We assessed the overall levels of parenting stress (PS), as well as different components of PS according to the three-factor model of the PSI-SF, at 3, 12 and 24 months postpartum in a sample of sub-Saharan African women after low-risk pregnancies and the birth of an infant without major disability or disease. Women who exceeded cut-off scores indicating clinically significant depression and anxiety had significantly higher PS scores than those who did not in Ghana and Côte d’Ivoire. The total PS level was similar in the two countries at 3 month postpartum, and decreased with time in Ghana, but remained consistent in Côte d’Ivoire. Antepartum and postpartum depression were consistently associated with total PS scores in both countries.
The observed mean PS score, even in mothers not classified as depressed or anxious, was relatively high compared with previous studies from high-income countries [11, 50, 51]. This was somewhat unexpected, since previous research on PS predominantly addressed parents with ill or disabled children, whose condition per se is assumed to cause distress and negatively impact family functioning [49, 50, 52]. Only one study in sub-Saharan African caregivers whose children are HIV positive reported PS scores higher than ours, which was ascribed to a “double burden” from the transgenerational disease hazard .
Given the lack of comparable studies on PS in sub-Saharan Africa, we can only speculate about the reasons for this finding. As most studies assessed PS when the children were older, a comparison of mean values with our sample may not be reasonable. According to a recent meta-analysis, PS in mothers of infants and toddlers with and without medical risks was found to be highest at 3 months and to decline rapidly in the first year of the children’s lives, reflecting normal psychological adaptation during early parenthood . The high initial PS scores that we observed in the mothers may be partially explained by phase-specific insecure feelings about parenting, perceived lack of caregiving skills and confidence while confronting the infant’s needs and her difficult or ambiguous signals .
This psychobiological condition, first described by D.W. Winnicott as “primary maternal preoccupation” , comprises increased levels of distress, worries and anxiety and may be even functional because it can result in frequent checking of the fragile infant’s safety and health . Although we did not investigate attitudes towards childbearing, our observed high levels of perceived maternal PS may be linked to the high proportion of unintended pregnancies occurring in sub-Saharan Africa. Safe birth control can be difficult to access or may be avoided by the women for a variety of reasons [56, 57]. Unintended pregnancies may put strain on maternal role assumption and mother-infant relationships [58, 59]. Other causes for high PS may include poverty , exhaustion following childbirth due to iron deficiency anemia [61, 62], pregnancy and childbirth not providing relief from daily duties, and the continued maternal responsibility for family income in addition to early childcare, that is imposed mainly on the mothers .
According to our longitudinal data, the trajectory of PS from 3 months to 24 months postpartum revealed a clear decline over time in Ghana. Mean scores two years post birth were consistent with those in a sample of disadvantaged single African American mothers of preschool children . However, scores remained at a high mean level throughout the investigation in Côte d’Ivoire. Since the Ivorian women experienced a severe political crisis and acute threat of harm due to armed conflict and displacement during the assessment period, these mothers were likely to perceive higher distress, which may have also affected their parenting capacities.
In our sample, Parental Distress made the largest contribution to mean general PS scores in both countries, while Parent-Child Dysfunctional Interaction scores contributed less. This result is consistent with findings from a South-African population of HIV-positive children  and implies that in our sample, parental role requirements and contextual conditions were perceived as more burdensome than the relationship with the child as such. Parental Distress and Parent-Child Dysfunctional Interaction resolved with time in Ghana, but not in Côte d’Ivoire. Interestingly, scores on the Difficult Child subscale, which represents parental interpretation of basic behavioral characteristics of the children, kept constant and at a similar level in the two countries. Means were high, even in relation to studies on infants and toddlers with biological risks or from disadvantaged backgrounds in high-income countries [49, 51]. This may imply that the mothers’ perception of their children as being difficult and demanding do not only reflect stable traits of temperament in their offspring, but also normative cultural expectations of obedience and adaptability to parental authority . In Western surveys, small children reported as being more difficult have been found to receive less responsive mothering, putting them at increased developmental risk [5, 65], while this link has not yet been established for African populations.
As hypothesized, we found that antepartum and postpartum depression were associated with PS, while antepartum and postpartum anxiety were not after adjusting for confounders. The total PS score may range from 30 to 180. The difference in total PS score between women who met criteria for postpartum depression and those who did not was 8.67 and 8.17 respectively in Ghana and Côte d’Ivoire, after adjustment for other variables. The magnitude of the difference is comparable to the differences detected in studies using PSI-SF to compare PS between parents of children with impairment such as cerebral palsy and parents of healthy children . The association between postpartum depression and PS has been replicated in a number of studies. The direction of the association, however, may be complex and reciprocal [66–69].
Contrary to our expectation, depressed and non-depressed mothers did not differ significantly on the Difficult Child scale. Our study did not provide support for the assumption that mothers who are depressed feel emotionally overburdened, are biased to negative cognitions and attributions and may judge their child as less adaptable and more difficult to manage than non-depressed mothers . Given that the children in our study were generally perceived as more difficult than in other settings, maternal mental health does not seem decisive for this finding.
The association between antepartum depression and PS is still inconclusive. The woman’s depressed mood may influence the prenatal expectations and representations concerning herself as a parent and her relationship with the infant, and this may impact on the way she feels and acts postnatally . Some studies suggested that antepartum depression was the strongest predictor of postpartum depression, which in turn was the predictor of PS . However direct evidence of association between antepartum depression and postpartum PS controlling for postpartum depression is rare. Misri et al. found that treatment of antepartum depression did not impact PS . Yet, we found that antepartum depression was independently associated with PS.
We did not replicate some previously described predictors for PS in our study. For example, the number of children in the household was not associated with PS in our study. It is possible that help with the older offspring from other family members mitigated the effects of having many children in the household. Lower education and decreased income have been associated with PS in some previous studies , but this association was not seen in our sample. Mothers in both urban settings were comparably well off and childhood malnutrition as an indicator of poverty was rare .
This study has limitations. The GAD-7 has rarely been used in African women, and its content is not specifically related to the perinatal mental condition. Almost all of the studies on psychometric properties of the GAD-7 focused on high-income western countries. The reliability of the PHQ-9 and the GAD-7 was moderate, which impairs the precision of the measurements. We examined reasons for this moderate reliability elsewhere (Barthel et al.; manuscripts submitted). In short, a different understanding of item wordings may have contributed to this. Moreover, 60 women who did not return for any follow up visits after birth were removed from the analysis. These women had higher PHQ-9 and GAD-7 scores when compared with the women who returned for follow up visits. The drop out of the 60 high risk mothers likely resulted in an underestimation of the PS. Lastly, there may be unmeasured confounders, such as social support from partners or relatives, marital conflict and domestic, intimate partner violence, and children’s mental health and attachment.