|ORIGINAL RESEARCH REPORT
|Year : 2016 | Volume
| Issue : 3 | Page : 105-111
Impact of maternal mental health on maternal-child interaction in attendees in a community health clinic in Lagos, Nigeria
Motunrayo A Oyelohunnu1, Yewande O Oshodi2, Elizabeth A Campbell1, Mercy Eigbike1, Kofoworola A Odeyemi3
1 Department of Psychiatry, Lagos University Teaching Hospital, Lagos, Nigeria
2 Department of Psychiatry, Lagos University Teaching Hospital; Department of Psychiatry, College of Medicine, University of Lagos, Lagos, Nigeria
3 Department of Psychiatry, College of Medicine, University of Lagos; Department of Community Health, Lagos University Teaching Hospital, Lagos, Nigeria
|Date of Web Publication||4-Jul-2016|
Yewande O Oshodi
Department of Psychiatry, College of Medicine, University of Lagos, Lagos
Source of Support: None, Conflict of Interest: None
Background: Maternal mental health, in particular depression, has been found to negatively impact mother-child interaction, attachment, stimulation, growth, and many important aspects of development in the young child. These early deficits if sustained and unattended may have negative immediate and long-term consequences on the outcomes in the child. The study aimed to assess psychological distress and postpartum depression in mothers, and their relationship to the mother-child interaction. Methodology: This is a descriptive clinic-based study. Eligible and consenting mothers are attending the child immunization clinic in the Lagos University Teaching Hospital, Lagos, Nigeria participated. Consecutive mothers completed the interview questionnaires independently while those who were not literate had the questionnaires administered by trained interviewers. Instruments used were a sociodemographic proforma, the General Health Questionnaire-12, Mother and Infant Attachment Scale (MIAS), and the Zung Depression Scale. Results: In total, ninety-eight women were enrolled, 66.3% were aged between 26 and 35 years, and mean age of 30.9 years (±5.1 standard deviation). Most were aged between 26 and 35 years (66.3%). Over 90% had at secondary school education or more. Over a 10 th (13.3%) was unemployed and 96% married. The children were aged between 6 weeks and 1 year, males (63.1%), and females (46.9%), and the majority were born by spontaneous vaginal delivery (82.7%). A 10 th (10.2%) of the women had probable psychiatric morbidity, 14.3% had scores suggestive of postpartum depression, and 18 (16.3%) scored below average attachment in interaction with their children on the MIAS. There was an association found between reduced maternal-child attachment interaction and maternal depression (P ≤ 0.05). Conclusions: Emotional disorders, such as depression, in mothers can be associated reduced maternal-child interaction. It is important that integrated mental health care services be offered to women.
Keywords: Attachment, infant, maternal, mental-health
|How to cite this article:|
Oyelohunnu MA, Oshodi YO, Campbell EA, Eigbike M, Odeyemi KA. Impact of maternal mental health on maternal-child interaction in attendees in a community health clinic in Lagos, Nigeria. J Clin Sci 2016;13:105-11
|How to cite this URL:|
Oyelohunnu MA, Oshodi YO, Campbell EA, Eigbike M, Odeyemi KA. Impact of maternal mental health on maternal-child interaction in attendees in a community health clinic in Lagos, Nigeria. J Clin Sci [serial online] 2016 [cited 2019 Aug 21];13:105-11. Available from: http://www.jcsjournal.org/text.asp?2016/13/3/105/185246
| Introduction|| |
The postpartum period is a very sensitive period for the development of mother-child interaction and bonding  and in the development of a relationship with the newborn, and it has been found that the maternal-child interaction is a central psychological process that goes on in the puerperium period. 
The role of maternal mental health disorders as a leading cause of maternal morbidity and mortality has also been established in developed countries,  with one in five mothers of full-term infants experiencing a perinatal mental health problem.  This highlights the significant interplay between poor mental health during pregnancy and in the year following birth, its potential significant impact on the mother-infant relationship and consequently on the social and emotional development of the infant. ,
Maternal mental illness has often would have a detrimental impact on a woman's ability to care optimally for her child. ,, It has been established that social, emotional, and mental health problems such as depression, anxiety disorders, domestic violence, drug and/or alcohol misuse, and lack of social support occurring in women during the perinatal period are major public health concerns  and are associated with poor outcomes for women and their children. ,,, Many of the maternal health conditions are often not diagnosed or treated,  and these psychiatric morbidities in woman perinatally have not been studied in detail, depression seems to have been studied quite a bit.
Postpartum depression has been consistently reported to produce significant distress in the new mother and her family and may have a further adverse impact on the cognitive and emotional development of the child. , The adverse effects of maternal depression on the child include low birth weight, undernutrition and stunted growth, and frequent episodes of diarrhea. Other infant-related challenges linked to maternal mental illness is increased admission to neonatal care units, higher rates of infectious illness higher hospital admissions, and diminished completion of recommended immunization schedules. ,
The infant survival is also threatened particularly with poor linear growth (stunting), malnourishment, and gastrointestinal problems as reported by some researchers in resources challenged settings. ,,
Such mental health disorders are known to constitute significant obstacles to the health-seeking behavior in mothers for themselves and their children. 
Disorders of the mother-infant relationship are prominent in 10-25% of mothers referred to psychiatrists after childbirth.  Though the mechanism whereby depression contributes to future functioning in offspring has been said to require further ascertainment,  there appears to be evidence to imply the important role such interactions can play on outcomes. An important form of mother-child interaction called attachment has been studied extensively. Attachment as a complex growing research from neuroscience, molecular biology, and social ecology further demonstrates the significance of the early childhood years for the long-term well-being of the child. ,, There is a strong evidence established that depression in mothers has a negative influence on the interaction and attachment displayed with their children as such mothers tend to display more insecure attachment with their children compared nondepressed mothers. , The offspring of depressed mothers has also been found to have more developmental problems compared with those of nondepressed mothers. ,
In Sub-Saharan Africa, where the millennium development goal 4 (MDG4) aimed to reduce child mortality and goal 5 (MDG5) aimed to reduce maternal mortality, this goal is yet to be reached as the outcomes have generally not improved.  It is necessary to continue to emphasize the importance of integrating maternal mental health services as part of the primary health care strategies to improve these MDG indices as recommended by global health bodies.
Though considerable work has been done in Nigeria to describe the burden of maternal mental health problems, , and the impact on child physical development, there is still a dearth of studies on maternal mental health and the links with maternal-infant bond and child emotional development in this environment. There is a need for locally relevant evidence in this area that will be useful in advocating for implementation of relevant policies and interventions that will promote the mother-child emotional well-being and their long-term outcomes. This study aimed to assess for psychological distress and postpartum depression in mothers, and the relationship to mother-child interaction among users of a community health well child clinic.
| Methodology|| |
This is a descriptive cross-sectional study. The study was conducted in the child welfare clinic run by the Community Health Department of the Lagos University Teaching Hospital (LUTH). This clinic serves the immediate community around the LUTH environ. Among other community health services, it offers well child clinics and infant immunizations.
Eligible participants were mothers aged between 16 and 55 years of age. Each eligible mother should have a child being brought to clinic aged 1 year and below. Mothers with an acutely ill child or a child with congenital deformities were excluded and also mothers with known history of psychiatric morbidity or psychiatric treatment were excluded.
At each clinic, day attending mothers were briefed about the ongoing study, and those who indicated a willingness to participate were evaluated with the eligibility criteria. Participants were those meeting the predetermined inclusion criteria and gave informed consent to participate in the study. Mothers were recruited to the study during visits on routine clinic appointments. Sample of convenience was used, and the data obtained over a 6-month period. Selection was by consecutive sampling a total of 101 mothers were selected, of which data of 98 of them were found to be usable, due to significantly incomplete questionnaires.
Consecutive mothers who were eligible and willing were given the questionnaires by the researchers to complete. Those who were not literate had the questionnaires administered by trained interviewers. Completion of questionnaires lasted 20-30 min per participant. Data were collected once a week, an average of 3-5 mothers were recruited at each clinic visit.
The used were the Mother and Infant Attachment Scale (MIAS), the Zung Depression Scale (ZDS), the General Health Questionnaire-12 (GHQ-12), and Sociodemographic Questionnaire.
- Sociodemographic Questionnaire - This was used to obtain sociodemographic details of the mother and the infant, details of pregnancy, delivery, and development
- Maternal Infant Attachment Scale (MIAS) - This served to assess the interaction between mother and child. The scale was described by Bhakoo et al.  and found to be reliable in assessing the domains of attachment and expectation expressed by mother toward her child. The instrument is a simple brief tool and found easy to comprehend even by illiterate rural women in their study. The split-half reliability was found by the authors to be 0.83, and there was a high internal consistency. It has a high face and construct validity.  Though this scale had not been validated locally, the researchers found it to have good face validity and in the absence of a locally suitable alternative chose it as a measure for maternal-child interaction in this study seeing that it was earlier used among women in a similar resource challenged and developing country.  On the MIAS, the items are grouped into three Clusters I, II, and III. Cluster I represented the attachment of the mothers with their children, while Clusters II and III represented the expectation of the mothers had for their children. These clusters had already been grouped by the authors who developed the scale. Using the mean score, the total scores on the MIAS and here each cluster was further grouped into less than average and average/above average performance
- Zung Depression Scale (ZDS), a self rating tool, was used to screen for depressive symptoms. It is an instrument developed to provide a simple quantitative measure of the subjective experience of depression.  It is made up of 20 items and yields scores on a 4-point Likert response format ranging from 1 (some or a little of the time) to 4 (most or all of the time). Total score of below 50 is within the normal range, while an index of 50-59 indicates mild depression, 60-69 moderate depression, and 70 and above severe depression. The instrument has been found to have adequate psychometric properties. For instance, Okulate and Jones  found the ZDS to have a good predictive value of depression severity in Nigerian respondents and several other studies have been done with the ZDS applying a cut-off point of 50 both in Nigeria and elsewhere ,,
- GHQ-12 - The GHQ-12 assesses for probable psychiatric morbidity. It has been found as a reliable and useful screening tool in primary care settings in this environment and has been used extensively by researchers.  The GHQ-12 served as a screening instrument to assess probable psychiatric morbidity in the subjects. In this study, mothers scoring a total of 3 and more were regarded as subjects with probable psychiatric morbidity.
All measures had been pretested in a pilot study at the Community Health Clinic at the LUTH with 20 mothers not included in this current study. The questionnaires were found to be understandable and comprehensible by the mothers tested.
Eligible mothers received a detailed explanation about the study and gave written informed consent to participate in the study. Institutional ethical approval was obtained from the Health Research and Ethics Committee of the LUTH.
Identified mothers with probable mental health challenges based on their Zung scores suggestive of depressive illness were counseled on site and asked to proceed for further mental health assessment and care with the relevant department health providers. Some mothers were reluctant to participate due to the perception that this will delay them in their clinic attendance, seeing that it was questionnaire-based and somewhat lengthy. Such mothers were not coerced into participating. This, however, slowed down lengthened the duration of data collection to 6 months.
Data were analyzed using the Statistical Package for Social Sciences  version 17. SPSS Inc. Descriptive analyses were carried out for relevant parameters. Categorical variables were cross-tabulated and subjected to the Chi-square test. Paired t-tests were done to compare mean scores on some of the measures used. A P < 0.05 was set for the determination of levels of significant.
| Results|| |
The mean age of the mothers was 30.9 years (±5.1 standard deviation), with the age range from 20 to 52 years. Most were aged between 26 and 35 years (66.3%). Over 90% had at secondary school education or more. Over a 10 th (13.3%) was unemployed. While 96% in this study group were married [Table 1].
A total of 98 children were involved all being aged between 6 weeks and 1 year of age. There was an almost equal distribution of males (63.1%) and females (46.9%), with the majority being delivered via spontaneous vaginal delivery (82.7%). Most of the mothers (66.3%) were exclusively breastfeeding their child. All the mothers except one claimed to regularly spend time with their child, while over 90% affirmed they spent at least more than 5 hours daily with their child [Table 2].
Performance on maternal emotional well-being and maternal-infant interaction measures.
Maternal mental health characteristics
Of the 98 mothers, 10 (10.2%) had positive GHQ scores suggestive of emotional distress and probable psychiatric morbidity, and 14 (14.3%) had scores on the Zung questionnaire indicating possible depressive illness [Table 3]. Maternal-infant interaction based on the mean scores on the MIAS; the Cluster I (attachment) had 15 (15.3%) of the mothers with below average attachment with their children, while Cluster II (expectation) had 21 (21.4%) having below average in expectation toward their children, while on Cluster III, 11 (11.2%) had below average expectation scores [Table 3].
|Table 3: Performance on maternal emotional well-being and maternal-infant interaction measures|
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Attachment versus maternal mental health
Comparing mean scores of mothers on the GHQ and on the Zung scale in relation to their performance on the different clusters [Table 4]. The emotional distress showed a significant relationship with the mothers attachment on Cluster I. While the presence of a low mood was statistically significantly associated with lower mean attachment scores on Cluster I and higher mean expectation scores on Cluster II and III ( P ≤ 0.05).
|Table 4: Comparing mean scores of maternal-infant interaction based on mothers emotional wellbeing|
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| Discussion|| |
The sociodemographic variables of the study show that the majority of the mothers were in the reproductive age bracket of 16-45 years and almost all of them were married, which is the common age bracket and marital status found in similar study locations in Nigeria.  These women had some form of education and most had a means of livelihood, except for the 13.8% who were unemployed. It is noteworthy that almost all the women claimed they talk with their children (described as singing to them, playing with them, and having regular age-appropriate conversations with them) and also spend more than 12 h daily with them, practices which are believed to be attachment-enhancing. This is in keeping with the fact that women play a significant part child rearing activities in this part of the world, as reported by other researchers. 
The characteristics of the children show that majority were <12 months old, there was an equal distribution as regards gender and most were delivered normally as would be expected of those that would be having a follow-up after uncomplicated pregnancies and deliveries as are often seen in primary health care centers. 
Some of the results from this work conform to findings in some other studies. 12.6% of the mothers in our study had GHQ scores suggestive of probable psychiatric morbidity while 14.2% had scores implicative for depression. The latter figure is similar to the work carried out by Adewuya et al. (2008)  who found a rate of 14.6% prevalence for postnatal depression. Furthermore, perinatal mental disorders including depression in low- and middle-income countries fall in the range of 14-50%.  Some variability is seen when comparing with figures from high-income countries and possible postulations for this variability include the type of screening instrument or diagnostic instrument used, cross-cultural variables, reporting style, differences in socioeconomic environments (e.g., poverty, levels of social support or its perception, nutrition status, and stress), and biological variability factors. 
Most mothers had at least average expectation and attachment with their children, which are known to be positive correlates of maternal-infant attachment. The poor maternal-infant attachment found was significantly related to depressive symptomatology in the affected mothers. Some researchers have demonstrated that infants born to depressed mothers perform less optimally on several parameters, using the Brazelton Neonatal Assessment Scale have shown less auditory and visual orientation, motor tone, activity level, and robustness, but more irritability than newborns of nondepressed mothers. ,, This poorer performance may also be reinforced by the disturbed postnatal interactions offered by their depressed mothers. Reciprocally, infants born to depressed mothers may, therefore, discourage the mother's effort to interact with their infant and thereby entrain a vicious circle of disturbed and poorer interactions. ,
Some researchers have reported that attachment insecurity was significantly associated with maternal depression among infants and preschoolers. ,
There were no significant differences demonstrated when the characteristics of the children were cross-tabulated with each of the attachment clusters. This is to be expected as the commonly reported child characteristics that have been found associated with attachment are child's temperament, maternal perception of child's personality, and the presence of the medical condition in the infant.  These were, however, not the focus of this study and as such were not explored into. Our study, however, did show that these mothers had lower expectation toward their children, this may be a reflection of the negative maternal cognition in the state of depression which will also color her perception of the child. This is also in keeping with some researchers that show maternal depression to be associated with undesirable parenting practices such as unresponsiveness, inattentiveness, intrusiveness, inept discipline, and negative perceptions of children. 
This research will contribute relevantly to the body of knowledge of child mental health development as it examines the relationship between any psychiatric morbidities and maternal-infant interaction in African settings such as Nigeria. Several studies that have studied postpartum mental illnesses, including depression, in this part of the world have been largely focused on the sociodemographic correlates and physical effects on the children. ,, The finding of abnormal maternal-child interaction in relation to maternal depression in this Nigerian clinic population of mothers, however, does highlight the need for further deliberate screening evaluation of maternal-child attachment and provision of appropriate care to mitigate unwanted adverse long-term effects on both mother and child.
This is a cross-sectional study, thus it is limited toward making inferences on causation or risk factors.
Second, there is the consideration that some of the subjects may have developed undetected depressive symptoms during pregnancy which extended into the postpartum period, but this group was, however, not separated from those whose depression developed solely in the postpartum period and the effects of this distinction on the maternal-infant relationship were not accommodated. Finally, because of the nature of study design, the participants and their infants were not followed up to identify other long-term consequences of depression on maternal-child attachment such as have been found in some other studies.
| Conclusion|| |
The study lends support to the relationship between maternal depression within the postpartum period and the effects on the early interaction between the infant and the mother. To mitigate important long-term consequences on the child, we recommend that screening for psychiatric morbidities in new mothers be incorporated in the routine community health programs of postpartum women at well child clinic visits. This along with the use of evidence-based interventions that improve maternal-child relationship can assist in the prevention, early identification, treatment, and outcomes in affected mothers and infants.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]