Abstract
Approximately 1 in 5 women in low- and middle-income countries experience postpartum depression, and the risk is higher among mothers of low-birth-weight (LBW) infants. Kangaroo mother care (KMC) is effective in improving survival among LBW infants, but the benefits of KMC for mothers are not well described. To estimate the effects of community-initiated KMC (ciKMC) on maternal risk of moderate-to-severe postpartum depressive symptoms and on salivary cortisol concentration, a biomarker of stress. This was an unmasked, parallel-group, individually randomized clinical trial. Participants included 1950 mothers of stable LBW infants (weighing 1500-2250 g) in rural and semiurban low-income populations in North India enrolled between April 2017 and March 2018. Data analysis was performed from January to July 2020. Eligible participants were randomly assigned to the intervention or control group by block randomization. The mothers in the intervention group were supported to practice ciKMC until 28 days after birth or until the infant wriggled out of the KMC position (ie, was no longer staying in the KMC position). The intervention included promotion and support of skin-to-skin contact and exclusive breastfeeding through home visits. Postpartum depressive symptoms at the end of the neonatal period were measured using the Patient Health Questionnaire-9, with a score of 10 or higher used to identify moderate-to-severe depressive symptoms. Salivary cortisol concentration was measured in a subsample of 550 mothers before and after breastfeeding on day 28 after birth. Of the 1950 participants (mean [SD] age, 23 [3.5] years), outcome assessment was completed for 974 of 1047 participants (93%) in the intervention group and 852 of 903 participants (94%) in the control group. Sixty-four percent of participants (1175 of 1826 participants) belonged to the lowest 3 wealth quintiles. The proportion of mothers with moderate-to-severe postpartum depressive symptoms was 10.8% (95% CI, 8.9%-12.9%; 105 of 974 mothers) in the intervention group vs 13.6% (95% CI, 11.4%-16.1%; 116 of 852 mothers) in the control group. The adjusted relative risk of moderate-to-severe maternal postpartum depressive symptoms was 0.75 (95% CI, 0.59-0.96), or an efficacy of 25%. There was no difference in day-28 salivary cortisol concentration between the ciKMC and control group mothers before or after breastfeeding. The analysis estimated that supporting 36 mothers to perform KMC at home would prevent 1 mother from experiencing moderate-to-severe postpartum depressive symptoms. These findings suggest that ciKMC practice may substantially reduce the risk of moderate-to-severe maternal postpartum depressive symptoms. This evidence supports KMC as an intervention to be incorporated in essential newborn care programs in low- and middle-income settings. Clinical Trials Registry-India Identifier: CTRI/2017/04/008430.
Highlights
Postpartum depression[1,2] affects quality of life and long-term psychological health in mothers and can adversely affect mother-child interaction, breastfeeding, infant growth, and development.[3,4,5,6,7] Pooled estimates from 53 studies in 23 low- and middle-income countries reported the prevalence of postpartum depression to be 19%.[8]
The adjusted relative risk of moderate-to-severe maternal postpartum depressive symptoms was 0.75, or an efficacy of 25%
There was no difference in day-28 salivary cortisol concentration between the community-initiated Kangaroo mother care (KMC) (ciKMC) and control group mothers before or after breastfeeding
Summary
Postpartum depression[1,2] affects quality of life and long-term psychological health in mothers and can adversely affect mother-child interaction, breastfeeding, infant growth, and development.[3,4,5,6,7] Pooled estimates from 53 studies in 23 low- and middle-income countries reported the prevalence of postpartum depression to be 19% (95% CI, 16%-23%).[8]. Several psychosocial and psychological interventions have been evaluated for their effect on the risk of postpartum depression These include postpartum home visits by professionals, telephone-based peer support, and interpersonal psychotherapy. Promising, they are not widely implemented in the Indian public health system.[12] Kangaroo mother care (KMC), an intervention encompassing skin-to-skin contact (SSC) and exclusive breastfeeding, reduces the risk of death and severe infection in low-birth-weight (LBW) infants and is recommended by the World Health Organization and the Government of India.[13,14,15] In a large randomized clinical trial[16] in India among 8402 LBW infants, promotion of community-initiated KMC (ciKMC) improved postenrollment neonatal survival by 30% and infant 6-month survival by 25%. KMC could reduce the risk of postpartum depressive symptoms through mother-infant bonding and possibly via the release of maternal oxytocin and lowering of cortisol secretion.[17,18,19] Data from observational and quasiexperimental studies[20,21,22,23] suggest such a beneficial effect on mothers, but conclusive evidence is lacking
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