The impact of depression at preconception on pregnancy planning and unmet need for contraception in the first postpartum year: a cohort study from rural Malawi

Plain language summaryFamily planning programmes have traditionally focused on increasing access to modern contraceptive methods. There is growing evidence that merely increasing access will not reach every woman. More focus on improving the quality of the family planning programmes and developing targeted interventions for women and men not currently reached with the current models is necessary. Despite the high prevalence of depression in women of reproductive age living in LMICs, its impact on women's access and use of contraception has been largely neglected. Our study using data from a cohort of pregnant women recruited in rural Malawi aimed to investigate if depression in the year before pregnancy impacted on women's risk of having an unintended pregnancy and on contraceptive use at time of pregnancy and in the postpartum period. Our results show that women who reported depression in the year before pregnancy had increased risk of inconsistent contraceptive use and having an unplanned pregnancy. They were also more likely to not use contraception in the early postpartum period and choose less effective methods, with important consequences for risk of subsequent unplanned pregnancies. Our results highlight a need for health services to develop holistic models of care for women where both their mental and reproductive health needs are met. BackgroundThe impact of depression on women's use of contraception and degree of pregnancy planning in low-income settings has been poorly researched. Our study aims to explore if symptoms of depression at preconception are associated with unplanned pregnancy and nonuse of contraception at the point of conception and in the postpartum period.MethodsPopulation-based cohort of 4244 pregnant women in rural Malawi were recruited in 2013 and were followed up at 28 days, 6 months and 12 months postpartum. Women were asked about symptoms of depression in the year before pregnancy and assessed for depression symptoms at antenatal interview using the Self-Reporting Questionnaire-20, degree of pregnancy planning using the London Measure of Unplanned Pregnancy and use of contraception at conception and the three time points postpartum.ResultsOf the 3986 women who completed the antenatal interview, 553 (13.9%) reported depressive symptoms in the year before pregnancy and 907 (22.8%) showed current high depression symptoms. History of depression in the year before pregnancy was associated with inconsistent use of contraception at the time of conception [adjusted relative risk (adjRR) 1.52; 95% confidence interval (1.24-1.86)] and higher risk of unplanned [adjRR 2.18 (1.73-2.76)] or ambivalent [adj RR 1.75 (1.36-2.26)] pregnancy. At 28 days post-partum it was also associated with no use of contraception despite no desire for a further pregnancy [adjRR 1.49 (1.13-1.97)] as well as reduced use of modern contraceptives [adj RR 0.74 (0.58-0.96)]. These results remained significant after adjusting for socio-demographic factors known to impact on women's access and use of family planning services, high depression symptoms at antenatal interview as well as disclosure of interpersonal violence. Although directions and magnitudes of effect were similar at six and 12 months, these relationships were not statistically significant.ConclusionsDepression in the year before pregnancy impacts on women's use of contraception at conception and in the early postpartum period. This places these women at risk of unplanned pregnancies in this high fertility, high unmet need for contraception cohort of women in rural Malawi. Our results call for higher integration of mental health care into family planning services and for a focus on early postnatal contraception.