Unraveling the link between the mistreatment of women during childbirth and postpartum depression: a prospective longitudinal study in Ethiopia and Guinea

Background
The mistreatment of women during facility-based childbirth is widespread in sub-Saharan Africa and has a negative impact on women's mental health. We aimed to examine the association between childbirth-related mistreatment and postpartum depression in Ethiopia and Guinea.

Methods
Between May 2023 and February 2024, we conducted a prospective longitudinal survey of pregnant women recruited from 22 health facilities in Addis Ababa, Ethiopia, and 20 health facilities in Conakry, Guinea. Participants were surveyed during the third trimester in health facilities and were followed up in the community for a second survey, which was conducted between 6 and 16 weeks postpartum. Depression was assessed using the Edinburgh Postnatal Depression Scale (EPDS), and mistreatment was measured across seven categories. We used multilevel mixed effects Poisson regression to assess the association between the number of mistreatment categories experienced and women's postpartum depression scores.

Findings
Of the 859 women enrolled during pregnancy, 711 women completed the postpartum survey. 87.4% of women in Addis Ababa and 71.2% in Conakry had experienced at least one category of mistreatment. Symptoms suggestive of postpartum depression (EPDS ≥11) were reported by 20.9% of women in Addis Ababa and 31.0% in Conakry. After adjusting for antepartum depression, intimate partner violence, and other sociodemographic, obstetric, and health service-related characteristics, experience of each additional mistreatment category was associated with a 5% increase in women's postpartum depression scores (adjusted incidence rate ratio [AIRR] = 1.05, 95% CI: 1.01–1.09). Among women without symptoms suggestive of antepartum depression (EPDS <11), the effect was even greater, with an 11% increase in postpartum depression scores (AIRR = 1.11; 95% CI: 1.06–1.17).

Interpretation
The strong association between mistreatment and postpartum depression, particularly among women without antenatal depressive symptoms, highlights the potential causal role of mistreatment and underscores the urgent need for coordinated, evidence-informed, and context-appropriate strategies to promote respectful maternity care and safeguard women's mental health.

Funding
Research Foundation Flanders (FWO file number 1261923N) and the Institute of Tropical Medicine (ITM), Antwerp, Belgium, with support from the Flemish Government Department of Economy, Science and Innovation (EWI) and the Belgian Federal Directorate-General for Development Cooperation and Humanitarian Aid (DGD).