Dr Kazione Kulisewa Medical Officer- Zomba Mental Hospital/ Mmed (Mw) trainee

1. The Prevalence of Depression and other Common Psychiatric Disorders in women who have experienced pre-natal foetal loss at QECH Dr KazioneKulisewa Medical Officer- Zomba Mental Hospital/ Mmed (Mw) trainee

2. Abortion: The Situation in Malawi • ‘In Malawi, abortion is restricted by law to circumstances where it is performed to preserve the pregnant woman’s life.’ B.A Levandowski et al 2011 • Prevalence of Abortion in Malawi (2009) • 24.0 /1000 women (15-44yrs) B.A Levandowski et al • →70,194 induced abortions (range 50,696-89,692) • Under-estimated ? 38/1000 women (1995 to 2008) Dr Gilda Sedgh et al 2012

3. Global incidence of induced abortion (1995-2008) Dr Gilda Sedgh et al

4. ‘In legally restrictive settings, women turn to unsafe abortion to manage unwanted pregnancy. Many suffer long-term health consequences…’ B.A Levandowski et al

5. Post Abortion Care (PAC) in Malawi • ‘1.emergency treatment of incomplete abortion (uterine evacuation) and potentially life threatening complications; • 2.provision of Family Planning counselling and services; • 3. and links between emergency care and other Reproductive Health services’ . Malawi Ministry of Health and Population, Reproductive Health Unit, National Post-Abortion Care Strategy • Impact on Mental Health? • no protocols for management or mention of the psychological impact/ psychiatric morbidity

6. Abortion and Mental Health- is there an association? • significant body of literature: • ABORTION→ MENTAL ILLNESS (MI) • ‘…having an abortion, independent of other life circumstances, is a traumatic experience with consequences similar to other traumatic experiences, such as rape or war.’ J.R Steinberg et al 2011 • MORBID PREDISPOSITION + STRESSOR (Abortion)→MI • ‘Women likely to have negative psychological outcomes following an abortion are those least apt to cope with any stressful life event…’ J.R Steinberg et al

7. PSYCHOSOCIAL STRESSORS→ ABORTION + MI • Psychiatric Morbidity associated with Abortion • Post Abortion Syndrome M.Boulind et al 2008 • ‘ … women who have aborted are at a higher risk for a variety of mental health problems including anxiety (panic attacks, panic disorder, agora-phobia, PTSD), mood (bipolar disorder, major depression’ J.R Steinberg et al 2011, E .Robertson Blackmore et al 2011 [8] • ‘Numerous studies have demonstrated statistically significant associations between abortion and subsequent substance misuse, a widely recognised and prevalent mental health problem.’ P. Coleman 2011 • ‘analysis of the largest and strongest studies available resulted in the conclusion that abortion is associated with an increased risk of depression that may lead to self-harm.’ P. Coleman

8. Dissenting views: abortion does not pose serious risks above those associated with unintended pregnancy that are carried to term . American Psychological Association Task Force on Mental Health and Abortion. Report of the American Psychological Association Task Force on Mental Health and Abortion.APA, 2008; VE Charles et al 2009; GE Robinson et al 2008 • The general consensus across literature = prenatal foetal loss (induced abortions or spontaneous miscarriages) put women at an ↑ risk of poor mental health (P. Coleman)possibly due to the psychological factors that preceded and led to the event or directly as a result of the abortion itself.

9. Rationale • Lack of local literature describing association in a local Malawian context • NEED for clarifying the extent of psychiatric morbidity associated with prenatal foetal loss and using this data to critically inform our post-abortion policies.

10. Broad Objective • To describe the prevalence of common mental disorders CMD) in women presenting at Queen Elizabeth Central Hospital for Post Abortion Care

11. Specific Objectives • 1) To describe demographic details of women with prenatal foetal loss at QECH • 2) To describe the prevalence of Depressive disorders among these women • 3) To describe the prevalence of other probable CMD among these women • 4) To describe the obstetric/gynaecologic, social and demographic factors associated with CMD in women with prenatal foetal loss • 5) To determine the detection rate of probable CMD or Depression associated with prenatal foetal loss by gynaecological staff at QECH

12. Study Design • Cross sectional quantitative study at QECH • Study population • Gynaecological admissions; attendees at Gynaecological clinics seeking PAC • Sample size: 130 participants (65 cases, 65 controls)

13. Cases • Inclusion criteria • Admissions or outpatient clinic attendees seeking PAC following an abortion, miscarriage or termination of pregnancy • Exclusion criteria • Women with prior and pre-existing CMD not related to index pregnancy • Women who don’t consent • Women under 18yrs lacking a guardian

14. Controls • Inclusion criteria • Gynaecology admissions being managed for conditions other than miscarriages or abortions • Exclusion criteria • Women with a prior and pre-existing CMD • Women who don’t consent • Women under 18yrs lacking a guardian

15. Data Collection • Identification of possible participants from registers • Provision of Informed Consent • Initial 2 part questionnaire • Part 1: Demographic, Gynaecological and Social Details • Part 2: Chichewa Self Reporting Questionnaire (SRQ)20 • Probable CMD (cut-off scores ≥ 9/20)→ Chichewa Structured Clinical Interview for DSM-IV Major/Minor Depressive Episode (SCID-MDE) • Case notes/health passports of women with probable CMD read to determine if CMD detected

16. Ethical Considerations • Participants who score highly on the SRQ-20 will subsequently be referred to the QECH Psychiatric Unit for further and comprehensive assessment following the SCID • Voluntary participation • Informed consent

17. Discussion and questions

18. References • The estimated incidence of abortion in Malawi. Brooke A. Levandowski, Edgar Kuchingale, Linda Kalilani-Phiri, Hans Katengeza, YirguGebrehiwot, HailemichaelGebreselassie, Juliana Lunguzi, Fanny Kachale, Godfrey Kangaude, ChisaleMhango • Induced abortion: incidence and trends worldwide from 1995 to 2008, Dr Gilda Sedgh et al The Lancet , Vol 179, Issue 9816, pg625-632, 18 Feb 2012 • Malawi Ministry of Health and Population, Reproductive Health Unit, National Post-Abortion Care Strategy • Examining the association of abortion history and current mental health: A reanalysis of the National Comorbidity Survey using a common-risk-factors model Julia R. Steinberg, Lawrence B. Finer Soc Sci Med 2011 Jan;72(1):72-82: doi:10.1016

19. The Assessment and Treatment of Post-Abortion Syndrome: A Systematic Case Study From Southern Africa, Boulind M, Edwards DJA Journal of Psychology in Africa, 2008 18 (4).pp. 539-548. ISSN 1433-0237 • Previous prenatal loss as a predictor of perinatal depression and anxiety, Emma Robertson Blackmore, Denise Côté-Arsenault et al) BJP 2011 May;198(5):373-8. doi: 10.1192 • Abortion and mental health; quantitative synthesis and analysis of research published 1995-2009, Priscilla Coleman BJP Sept 2011 • American Psychological Association Task Force on Mental Health and Abortion. Report of the American Psychological Association Task Force on Mental Health and Abortion.APA, 2008. • Abortion and long-term mental health outcomes: a systematic review of the evidence.Contraception2008; 78: 436–50.Charles VE, Polis CB, Sridhara SK, Blum RW • Is there an ‘abortion trauma syndrome’? Critiquing the evidence. Harv Rev Psychiatry 2009;17: 268–90Robinson GE, Stotland NL, Russo NF, Lang JA, Occhiogrosso M