In this first explorative study assessing antenatal psychopathology in Central-America, we found higher prevalences of anxiety and depression than observed in developed countries. The scores in our Nicaraguan sample were substantially higher than in the Netherlands and this difference was statistically significant. Further, we found a weaker correlation between anxiety and depression scores in Nicaragua than in the Netherlands. Additionally, although there may be psychological help available for the Nicaraguan pregnant women, these women were mostly not aware of this possibility or they were unable to attain this help. We found a significant association between women’s knowledge how to reach psychological help for these women and symptoms of anxiety, but not with depression.
With respect to the burden imposed by mental disorders, mental health is known to be an under-researched health area, especially during pregnancy [24]. Although the WHO recognises psychopathology as an important global health problem which causes morbidity and mortality in both mother and child, the problem may be even bigger than earlier thought [1–4]. Most earlier published prevalences of depression and/or anxiety during pregnancy were found in developed countries and were lower compared to those we found in our Nicaraguan sample, namely 10-15 % [6, 9, 12].
Literature demonstrating prevalences of antenatal anxiety and depression in developing countries outside Central America showed various results. For example, in Nigeria a low prevalence of 10.5 % for generalized anxiety disorder was found among pregnant women [25], but the severity and effect of anxiety symptoms (e.g. worry, avoidance, and obsessions) may not always rise to the level of an anxiety disorder diagnosis [26]. In contrast, in Brazil, the prevalence rate of anxious symptoms among pregnant women is estimated to be 60 %, and the rate for depressive symptoms was about 20 % [27]. Furthermore, in Bangladesh the prevalence rate of depressive symptoms among pregnant women is estimated to be 33 % [28] and 42.7 % in Pakistan [29]. The prevalences of anxiety (41 %) and depression (57 %) in our sample of Nicaraguan pregnant women were comparable to these earlier studies in developing countries but notably higher than in developed countries.
Unlike in developed countries, where anxiety and depression are highly correlated [9], in our Nicaraguan sample the observed correlation was substantially lower. Although possibly (partly) caused by the limited sample size, this finding suggests that anxiety and depression may have different origins, more often so in developing countries.
Although we neither performed a longitudinal study nor we searched for causal factors, the results of this first study on this subject in Nicaragua, indicate the need for further research. Compared to developed countries, lower education, lower income, younger maternal age, and more negative or traumatic life events could be factors in Nicaragua that relate to a higher risk of suffering from psychopathology during pregnancy [4, 30].
As one of the low-income countries in the Central American region, Nicaragua reported only 1 % of the total health care budget is reserved for mental health, and 91 % of that is given to psychiatric hospitals [14]. Under this condition, it is likely that relatively mild mental health issues in a specific population like pregnant women are neglected.
A very small proportion of the women, less than ten percent, indicated that psychological help was available and that they knew how to reach that help. This statement was associated with a higher anxiety score, suggesting that the anxious women know how to find psychological help. This was not the case for the depressive women. In any case, for the women in the rural areas psychological help may not be commonly available, so besides more knowledge about the problems, the possibilities of providing effective treatment if needed, e.g. psychotherapy for antenatal psychopathology, should be explored. It would be desirable to investigate the results of this possible solution in a follow-up study in the same geographical area.
The present study is not without limitations. First, both the STAI as the EPDS are self-report questionnaires. Even though these are worldwide commonly used questionnaires, misunderstandings of the questionnaire, possibly due to illiteracy, may have led to over- or under-reporting. Earlier research showed that a lower educational level was associated with a higher rate of psychopathology during pregnancy [30]. Nevertheless, when a participating woman was unlettered, we read the questionnaire aloud. We believed this was a better method then excluding all illiterate women. Furthermore, our analyses showed similar results in both illiterate and non-illiterate women. Secondly, cut-off values for both STAI and EPDS questionnaires may depend on different cultural backgrounds. However, since this is the first study among Nicaraguan women, we considered it justified using the widely recognised cut-off values for an at least moderate level of anxiety (STAI >42) [19] and depression (EPDS ≥12) [22]. Third, the sample sizes differed strongly between both samples, diminishing statistical power. Nevertheless, we demonstrated statistically significant differences between the Dutch and Nicaraguan groups. Finally, in our longitudinal Dutch cohort, women received multiple questionnaires during pregnancy, including STAI and EPDS questionnaires at twenty-three weeks gestational age. Our Nicaraguan cohort consisted of women who participated at any moment of pregnancy, with a mean gestational age of 30.6 weeks. The mean gestational age may be comparable (end of second versus start of third trimester), but the SD was increased fivefold.
A strong point is in our view that we were able to include a population-based sample of Nicaraguan pregnant women in a rural area, from both a public hospital and community health centers and had a remarkably high response rate (93 %). Because of the use of equal questionnaires in both Nicaragua and a large sample in the Netherlands, we were able to compare symptomatology of antenatal psychopathology between Nicaragua and a developed country. This study only explored the presence of anxiety and depression and the women’s knowledge how to reach psychological help, but since this was the first study on antenatal psychopathology in a rural area in Central-America, this publication can be a supplement to the literature on this topic.