, Lovel H, Bunn J, Iqbal Z, Harrington R. Mothers' mental health and infant growth: a case-control study from Rawalpindi, Pakistan. Child Care Health Dev 2004;30: 21-7.
Hedegaard M, Henriksen TB, Sabroe S, Secher NJ. Psychological distress in pregnancy and preterm delivery. BMJ 1993;307: 234-9.
Pagel MD, Smilkstein G, Regen H, Montano D. Psychosocial influences on newborn outcomes: a controlled prospective study. Soc Sci Med 1990;30: 597-604.
Copper RL, Goldenberg RL, Das A, Elder N, Swain M, Norman G, et al. The preterm prediction study: maternal stress is associated with spontaneous preterm birth at less than thirty-five weeks' gestation. Am J Obstet Gynecol 1996;175: 1286-92
Milberger S, Biederman J, Faraone SV, Chen L, Jones J. Is maternal smoking during pregnancy a risk factor for attention deficit hyperactivity disorder in children? Am J Psychiatry 1996;153: 1138-42.
Bettes BA. Maternal depression and motherese: temporal and intonational features. Child Dev 1988:59: 1089-96.
Livingood AB, Daen P, Smith BD. The depressed mother as a source of stimulation for her infant. J Clin Psychol 1983;39: 369-75.
Kochanska G, Radke-Yarrow M, Kuczynski L, Friedman S. Normal and affectively ill mothers' beliefs about their children. Am J Orthopsychiatr 1987;57: 345-50.
Cooper P, Tomlinson M, Swartz L, Woolgar M, Murray L, Molteno C. Post-partum depression and the mother-infant relationship in a South African peri-urban settlement. Br J Psychiatry 1999;175: 554-8.
Baker-Henningham H, Powell C, Walker S, Grantham-McGregor S. Mothers of undernourished Jamaican children have poorer psychosocial functioning and this is associated with stimulation provided in the home. Eur J Clin Nutr 2003;57: 786-92.
Montgomery SM, Bartley MJ, Wilkinson RG. Family conflict and slow growth. Arch Dis Child 1997;77: 326-30.
Hay D, Pawlby S, Sharp D, Asten P, Mills A, Kumar R. Intellectual problems shown by 11-year old children whose mothers had postnatal depression. J Child Psychol Psychiatry 2001;42: 871-89.
Wilensky DS, Ginsberg G, Altman M, Tulchinsky TH, Ben Yishay F, Auerbach J. A community based study of failure to thrive in Israel. Arch Dis Child 1996;75: 145-8.
Wright CM. Identification and management of failure to thrive: a community perspective. Arch Dis Child 2000;82: 5-9.
Patel V, Chisholm D, Rabe-Hesketh S, Dias-Saxena F, Andrew G, Mann A. The efficacy and cost-effectiveness of a drug and psychological treatment for common mental disorders in general health care in Goa, India: a randomised controlled trial. Lancet 2003;361: 33-9.
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