Prevalence and associated factors of antenatal depression in rural Bangladesh

16 Antenatal Depression, Mental Health in Pregnancy, Rural Bangladesh, Factors influencing 17 maternal mental health, Prenatal depression, Prevalence, Associated Factors, Risk Factors, 18 Depression 19 20

21 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.

According to the World Health Organization (WHO), approximately 322 million 22 individuals globally were grappling with depressive disorders in 2015. During pregnancy, the 23 risk of experiencing depression is elevated due to certain hormonal changes. Despite the 24 potentially severe consequences of antenatal depression for both the mother and newborn, there 25 have been limited studies conducted on this issue in Bangladesh. 26

To find out the prevalence and associated factors of antenatal depression in a rural 27 sub-district in Bangladesh. 28

A cross-sectional study was performed in Lohagara, a rural subdistrict in Narail, 29 situated in the southern part of Bangladesh between January 08 and 14, 2024. 350 subjects were 30 recruited for the study, who were pregnant at various trimesters and attended antenatal check-ups 31 in a government health complex and a private hospital in Lohagara. The Bengali-translated 32 version of the Edinburgh Postnatal Depression Scale (EPDS) and a structured questionnaire were 33 used for data collection. Data were analyzed in STATA version 14. 34

The point prevalence of antenatal depression is 39% (38.86%, in 95% CI: 33.9% to 35 44%). Gestational week (AOR: 0.4, 95% CI: 0.2, 0.8), unintended pregnancy (AOR: 1.7, 95% 36 CI: 1, 3), intimate partner violence (AOR: 3.3, 95% CI: 1.1, 9.7), a history of previous diseases 37 (AOR: 2.4, 95% CI: 1.1, 5.2), and the history of having polygamous husbands (AOR: 13.6, 95% 38 CI: 1.1, 164) are found to be significantly associated with the development of depression in the 39 prenatal period. 40

In rural Narail, high rates of antenatal depression underscore the importance of 41 increased awareness among healthcare professionals and families. Strategic involvement of 42 stakeholders and policymakers is essential to address issues like intimate partner violence and 43 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint polygamy. Moreover, there's a critical need for extra care and counseling for pregnant women 44 with a history of health problems or facing unexpected pregnancies. 45 46

47 Globally, depression stands out as a prevalent mental health disorder, marked by symptoms such 48 as a low mood, changes in appetite and sleep patterns, loss of interest in activities, significant 49 weight fluctuations, feelings of hopelessness, concentration difficulties, low self-esteem, and 50 frequent thoughts of mortality. It holds a prominent position among the top five causes of the 51 global disease burden (1). Projections suggest that by 2030, depressive disorders will likely 52 become one of the three leading contributors to the overall global burden of disease (2). 53 In 2015, the World Health Organization (WHO) approximated that there were 322 million 54 individuals globally experiencing depressive disorders and 27% of them were from the Southeast 55 Asian region (1). The risk of mental disorders, especially depression is more in females than in 56 males (3). In pregnancy, the risk of depression is higher than general female population due to 57 hormonal changes (4). The global occurrence of antenatal depression ranges from 15% to 65% 58 (5). In high-income countries, the prevalence ranges from 5% to 30% (6, 7, 8), while in low-59 income countries, it is 15.6% to 31.1% (9, 10, 11). 60 The occurrence of depression during pregnancy in Bangladesh varies between 18% and 33% 61 (12), which is not too small. A recent study, carried out in a rural sub-district in Matlab, 62 involving pregnant women at their 34-35 weeks of pregnancy showed a 33% prevalence and the 63 associated factors included an unsupportive husband or mother-in-law, domestic violence, and 64 mental pressure for male gender preference of the family (13). A recent cross-sectional study, 65 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint conducted in rural Sylhet highlighted male gender preference of husband, low family support, 66 and sexual violence as the main associated factors for developing antenatal depression (12). 67 The consequences of depression in pregnancy can be devastating and it may affect both mother 68 and child. A pregnant woman experiencing depression may release a hormone called cortisol, 69 which can have detrimental effects on fetal growth and brain development (14). Women with 70 antenatal depression have a higher risk of developing Hyperemesis gravidarum, which increases 71 the probability of miscarriage, low birth weight, and preterm birth (15). Not only that, the risk of 72 substance abuse, preeclampsia, hemorrhage, edema, postpartum depression, and severe 73 headaches is higher in a woman with antenatal depression (16, 17). The neonatal outcomes of 74 antenatal depression are reported as low birth weight (LBW), low mean APGAR scores at 1 and 75 5 minutes following birth, and premature mortality (18, 19). 76 Antenatal depression poses a significant challenge for expectant mothers, particularly in 77 Bangladesh. Research on this topic is predominantly limited to rural areas, with scant urban-78 based studies available. Moreover, there is a notable dearth of information regarding the 79 prevalence of depression during different trimesters of pregnancy in Bangladesh. This gap in 80 research underscores the need for a more comprehensive understanding of antenatal depression 81 across diverse geographic and demographic settings in the country. The absence of research on 82 antenatal depression in Narail, a southern district in Bangladesh, underscores the significance of 83 this study. By shedding light on the current status of antenatal depression at the sub-district level 84 in Narail, this research aims to provide a crucial snapshot of the situation. The findings from this 85 study can play a pivotal role in identifying necessary interventions, informing policy-making 86 decisions, and structuring health education programs. The ultimate goal is to enhance awareness 87 and establish effective measures for controlling antenatal depression in the future. 88 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint 89

90 Study Design and Setting 91 A cross-sectional study was performed between January 08 and 14, 2024 in Upazila Health 92 Complex, Lohagara, a government hospital, and Khan General Hospital, Lahuria, a private 93 hospital in Lohagara, a rural sub-district in Narail, situated in the southern part of Bangladesh. 94 Study Participants 95 The target population was pregnant mothers of any trimester in the Lohagara sub-district and the 96 sample population was pregnant mothers of any trimesters attending the ANC Corner of Upazila 97 Health Complex, Lohagara, Narail, and Khan General Hospital, Lahuria for antenatal checkups. 98 Sample Size and Sampling Technique 99 Considering the prevalence of antenatal depression in Bangladesh is 33% according to a study 100 conducted in a rural sub-district in Matlab (13), 95% confidence interval, and with 5% margin of 101 error, calculated sample size, /g1866/g3404 /g4666 1.96 /g4667 /g2870 /g1499 /g2868./g2871/g2871 /g4666 /g2869/g2879/g2868./g2871/g2871 /g4667 /g4666 /g2868./g2868/g2873 /g4667 /g3118/g3404 340 102 The sampling technique was systematic sampling. Every third patient attending ANC Corner for 103 antenatal checkups in both government and private hospitals was selected as a participant in the 104 interview for data collection. 105 Data Collection Tools 106 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint The presence of depression was assessed by the Bengali-translated version of the Edinburgh 107 Postnatal Depression Scale (EPDS). This questionnaire consists of 10 questions scoring from 0 108 to 30. A score of 10 or higher on the assessment indicates probable antenatal depression. 109 Another structured questionnaire, which was also translated into Bengali, was used to collect 110 data on the sociodemographic, obstetric, psychosocial, psychological, and disease and treatment-111 related factors of patients. The questionnaire was tested on some target population rather than the 112 study participants and the necessary changes were made before the data collection. 113 Data Management & Analysis Plan 114 The data for the study was analyzed by STATA version 14. Pearson’s chi-square test was 115 performed to find out the possible association of sociodemographic, obstetric, psychosocial, 116 disease, and treatment-related factors with prenatal depression. A binary logistic regression was 117 also performed to find out the crude odds ratio of variables. To adjust the confounding factors, a 118 multivariate analysis using multivariate logistic regression was performed. Adjusted and 119 unadjusted odds ratio and their 95% CI were used as indicators strength of the association. 120 Ethical Considerations 121 Ethical permission was taken from the Institutional Ethics Committee of North South University 122 before data collection (Approval Number: 2023/OR-NSU/IRB/1224). Permission letters from 123 Upazila Health Complex, Lohagara, and Khan General Hospital, Lahuria were also obtained. 124 Informed written consent was obtained from pregnant mothers of 18 years or more and guardians 125 of pregnant women aged below 18 years before data collection. The respondents were assured of 126 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint the confidentiality of information and also informed about the purpose, advantages, and potential 127 risks of the study. 128 129

130 Socio-demographic Characteristics of Pregnant Mothers 131 In this research involving 350 women in any trimester of gestation, with a high response rate of 132 98.5%, several demographic characteristics were examined. The median Edinburgh Postnatal 133 Depression Scale (EPDS) score was 8, with an interquartile range of 4 to 12. The respondents 134 had a median age of 23 years, falling within an interquartile range of 20 to 27 years. Among the 135 respondents, 5.7% (20) were below 18 years old, while a majority of 83.7% were in the age 136 bracket of 18 to 30 years. The rest 10.6% were over their thirties. 137 Regarding educational background, 26 participants (7.4%) did not have a minimum primary 138 level education. All participants were married, with the majority being housewives. However, a 139 small percentage (4%) were employed. In terms of monthly family income, 26% of women (91) 140 had an income below 10,000 tk, 58% (203) had an income between 10,000 to 20,000 tk, and the 141 remaining 16% (56) had an earning per month exceeding 20,000 tk. 142 Religiously, the participants belonged to two communities, with 96.3% (337) identifying as 143 Muslim and 3.71% (13) as Hindu. These demographic details provide a comprehensive snapshot 144 of the participants in the study, offering insights into their socioeconomic and cultural 145 backgrounds. 146 Obstetric History of Pregnant Mothers 147 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint A large percentage (53.4%) of respondents were in their second trimesters. 107 women (30.6%) 148 were in the third trimester, and the rest 16% (56) were passing the first trimester. In this study, 149 the median age of marriage was found to be 18 years, with an interquartile range spanning from 150 16 to 19 years. Significantly, almost half of the participants (48.6%) reported a history of getting 151 married before the age of 18. Regarding pregnancy status, 38.6% (135) of the total expectant 152 mothers were experiencing pregnancy for the first time. 153 Among the multiparous women, 51% (105) had undergone at least one cesarean section (46.6% 154 only caesarian section, 4.4 % had both vaginal delivery and caesarian section), and 30.6% (63) 155 faced complications during their previous deliveries. Additionally, 21.5% (75) of the women 156 reported a history of abortion, stillbirth, or intrauterine fetal death. These findings provide 157 important contextual information about the participants' marital and reproductive histories, 158 contributing to a more comprehensive understanding of the factors influencing antenatal 159 depression in this population. 160 Psychosocial Criteria of Pregnant Mothers 161 In the study, 74% of the women (259) reported that their current pregnancies were planned, 162 while 26% (91) indicated the opposite. Regarding satisfaction with their husbands' behavior, the 163 majority of women (50.3%) expressed moderate satisfaction, while a small proportion (4.8%) 164 reported poor relationship status. 165 Concerning relationships with in-laws, the majority (77.8%) reported good relationships, and 166 15.7% (55) described their relationships as moderate. However, 6% (21) of women had a history 167 of poor relationship status, with 1.43% (5) being separated from or having deceased parents-in-168 law. 169 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint The study also highlighted instances of violence. Approximately 5.14% of women (19) reported 170 being victims of domestic violence, and 5.43% (18) reported experiencing sexual violence. 171 Notably, 10% of women (35) had faced sexual violations during the current pregnancy. 172 Additionally, family dynamics played a role, with 18.6% of women (65) reporting that their 173 husbands preferred male children, and 18% (63) mentioned specific demands from their in-laws 174 for a male child. These findings provide insights into the social and familial factors that may 175 contribute to antenatal depression in the study population. 176 Disease and Treatment-related History of Pregnant Mothers 177 Among the 350 women, 37 (10.57%) were suffering from diseases like Diabetes Mellitus, 178 Hypertension, Bronchial Asthma, and Thyroid disorders, while 49 (14%) had a history of at least 179 one previous surgery other than caesarian section. 180 Psychological Factors of Pregnant Mothers 181 In the study, a small percentage of women reported certain marital challenges. Specifically, 182 2.57% (9) of the women mentioned that their husbands had other wives, and a couple of women 183 (0.6%) indicated a history of their husbands having extra-marital relationships with other 184 women. However, none of the participants reported having such relationships themselves. These 185 findings offer insights into the complex dynamics within marital relationships and potential 186 factors that may contribute to antenatal depression in the studied population. 187 Prevalence of Depression among Pregnant Mothers 188 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint In the study, the scores from the 30 questions of the Edinburgh Postnatal Depression Scale 189 (EPDS) were summed up, creating a new variable ranging from 0 to 30. The findings revealed 190 that 150 (42.9%) women had none or minimal depression, and 141 women (40.29%) had mild 191 depression, scoring between 7 to 13 on the EPDS. Another 43 women (12.29%) scored between 192 14 to 19, indicating moderate depression. Additionally, 16 women (4.57%) had severe 193 depression, with scores exceeding 19. Table 1 194 Table 1. Extent of Depression among pregnant women in Lohagara 195 196 197 198 199 200 201 To simplify the interpretation, the scores were further categorized into two classes: "Having 202 Depression" and "No Depression." A cut-off score of 10 or more was used to indicate the 203 presence of depression. The results showed that nearly one in three women (38.86%, with a 95% 204 confidence interval ranging from 33.9% to 44%) exhibited symptoms of depression during 205 pregnancy. These figures highlight the prevalence and varying degrees of depression among the 206 study participants Error! Reference source not found.. 207 Extent of Antenatal Depression Class EPDS score n % None or minimal Depression 0-6 150 42.9 Mild Depression 7-13 141 40.3 Moderate Depression 14-19 47 13.4 Severe depression 20-30 12 3.4 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint Table 2. Prevalence of Antenatal Depression in Lohagara 208 Prevalence of Antenatal Depression Depression EPDS score n % Yes 10-30 136 38.86 No 0-9 214 61.14 209 Factors associated with Antenatal Depression 210 Sociodemographic, Obstetric, Psychosocial, Psychological, and Disease and treatment-related 211 factors were used to identify the factors that were significantly associated with the development 212 of depression in pregnancy. Among the variables, gestational week, number of pregnancies, type 213 of pregnancy, relationship with husband as well as in-laws, history of domestic and sexual 214 violence, having a husband with multiple marriages, and history of previous disease were found 215 statistically significant with a p-value <0.05 in the chi-square test Table 3. 216 Table 3. Factors associated with antenatal depression in women visiting for antenatal 217 check-ups in UHC, Lohagara, and Khan General Hospital, Lahuria from July to August 218 2023 (bivariate analysis by chi-squared test). 219 Variables Category No Depression Mild Depression Moderate depression Severe Depression Chi2 p- value Gestational week <12 weeks 14 9.3% 30 21.3% 10 21.3% 2 16.7% 0.026 12-28 weeks 92 61.3% 74 52.5% 15 31.9% 6 50% . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint 29-40 weeks 44 29.3% 37 26.2% 22 46.8% 4 33.3% Para Nulliparous 68 45.3% 48 34.4% 16 34.4% 3 25% 0.005 Multiparous 82 54.7% 93 66% 31 66% 9 75% Type of pregnancy Planned 123 82% 97 68.8% 35 72.3% 4 33.3% 0.002 Unplanned 27 18% 44 21.2% 12 27.7% 8 66.7% Relationship with husband Good 72 48% 60 42.6% 22 46.8% 3 25% 0.017 Moderate 73 48.7% 78 55.3% 20 42.6% 5 41.7% Poor 5 3.3% 3 2.1% 5 10.6% 4 33.3% Relationship with in-laws Good 128 85.3% 110 78% 28 79.6% 3 25% 0.001 Moderate 16 10.7% 24 17% 12 25.5% 3 25% Poor 5 3.3% 4 2.8% 7 14.9% 5 41.7% Dead/Separated 1 0.7% 3 2% 0 1 8.3% . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint Domestic violence Yes 5 3.3% 7 5% 4 8.5% 2 16.7% 0.047 No 145 96.7% 134 95% 43 91.5% 10 83.3% Sexual violence Yes 4 2.7% 9 6.4% 3 6.4% 3 25% 0.007 No 146 97.3% 132 93.6% 44 93.6% 9 75% Polygamous husband Yes 1 0.7% 4 2.8% 1 2% 3 25% 0.002 No 149 99.3% 137 97.2% 46 97.9% 9 75% Previous disease Yes 9 6% 18 12.8% 7 14.9% 3 25% 0.007 No 141 94% 123 87.2% 40 85% 9 75% 220 A binary logistic regression was also performed to find out the odds ratio of variables Table 4. 221 These covariates were then considered for the multiple logistic regression analysis. 222 Table 4. Factors associated with prenatal depression among women attending antenatal 223 care in UHC, Lohagara and Khan General Hospital, Lahuria from June to August 2023 224 (after bivariate and multivariate regression analysis). 225 Variables Category Depression No COR AOR . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint Depression (95% CI) (95% CI) Gestational week <12 weeks 30 26 1 1 12-28 weeks 63 124 0.4 (0.2, 0.8) 0.4 (0 .2,0 .8) 29-40 weeks 43 64 0.6 (0.3, 1.1) 0.6 (0.3, 1.2) Para Nulliparous 40 95 0.5 (0.3, 0.8) 0.9 (0.5,1.5) Multiparous 96 119 1 1 Type of pregnancy Planned 88 171 1 1 Unplanned 48 43 2.2 (1.4, 3.6) 1.8 (1, 3.1) Relationship with husband Good 55 102 1 1 Moderate 69 107 1.2 (0.8, 1.9) 1.2(0.7, 1.9) Poor 12 5 4.5 (1.3, 13.3) 1.6 (0.3, 8.9) Relationship with in-laws Good 91 178 0.3 (0.06, 2.08) 2.6 (0.2, 38.7) Moderate 27 28 0.6 (0.1, 4) 4.7 (0.3, 71.7) Poor 15 6 1.7 (0.2, 12.6) 11.2 (0.6, 194) Dead/ 3 2 1 1 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint Separated Domestic violence Yes 11 7 2.6 (1, 6.9) 1.2 (0.3, 5.7) No 125 207 1 1 Sexual violence Yes 13 6 3.7 (1.4, 9.9) 3.3 (1.1, 9.6) No 123 208 1 1 Polygamous husband Yes 8 1 13.3 (1.6, 107.7) 13.6 (1.1,163) No 128 213 1 1 Previous disease Yes 22 15 2.6 (1.3, 5.1) 2.4 (1.1, 5.3) No 114 199 1 1 226 Gestational weeks, intimate partner violence, unwanted pregnancy, a history of previous disease, 227 and multiple married husbands were found to be significantly associated with the development of 228 depression in pregnancy. Those who were in their 2nd trimester of pregnancy had 60% less 229 chance of developing antenatal depression than those who were in the first trimester. (AOR: 0.4, 230 95% CI: 0.2, 0.8) Table 5. 231 Table 5. Multivariate logistic regression of possible factors associated with antenatal 232 depression in women visiting for antenatal check-ups in UHC, Lohagara, and Khan 233 General Hospital, Lahuria from July to August 2023. 234 Variables Category Reference Odds P>|z| . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint Category ratio Gestational week 13-28 28 0.59227 0.15 Para Nulliparous Multiparous 0.88095 0.633 Type of pregnancy Unplanned Planned 1.81135 0.027 Relationship with husband Moderate Good 1.15832 0.562 Poor 1.59752 0.593 Relationship with in-laws Good Dead/ Separated 1.85478 0.653 Moderate 3.57372 0.363 Poor 8.56358 0.098 Domestic violence Yes No 1.2175 0.803 Sexual violence Yes No 3.09672 0.03 Polygamous husband Yes No 13.6921 0.04 History of previous diseases Yes No 2.56009 0.025 235 Among the pregnant women suffering from depression, 53.6% (30) were in the first trimester. 236 33.7% (60) of prenatally depressed women were between 13 to 28 weeks of gestation. 40% (43) 237 were passing their 3rd trimester of pregnancies. 238 The odds ratio revealed three times increase in expectant women who had a history of 239 experiencing intimate partner violence than those who did not have (AOR: 3.3, 95% CI: 1.1, 240 9.7). 241 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint Women facing intimate partner violence showed elevated levels of various forms of antenatal 242 depression. Roughly 21% (4) of pregnant women with a background of intimate partner violence 243 did not experience depression or had minimal symptoms, 47.4% (9) had mild depression, 15.8% 244 (3) had moderate depression, and another 15.8% (3) dealt with severe depression. 245 Type of pregnancy was also an important contributing factor as the odds ratio raised about two 246 times in cases of unplanned pregnancy (AOR: 1.8, 95% CI: 1, 3). 247 women had a history of unplanned pregnancy. Among them, 52.8% (48) were experiencing 248 prenatal depression. 34% (98) of the total 259 expectant mothers having a history of intended 249 pregnancies, were suffering from antenatal depression. 250 The incidence of moderate depression was nearly identical in both intended and unintended 251 pregnancies, ranging from 13.2% to 13.5%. However, in the case of unwanted pregnancies, the 252 rates of mild and severe depression were higher (mild depression: 48.4%, severe depression: 253 8.8%). Out of the 91 women with a history of unintended pregnancies, 48.4% (44) reported mild 254 depression, 13.2% (12) experienced moderate depression, and 8.8% (8) had severe depression. 255 Additionally, 29.7% (27) showed no or minimal signs of depression. 256 In contrast, among the total of 259 women with planned pregnancies, 37.5% (97) were dealing 257 with mild depression, 13.5% (35) reported moderate depression, and 1.5% (4) experienced 258 severe depression. Moreover, 47.5% (123) exhibited no or minimal signs of depression. 259 Women suffering from a disease from the past showed a 2 times escalated odds ratio than those 260 who were free from any medical condition (AOR: 2.4, 95% CI: 1.1, 5.2). 261 Out of the pregnant women undergoing prenatal depression, 59.5% (22) had a history of prior 262 diseases or illnesses. Within this group, 48.7% (18) were dealing with mild depression, 19% (7) 263 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint with moderate depression, and 8.1% (3) with severe depression. Additionally, 24% (9) showed 264 no or minimal signs of depression. 265 On the other hand, pregnant women married to husbands who have multiple wives unveiled a 13 266 times higher odds ratio than those having single-married husbands (AOR: 13.6, 95% CI: 1.1, 267 164). 268 Approximately 89% (8) of women with a history of multiple-married husbands were grappling 269 with prenatal depression. Within this group, approximately 55.6% (5) were undergoing mild to 270 moderate depression, while the remaining 33.3% (3) were dealing with severe depression during 271 pregnancy. The rest 11.1% did not experience depression or had minimal symptoms. 272 273

274 This study aimed to assess the prevalence and evaluate the sociodemographic, obstetric, 275 psychosocial, psychological, and disease and treatment-related determinants associated with the 276 development of antenatal depression in a rural subdistrict in Narail. The point prevalence of 277 antenatal depression accounted for 39% (38.86%, 95% confidence interval: 33.9% to 44%) in 278 this study. The elevated odds ratio of Antenatal Depression Syndrome (ADS) is attributed to 279 several significant social determinants, including sexual violence, and unplanned pregnancy. 280 Additionally, having a polygamous husband is identified as a crucial psychological factor, while 281 a history of previous disease serves as a notable disease and treatment-related factor contributing 282 to the increased odds of ADS. Gestational week is an important obstetric factor associated with 283 depression in pregnancy. 284 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint The obtained prevalence of depression in pregnancy in this study is in agreement with the 285 prevalence in lower (34.0%, 95% Confidence Interval: 33.1%-34.9%) and middle-income 286 countries ( 22.7%, 95% Confidence Interval: 20.1%-25.2%) (20). The result of this study also 287 aligns with the study conducted by Gausia et al. (33%, 95% CI, 27.6–37.5) (13), and Tasnim et 288 al. (36.2% in patients with GDM) (21), and that is perhaps because of similar locations. 289 However, this is higher than the study of Nasreen et al. (18.3%, 95% CI:15.9%-20.7%) (22). 290 That is probably because of the differences in the research methodology like sample size and 291 study area. This study was conducted in Narail, which is a district of Khulna division, while the 292 study conducted by Nasreen et al. was in the Mymensingh division, and there was a significant 293 gap between the period of conduction of both studies. The sample sizes are also different from 294 each other. Another study was conducted in a rural district in Sylhet which showed a higher 295 prevalence (56.6%, 95.5% CI 50.0–63.0%) of ADS than the prevalence obtained from this study. 296 The reason behind this distinction can be the difference in the location and number of 297 participants involved. A majority of women in the Khulna division, specifically 88.6%, have no 298 more than a primary education. 61% of mothers are unaware of the presence of Maternal Health 299 Clinics (MHC) in this area, and 36% of them are receivers of any form of antenatal care (ANC) 300 only. Additionally, ANC services from government healthcare facilities are sought by 47% of 301 expectant mothers. Regardless of potential complications and warning signs, 95% of births 302 usually take place at home that are assisted by untrained birth attendants. Merely, postnatal care 303 (PNC) is provided among 19.75% of mothers and 12.3% of infants. Multiple factors contribute 304 to the limited utilization of Maternal Health Clinic (MHC) services, including poor 305 communication, insufficient awareness of MHC services, limited financial resources, decision-306 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint making processes, and the absence of a companion for accessing healthcare services (23). On the 307 other hand, variations in the sample sizes are also an influencing factor for the differences. 308 Violence is a common problem in Bangladesh and it is one of the countries having the highest 309 records of violence (24). Intimate partner violence was revealed as a significant contributing 310 factor in many studies which include domestic and sexual violence. It encompasses various 311 forms of abusive behavior, including physical violence that occurs at any point in the 312 relationship, instances of forced sexual activity, and physical violence specifically during 313 pregnancy. (25). 37% of women living in cities and half of the village women are sufferers of 314 lifetime sexual violence. Causes include the history of physical abuse of mothers-in-law by 315 fathers-in-law, The degree of husband's controlling conduct, and the occurrence of forced or 316 coerced initial sexual activity. In rural areas, the likelihood of this violence increased when 317 women were between the ages of 20-24 as opposed to 15-19 and when there was a dowry 318 demand during marriage (26). In Bangladesh, a percentage of women believe, their husbands 319 have the right to raise their hands on them. Some women, who have been seeing their mothers 320 become dominated and being hit by their fathers for a long time, take it easy to believe that their 321 husbands can not only dominate them but also bear the right to beat them. These two groups of 322 women are more likely to be the victims of intimate partner violence (27). This study found 323 intimate partner violence as a significant contributing factor to antenatal depression which is 324 similar to the study conducted by Peltzer et al. in Thailand and Insan et al. in Bangladesh (12, 325 28). 326 This study obtained unplanned pregnancy as a responsible factor for antenatal depression. 327 Brazilian women who have experienced unplanned pregnancies face a 2.5 times higher risk of 328 experiencing depression during both pregnancy and the postpartum period compared to their 329 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint counterparts who have had planned pregnancies (29). Postnatal depressive symptoms among 330 socio-economically disadvantaged rural Bangladeshi women are notably linked to the perception 331 of paternal pregnancy unwantedness and couple pregnancy discordance. Additionally, maternal 332 intentions and pregnancy discordance are associated with prenatal depressive symptoms in this 333 population (30). A study conducted by Surkan et al. in northwestern Bangladesh and another 334 study conducted by Gausia et. al in eastern Bangladesh showed that unwanted pregnancy is a 335 significantly associated factor of antenatal depression which is similar to this study (13, 30). 336 Within the realm of obstetric factors, the gestational week emerges as a notable element 337 influencing the onset of prenatal depression. The study reveals a substantial decrease in the 338 likelihood of developing depression, amounting to a 60% reduction during the second trimester 339 compared to the first trimester. This aligns with findings from a systematic review and meta-340 analysis conducted by Okagbue et al., encompassing 26 articles, which underscores that the 341 prevalence of antenatal depression tends to be lower between the 13th and 28th weeks of 342 gestation (31). 343 While some studies have identified family support and a preference for the male gender within 344 families as significant contributing factors to prenatal depression (12, 13), this particular study 345 did not observe such associations. It suggests that with the progression of time, contemporary 346 family members may be more attentive and supportive of pregnant mothers than in the past. 347 Additionally, the inclination toward preferring male children within families appears to be less 348 prevalent today compared to historical trends. This study specifically noted that 18.5% (65) of 349 women reported a history of male baby preference from their husbands, and 18% (63) from their 350 families. However, a substantial majority, around 82%, did not report any history of a preference 351 for male children from either their husbands or family members. 352 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint However, unlike other studies, this study identified noteworthy connections between a previous 353 history of any disease and having a polygamous husband with depression during pregnancy. In a 354 study carried out by Nasreen et al. in rural sub-districts of Mymensingh, a significant correlation 355 was identified between a previous history of depression and prenatal depression (22). This 356 research revealed that women with a previous mental health condition, as well as those with a 357 history of other ailments such as Diabetes mellitus, Hypertension, and Thyroid disorders, are 358 prone to experiencing depression during pregnancy. 359

360 In summary, this study faced limitations primarily stemming from a small and constrained 361 sample size due to time and resource limitations. The study was carried out with women 362 attending antenatal check-ups at a particular government and private hospital in Lohagara. 363 Nevertheless, there could be a subset of women who do not seek medical attention throughout 364 their entire pregnancy unless they experience extreme physical challenges. In many instances, 365 these women opt for home deliveries assisted by unskilled birth attendants, bypassing hospitals 366 during childbirth. For this reason, the findings may not fully capture the diversity of the entire 367 community population, limiting the generalizability of obtained results. 368 369

370 In conclusion, the prevalence and associated factors of antenatal depression in rural Bangladesh 371 highlight a critical public health concern with far-reaching consequences for both mothers and 372 newborns. Antenatal depression is frequently observed in the rural areas of Bangladesh, 373 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint emphasizing the importance of increasing awareness among healthcare professionals and family 374 members. This awareness is crucial to offer additional mental support to pregnant women, 375 especially in their first and third trimesters of gestation. Furthermore, formulating strategic plans 376 and policies is essential to reduce intimate partner violence and discourage polygamy. The 377 situation also underscores the necessity of providing extra care to mothers with a history of 378 health-related issues and offering additional counseling to those who find themselves 379 unexpectedly pregnant. 380 To effectively tackle this issue, it is imperative for the government, stakeholders, and 381 policymakers to collaborate on comprehensive national programs and health education 382 campaigns. Resource allocation and the formulation of definitive policies are crucial steps 383 toward raising awareness and destigmatizing mental health concerns in rural communities. By 384 addressing the root causes and promoting a proactive approach to mental health, we can work 385 towards reducing the prevalence of antenatal depression and ultimately safeguarding the well-386 being of both mothers and newborns in rural Bangladesh. 387 388 Supporting Information 389 S1 File. Dataset. 390 https://doi.org/10.6084/m9.figshare.24994110 (xlsx) 391

392 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint I am profoundly thankful to the Almighty for granting me the opportunity to pursue MPH 393 (Epidemiology) at North South University. I am also grateful to North South University for 394 allowing me to do the research for the partial fulfillment of my MPH degree. My gratitude 395 extends to my supervisor, Dr. Dipak Kumar Mitra, Ph.D., MPH, MBBS, the current chairman of 396 the Department of Public Health at North South University, for his kind advice and guidance. I 397 am greatly thankful to Dr.S M Mashud, UH&FPO, Upazila Health Complex, Lohagara, for his 398 wonderful guidance and unwavering support to carry out the study. 399 400

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