Detection of antenatal depression in rural HIV-affected populations with short and ultrashort versions of the Edinburgh Postnatal Depression Scale (EPDS)

Tools for screening maternal mental health conditions in primary care settings in sub-Saharan Africa: systematic review

Introduction

In sub-Saharan Africa, pregnant and postpartum women with mental health problems are often missed in healthcare systems. To address this, a practical and simple screening tool for maternal mental health should be available to primary healthcare workers. An important step toward having such a tool is to assess the existing tools and their effectiveness in primary care settings.

Methods

We systematically searched PubMed, LILAC, CINAHL, Google Scholar, African Index Medicus, HINARI, and African Journals Online from inception to 31 January 2023, without language restriction. Reference lists of retrieved articles were reviewed and experts in the field were contacted for studies not captured by our searches. All retrieved records were collated in Endnote, de-duplicated, and exported to Rayyan for screening. Study selection and data extraction were done by at least two reviewers using a pre-tested flow chart and data extraction form. Disagreements between reviewers were resolved through discussion. We contacted primary authors for missing or insufficient information and conducted a content analysis of the psychometric properties of the tools.

Results

In total, 1,181 studies were retrieved by our searches, of which 119 studies were included in this review. A total of 74 out of 119 studies (62%) were screened for depression during pregnancy and or the postpartum period. The Edinburg Postpartum Depression Scale (EPDS) and the Patient Health Questionnaire (PHQ-9) were the most commonly used tools. In total, 12 studies reported specificity and sensitivity for tools for measuring depression (EPDS, PHQ-9, and Whooley) and psychological distress [Self Report Questionnaire (SRQ) and Kessler Psychological Distress Scale (KPDS)]. The average sensitivity and specificity of the EPDS reported were 75.5 and 76.5%, respectively, at a cut-off of ≥13. The EPDS appears to be the most acceptable, adaptable, user-friendly, and effective in screening for maternal mental health conditions during pregnancy and postpartum. However, the methodological approach varied for a particular tool, and documentation on the attributes was scanty.

Conclusion

The EPDS was the most commonly used tool and considered as most acceptable, adaptable, user-friendly, and effective. Information on the performance and psychometric properties of the vast majority of screening tools was limited.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022323558, identifier CRD42022323558 (PROSPERO).

Association between maternal HIV status and postpartum depressive symptoms in Botswana

Few studies have evaluated postpartum depression (PPD) in women living with HIV (WLHIV) in Botswana, a high prevalence HIV setting. The Edinburgh Postnatal Depression Scale (EPDS) was used to evaluate PPD symptoms in WLHIV (n = 300) and women who are HIV-uninfected (n = 131) in the Tshilo Dikotla study, an observational cohort study with a nested randomized trial. The EPDS was administered at 2, 6, and 12 months postpartum. We assessed the association of (1) HIV infection and (2) antiretroviral therapy (ART) with odds of PPD symptoms (EPDS ≥ 10 or thoughts of self-harm) in the first year postpartum using generalized estimating equations. Of WLHIV, 24 (8.00%) had PPD symptoms at one or more follow-up time points, compared to 9 (6.9%) women who were HIV-seronegative. There was no association between HIV status and PPD symptoms (adjusted odds ratio [aOR]:1.69, 95% confidence interval [CI]: 0.73-3.93, p = 0.225); however, WLHIV on efavirenz-based ART regimens had higher odds of experiencing PPD symptoms compared to dolutegravir-based ART (aOR:3.05, 95% CI:1.16-8.03, p = 0.024).

Depression Among Pregnant and Breastfeeding Persons Participating in Two Randomized Trials of the Dapivirine Vaginal Ring and Oral Pre-Exposure Prophylaxis (PrEP) in Malawi, South Africa, Uganda, and Zimbabwe

Depression is associated with lower adherence to oral pre-exposure prophylaxis (PrEP) to prevent HIV, but data are not currently available on how depression may affect use of other HIV prevention methods including the dapivirine vaginal ring (DVR). We conducted a mixed methods study using data from the Microbicide Trials Network (MTN) 042/DELIVER (n = 558) and MTN-043/B-PROTECTED (n = 197) studies to describe the prevalence of depressive symptoms and explore how depressive symptoms may have influenced attitudes about use of the monthly DVR and once-daily oral PrEP tablet among pregnant and breastfeeding persons, respectively, in Malawi, South Africa, Uganda, and Zimbabwe. Eleven participants had high Edinburgh Postnatal Depression scores ≥ 10 in MTN-042/DELIVER (2%) and four participants (2%) in MTN-043/B-PROTECTED. In interviews with 9 participants who had high scores (6 DVR, 3 oral PrEP), those with depressive symptoms described overlapping stressors which were magnified by job loss and economic instability during the COVID-19 pandemic, and by experiences of pregnancy/postpartum. These participants experienced a lack of support from partners or family members, and conflict with partners related to trust, and infidelity. While we did not find evidence of a change in product adherence, there was a strong sense of commitment and motivation to use the study products for protection from HIV for participants themselves and their baby. Although lack of social support is usually an obstacle to adherence, in this study, the participants' lives and relationships seemed to have reinforced the need for HIV prevention and motivated women to protect themselves and their babies from HIV.

Prevalence and factors associated with antepartum depression among adolescent women in the assin north district of Ghana: a cross-sectional study

BACKGROUND

Globally, depression is a leading cause of disease-related disability among women. In low-and-middle-income countries (LMICs), the prevalence rate of antepartum depression is estimated to range between 15% and 57% and even higher in adolescent antepartum women. Although a number of studies have shown that depression is common in adolescent pregnancies and has a prevalence rate between 28% and 67% among adolescent mothers, there currently exists no literature on depression among adolescent pregnant women in Ghana. The study aimed to determine the prevalence of antepartum depression and identify the factors associated with it among pregnant adolescent women.

METHODS

A quantitative cross-sectional study design was adopted by randomly recruiting 220 adolescent pregnant women visiting antenatal clinics in five selected health facilities in five communities in the Assin North District of Ghana. Data were collected using the Edinburgh Postnatal Depression Scale (EPDS). Data analysis was performed using Stata version 14. Both descriptive and inferential analyses were performed. A chi-square analysis was conducted to identify the association between independent and dependent variables. A multivariate logistic regression analysis was carried out to identify the independent variables that were significantly associated with the dependent variable. In all analyses, p-values ≤ 0.05 were deemed statistically significant at a 95% confidence interval.

RESULTS

The results indicated prevalence of depression was 38.6% using the EPDS cut-off ≥ 13. Respondents who were cohabiting were less likely to experiencing antepartum depression compared to those who were single (AOR = 0.36, 95% CI: 0.20-0.64, p = 0.001). Also, Respondents who had completed Junior High School had a lower likelihood of experiencing antepartum depression compared to those who had no formal education (AOR = 0.19, 95% CI: 0.05-0.76, p = 0.019). Respondents who perceived pregnancy-related items to be costly had higher odds of experiencing antepartum depression (AOR = 2.05, 95% CI: 1.02-4.12, p = 0.042). Lastly, adolescent pregnant women who reported that pregnancy-related items are costly were likely to experience antepartum depression compared to those who did not report such costs (AOR = 2.12, 95% CI: 1.20-3.75, p < 0.001).

CONCLUSION

The results of this study highlight the importance of a multi-pronged strategy for combating antepartum depression in adolescents and improving the overall health and well-being of pregnant adolescents. Considering that adolescence is a transitional period occasioned by several bio-psycho-social challenges, setting up systems to ensure that young girls are motivated and supported to stay in school will enhance their economic prospects and improve their standards of life while providing psycho-social support will benefit their health and general well-being.

Effects of M-DEPTH Model of Depression Care on Maternal Functioning and Infant Developmental Outcomes in the Six Months Post Delivery: Results from a Cluster Randomized Controlled Trial

Perinatal depression has been shown to have deleterious effects on maternal post-partum functioning, as well as early child development. However, few studies have documented whether depression care helps to mitigate these effects. We examined the effects of the M-DEPTH (Maternal Depression Treatment in HIV) depression care model (including antidepressants and individual Problem Solving Therapy) on maternal functioning and infant development in the first 6 months post-delivery in an ongoing cluster randomized controlled trial of 391 HIV-infected women with at least mild depressive symptoms enrolled across eight antenatal care clinics in Uganda. A subsample of 354 (177 in each of the intervention and control groups) had a live birth delivery and comprised the analytic sample, of whom 69% had clinical depression at enrollment; 70% of women in the intervention group (including 96% of those with clinical depression) received depression treatment. Repeated-measures multivariable regression models found that the intervention group reported better infant care, lower parental burden, and greater perceived adequacy of parental support, compared to the control group. These findings suggest that depression care for pregnant women living with HIV is important not only for maternal mental health, but it also helps women to better manage parenting and care for their infant.

Stressors and Maladaptive Coping Mechanisms Associated with Elevated Perinatal Depressive Symptoms and Suicidality Among Women Living with HIV in Uganda

BACKGROUND

Perinatal depression is highly prevalent among women living with HIV and contributes to nonadherence to the PMTCT (prevention of mother-to-child transmission) care continuum. We examined correlates of elevated depressive symptoms and suicidality in this population.

METHOD

Baseline data from 391 Ugandan women enrolled in a cluster randomized controlled trial of a depression care intervention were analyzed. Adult women with confirmed sero-positive HIV status were eligible if their gestation period was ≤ 32 weeks, and they had a Patient Health Questionnaire (PHQ-9) score ≥ 5. Correlates of elevated depressive symptoms (PHQ-9 > 9) and moderate-to-severe suicidal ideation (more than half of the days in the prior 2 weeks) were assessed using bivariate and multivariate logistic regression models, controlling for clustering within study sites by using a random effects specification (with study site as the random effect), as well as age and education.

RESULTS

The mean PHQ-9 score was 12.7 (SD = 5.1); 267 (68.3%) participants had elevated depressive symptoms, and 51 (13.0%) reported moderate-to-severe suicidality. In multiple logistic regression analysis, perceived provider stigma of childbearing [OR (95% CI) = 1.81 (1.16, 2.84)], greater use of negative problem-solving [OR (95% CI) = 1.09 (1.04, 1.15)], and lower general social support [OR (95% CI) = 0.50 (0.30, 0.82)] were correlated with elevated depression symptoms, while moderate-to-severe suicidal ideation was correlated with greater experience of physical interpersonal violence (IPV) and greater use of negative problem-solving.

CONCLUSIONS

Programs aimed at improving provider support for the childbearing needs of persons living with HIV, supporting women who are experiencing IPV, and helping women to develop effective problem-solving skills and social supports may reduce symptoms of perinatal depression and help optimize PMTCT care outcomes.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03892915 (registered March 21, 2019).

Effects of M-DEPTH Model of Depression Care on Maternal HIV Viral Suppression and Adherence to the PMTCT Care Continuum Among HIV-Infected Pregnant Women in Uganda: Results from a Cluster Randomized Controlled Trial at Pregnancy Completion

Perinatal depression has been shown to impede adherence to antiretroviral therapy (ART) and the prevention of mother-to-child transmission (PMTCT) care continuum; therefore, treating perinatal depression may result in increased viral suppression and PMTCT adherence. We examined the effects of the M-DEPTH (Maternal Depression Treatment in HIV) depression care model (including antidepressants and individual Problem Solving Therapy) on depression, maternal viral suppression and adherence to PMTCT care processes in an ongoing cluster-randomized controlled trial of 391 HIV-infected pregnant women (200 usual care; 191 intervention) with at least mild depressive symptoms enrolled across 8 antenatal care clinics in Uganda. At baseline, 68.3% had clinical depression and 41.7% had detectable HIV viral load. Adjusted repeated-measures multivariable regression models found that the intervention group was nearly 80% less likely to be clinically depressed [Adjusted OR (95% CI) 0.22 (0.05, 0.89)] at the 2-month post-pregnancy assessment, compared to the control group. However, the intervention and control groups did not differ meaningfully on maternal viral suppression, ART adherence, and other PMTCT care processes and outcomes. In this sample of women who were mostly virally suppressed and ART adherent at baseline, the depression care model had a strong effect on depression alleviation, but no downstream effects on viral suppression or other PMTCT care processes.Trial Registration NIH Clinical Trial Registry NCT03892915 (clinicaltrials.gov).

Optimizing PMTCT Adherence by Treating Depression in Perinatal Women with HIV in South Africa: A Pilot Randomized Controlled Trial

BACKGROUND

South Africa (SA) has the greatest HIV prevalence in the world, with rates as high as 40% among pregnant women. Depression is a robust predictor of nonadherence to antiretroviral therapy (ART) and engagement in HIV care; perinatal depression may affect upwards of 47% of women in SA. Evidence-based, scalable approaches for depression treatment and ART adherence in this setting are lacking.

METHOD

Twenty-three pregnant women with HIV (WWH), ages 18-45 and receiving ART, were randomized to a psychosocial depression and adherence intervention or treatment as usual (TAU) to evaluate intervention feasibility, acceptability, and preliminary effect on depressive symptoms and ART adherence. Assessments were conducted pre-, immediately post-, and 3 months post-treatment, and included a qualitative exit interview.

RESULTS

Most (67.6%) eligible individuals enrolled; 71% completed at least 75% of sessions. Compared to TAU, intervention participants had significantly greater improvements in depressive symptoms at post-treatment, β =  - 11.1, t(24) =  - 3.1, p < 0.005, 95% CI [- 18.41, - 3.83], and 3 months, β =  - 13.8, t(24) =  - 3.3, p < 0.005, 95% CI [- 22.50, - 5.17]. No significant differences in ART adherence, social support, or stigma were found. Qualitatively, perceived improvements in social support, self-esteem, and problem-solving adherence barriers emerged as key benefits of the intervention; additional sessions were desired.

CONCLUSION

A combined depression and ART adherence intervention appears feasible and acceptable, and demonstrated preliminary evidence of efficacy in a high-need population. Additional research is needed to confirm efficacy and identify dissemination strategies to optimize the health of WWH and their children.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03069417. Protocol available at https://clinicaltrials.gov/ct2/show/NCT03069417.

Perinatal Depressive Symptoms and Viral Non-suppression Among a Prospective Cohort of Pregnant Women Living with HIV in Nigeria, Kenya, Uganda, and Tanzania

Depression is common during pregnancy and is associated with reduced adherence to HIV-related care, though little is known about perinatal trajectories of depression and viral suppression among women living with HIV (WLHV) in sub-Saharan Africa. We sought to assess any association between perinatal depressive symptoms and viral non-suppression among WLWH. Depressive symptomatology and viral load data were collected every 6 months from WLWH enrolled in the African Cohort Study (AFRICOS; January 2013-February 2020). Generalized estimating equations modeled associations between depressive symptoms [Center for Epidemiological Studies Depression (CES-D) ≥ 16] and viral non-suppression. Of 1722 WLWH, 248 (14.4%) had at least one pregnancy (291 total) and for 61 pregnancies (21.0%), women reported depressive symptoms (13.4% pre-conception, 7.6% pregnancy, 5.5% one-year postpartum). Depressive symptomatology was associated with increased odds of viral non-suppression (aOR 2.2; 95% CI 1.2-4.0, p = 0.011). Identification and treatment of depression among women with HIV may improve HIV outcomes for mothers.

Reliability and validity of a perinatal depression screening instrument in rural Mali

Background

In order to reduce the burden of perinatal depression in low- and middle-income countries, health systems must be able to identify and treat women suffering from depression. The objective of our study was to develop a locally valid and reliable screening instrument for use in identifying pregnant women and mothers of young children with a local depression syndrome, dusukasi, in rural Mali.

Methods

We administered a locally adapted screening instrument containing items from the Edinburgh Postpartum Depression Scale (EPDS) and Hopkins Symptom Checklist (HSCL-25) to 180 pregnant women and mothers of children under age 2 in Sélingué, Mali to assess the instrument's psychometric properties and validity. Item Response Theory was used to develop an abbreviated version of the measure and the validity and psychometric properties of this shortened version were compared with the full-length scale.

Results

The full 28-item scale exhibited a single factor structure with good internal consistency (Cronbach's alpha = 0.92). Women who self-identified as suffering from dusukasi (n = 87) in a known groups analysis to assess construct validity had significantly higher depression and anxiety symptom scores (p < 0.0001) and functional impairment scores (p < 0.0001) compared to women not reporting dusukasi (n = 93). The shortened 16-item scale performed as well as the full scale in identifying women with dusukasi.

Conclusions

Construct validity of our adapted screening instrument was supported for identifying dusukasi in rural Malian women. Our methodology can be applied in other settings to develop similarly valid screening instruments for perinatal depression.

Acceptability and feasibility of a screening protocol for antenatal depression (SPADe) in Blantyre District, Malawi

BACKGROUND

Depression is one of the most common perinatal mental health problems that affect pregnant women. Antenatal depression can adversely affect the well-being of the pregnant woman and her foetus. Depression is rarely detected by midwives due to the unavailability of relevant screening instruments in Malawi. A Screening Protocol for Antenatal Depression (SPADe) was developed and recommended for possible use to screen for depression in antenatal clinics in the country. The acceptability and feasibility of using the SPADe protocol to screen for depression has not been established. The aim of this study was to assess the acceptability and feasibility of screening for depression by midwives using SPADe in antenatal clinics in Blantyre district.

METHODS

This study used a quantitative survey design to collect data among 60 midwives in three antenatal clinics in primary care settings. All inclusive sampling of all 60 midwives were used. The Structured Assessment of FEasibility and Ottawa Acceptability of Decision Rules Instruments were used to collect the data. Descriptive statistics and Chi square tests were used to analyse the data.

RESULTS

This study found that it was feasible to implement SPADe and the following enablers for screening depression had the highest ratings: the SPADe is applicable to pregnant women (M = 3.9, sd = 0.4); the intended goal of the SPADe matches the prioritised goals of Malawi Ministry of Health (M = 3.9, sd = 0.5); and the SPADe is likely to be effective (M = 3.8, sd = 0.6). On the other hand, barriers for implementing the SPADe were: the need for specific training to deliver the SPADe (M = 3.7, sd = 0.7); ongoing support and supervision (M = 3.5, sd = 0.8); and additional resources (M = 3.0, sd = 0.9). This study also found that the implementation of the SPADe was acceptable to respondents. The overall mean score for respondents on acceptability of screening antenatal depression using SPADe was found to be high (M = 4.6, sd = 0.6). However the differences in the respondents' mean scores on acceptability of screening for depression in antenatal clinics using SPADe in relation to their demographic characteristics were not significant (p > .05).

CONCLUSION

This study suggests that midwives feel that it is feasible and acceptable for them to implement the SPADe in antenatal clinics with ongoing training, support and clinical supervision.

Blood Pressure, Depression, and Suicidal Ideation Among Pregnant Women with HIV

Although prior research has examined associations between blood pressure (BP), depression, and suicidal ideation, few studies have examined this in high-risk populations such as pregnant women with HIV (WHIV). The current study examined the association of BP with depression and suicidal ideation among pregnant WHIV (n = 217) in rural South Africa. BP data (measured ≤ 1 month before the study visit) was extracted from medical records. Depressive symptomatology and suicidal ideation were assessed using the Edinburgh Postnatal Depression Scale. Diastolic BP was positively associated with both suicidal ideation and depressive symptomatology, even after controlling for demographic variables, gestational age, and intimate partner violence. These findings suggest that WHIV with elevated BP may be at greater risk for antenatal depression and suicidal ideation. Future research should utilize longitudinal designs to examine potential mechanisms and the directionality of the relationship, as well as other contributing factors.

Factor Structure and Differential Item Functioning of the Edinburgh Postnatal Depression Scale: A Comparison of Zulu and English Versions Among Ante- and Postnatal Women Living with HIV in South Africa

PURPOSE

Measuring perinatal depression in women with HIV poses a challenge to accurate assessment. South Africa has particularly high rates of perinatal depression, with antenatal depression rates ranging from 21 to 47% and postnatal depression rates ranging from 17 to 50%. With the goal of providing an examination of the psychometric properties of the Edinburgh Postnatal Depression Scale (EPDS) in a population at greater risk for depression, the current manuscript examined the factor structures and reliability of the English and Zulu versions of the EPDS among pre- and postnatal women with HIV in South Africa.

METHODS

This study included n = 1179 women who completed the EPDS in Zulu (n = 709) and English (n = 470) antenatally, and n = 866 women were analyzed at 12-months after birth (n = 494 in Zulu and n = 372 in English).

RESULTS

Using factor analytic and item response theory approaches, the English and Zulu versions of the EPDS were compared. Although a few items performed poorly, particularly item 4, the construct validity of the English and Zulu versions of the pre- and postnatally administered EPDS was supported; the reliability of the scale was also supported, with adequate reliability in Zulu and English ante-natally (α = .78), and postnatally (α = .82 and α = .77 respectively).

DISCUSSION

This study contributes to improved measurement of depressive symptoms among vulnerable women in a resource constrained setting. The early and accurate detection of depressive symptoms ante- and postnatally among perinatal women living with HIV can facilitate increased treatment which may in turn help prevent the negative maternal and neonatal outcomes associated with depression.

Depression Among HIV-Positive Pregnant Women at Northwest Amhara Referral Hospitals During COVID-19 Pandemic

Background

Depression is the most common mental health disorder among HIV-positive pregnant mothers, which increases mortality, poor quality of life; it also increases the burden of disease. Depression hurts birth outcomes and maternal health.

Objective

To assess depression and its associated factors among HIV-positive pregnant women attending antenatal care at Northwest Amhara referral hospitals, 2021.

Methods

An institution-based cross-sectional study was conducted among 291 HIV-positive pregnant mothers from March 15, 2021 to April 30, 2021 at Northwest Amhara referral hospitals. Census was applied to reach the study participants. An interviewer-administered questionnaire was used for data collection. A binary logistic regression was conducted to see the relationship between dependent variables and independent. Those variables having a p-value of ≤0.05 were found to be statistically associated with the response.

Results

Depression among HIV-positive pregnant women was found to be 28.7% [95% CI (24.8–33.40)] with a response rate of 96.04. Age ≥30 years [AOR = 1.32, 95% CI (1.24–3.35)], urban residency [AOR = 1.76, 95% CI (1.57–4.61)], having first pregnancy <18 years [AOR = 3.82, 95% CI (1.54–17.34)], known HIV serostatus during pregnancy [AOR = 1.29, 95% CI (1.08–2.47)], and COVID-19-related knowledge [AOR = 0.32, 95% CI (0.12–1.12) were significantly associated with depression.

Conclusions and Recommendations

Nearly one-third of the pregnant women attending antenatal care were depressed. The age of the mother, residence, known HIV serostatus during pregnancy, age in the first pregnancy, and COVID-19-related knowledge were significantly associated with depression, and strengthening the existing care provided was the recalled interventions to combat antenatal depression during the COVID-19 pandemic.

Roll-out of HIV pre-exposure prophylaxis: a gateway to mental health promotion

HIV remains a pressing global health problem, with 1.5 million new infections reported globally in 2020. HIV pre-exposure prophylaxis (PrEP) can lower the likelihood of HIV acquisition among populations at elevated risk, yet its global roll-out has been discouragingly slow. Psychosocial factors, such as co-occurring mental illness and substance use, are highly prevalent among populations likely to benefit from PrEP, and have been shown to undermine persistence and adherence. In this analysis, we review the high burden of mental health problems among PrEP candidates and contend that inattention to mental health stands to undermine efforts to implement PrEP on a global scale. We conclude that integration of mental health screening and treatment within PrEP scale-up efforts represents an important strategy for maximising PrEP effectiveness while addressing the high burden of mental illness among at-risk populations. As implementers seek to integrate mental health services within PrEP services, efforts to keep access to PrEP as low-threshold as possible should be maintained. Moreover, programmes should seek to implement mental health interventions that are sensitive to local resource constraints and seek to reduce intersecting stigmas associated with HIV and mental illness.

Maternal depressed mood and child development over the first five years of life in South Africa

BACKGROUND

While the negative impact of peri-natal depression is well-documented in high-income countries, the long-term effects across the life course in low and middle-income countries is less clear. Children's adjustment over the first five years is examined as a function of patterns of maternal depressed mood.

METHODS

Pregnant women in 24 peri-urban townships (N = 1,238) were randomized to a home-visiting intervention or standard care and reassessed five times, with high retention. There were no intervention effects on children past 18 months. Multilevel regression models examined the impact of depressed mood on child outcomes. Using the Edinburgh Postnatal Depression Scale, four patterns of maternal depressed mood were identified: never (40.6%); antenatal (13.0%); early childhood (26.1%); and recurrent episodes of depressed mood (20.3 %).

FINDINGS

Mothers' patterns of depressive symptoms and child outcomes were similar, regardless of intervention. Never depressed mothers were significantly younger, had higher income, less food insecurity, were more likely to have electricity, be living with HIV or have an HIV positive partner, and had fewer problems with alcohol than depressed mothers. Children of mothers who experienced depressed mood weighed less, were more aggressive, and were hospitalized more often than children of never depressed mothers, but were similar in cognitive and social development.

INTERPRETATIONS

Depressed mood, has significant negative impacts on South African children's growth and aggressive behavior. The timing of maternal depressed mood was less important than never having a depressed mood or a recurrent depressed mood.

FUNDING

There were no funding conflicts in executing this trial.

Maternal depression and infant social withdrawal as predictors of behaviour and development in vertically HIV-infected children at 3.5 years

BACKGROUND

In low- and middle-income countries, there is a high prevalence of post-partum depression and it is often associated with HIV status. Maternal depression negatively affects mothering and can lead to social withdrawal in infants. Maternal depression and infant social withdrawal can have deleterious long-term effects on children's behaviour and neurodevelopmental trajectories.

AIM

To investigate whether maternal depression and infant social withdrawal at 10-12 months post-partum were significant predictors of child behaviour and development at 42 months.

METHOD

Seventy-four mother-infant dyads living with HIV were followed in a prospective, longitudinal design. Mothers were assessed for depression using the Center for Epidemiologic Studies Depression scale (CES-D). Infant social withdrawal was assessed by the modified Alarm Distress Baby Scale (m-ADBB), and development and behaviour were evaluated by the Griffiths Mental Development Scales (GMDS) and the Child Behavior Checklist (CBCL), respectively.

RESULTS

Maternal depression  explained 4.8% of the variance in child behaviour (β = 0.98, t = 2.05, p < 0.05) and 10.3% of the variance in development   (β = -0.30, t = -2.66, p < 0.05). Infant social withdrawal   was not a significant predictor of behaviour   (β = 3.27, t = 1.36, p = 0.18), but it did uniquely explain 7% of the variance in development (β = -1.32, t = -2.48, p < 0.05).

CONCLUSION

In the context of HIV, screening for maternal depression and the quality of mother-infant interactions are important (especially in the 1st year post-partum), given the significant long-term impact they have on behaviour and neurodevelopment.

ABBREVIATIONS

ANOVA: analysis of variance; ART: antiretroviral therapy; CBCL: Child Behavioral Checklist; CES-D: Center for Epidemiologic Studies Depression Scale; CHEI: children HIV-exposed and infected; CHER: Children with HIV Early Antiretroviral Treatment Trial; CHEU: children HIV-exposed and uninfected; CHUU: children HIV-unexposed and -uninfected; GMDS: Griffiths Mental Development Scales; HIV: human immunodeficiency virus; LMIC: low- and middle-income countries; m-ADBB: modified Alarm Distress Baby Scale; NRF: National Research Foundation; SAMRC: South African Medical Research Council; WHO: World Health Organization.

Selective cutoff reporting in studies of the accuracy of the Patient Health Questionnaire-9 and Edinburgh Postnatal Depression Scale: Comparison of results based on published cutoffs versus all cutoffs using individual participant data meta-analysis

OBJECTIVES

Selectively reported results from only well-performing cutoffs in diagnostic accuracy studies may bias estimates in meta-analyses. We investigated cutoff reporting patterns for the Patient Health Questionnaire-9 (PHQ-9; standard cutoff 10) and Edinburgh Postnatal Depression Scale (EPDS; no standard cutoff, commonly used 10-13) and compared accuracy estimates based on published cutoffs versus all cutoffs.

METHODS

We conducted bivariate random effects meta-analyses using individual participant data to compare accuracy from published versus all cutoffs.

RESULTS

For the PHQ-9 (30 studies, N = 11,773), published results underestimated sensitivity for cutoffs below 10 (median difference: -0.06) and overestimated for cutoffs above 10 (median difference: 0.07). EPDS (19 studies, N = 3637) sensitivity estimates from published results were similar for cutoffs below 10 (median difference: 0.00) but higher for cutoffs above 13 (median difference: 0.14). Specificity estimates from published and all cutoffs were similar for both tools. The mean cutoff of all reported cutoffs in PHQ-9 studies with optimal cutoff below 10 was 8.8 compared to 11.8 for those with optimal cutoffs above 10. Mean for EPDS studies with optimal cutoffs below 10 was 9.9 compared to 11.8 for those with optimal cutoffs greater than 10.

CONCLUSION

Selective cutoff reporting was more pronounced for the PHQ-9 than EPDS.

The Effects of Antenatal Depression and Women's Perception of Having Poor Health on Maternal Health Service Utilization in Northern Ghana

OBJECTIVES

To examine the effects of antenatal depression and women's perceived health during the antenatal period on maternal health service utilization in rural northern Ghana; including how the effect of antenatal depression on service use might be modified by women's perceived health.

METHODS

Probable antenatal depression was assessed using the Patient Health Questionnaire (PHQ-9). Linear regression was used for the outcome of number of antenatal care (ANC) visits, and logistic regression was used for the outcomes of facility delivery, postnatal care (PNC) within 7 days and completion of continuum of care. Continuum of care was defined as having had four or more ANC visits, delivered at a health facility and had PNC visit within 7 days.

RESULTS

Antenatal depression had very small or no association with maternal health service utilization. Women with self-perceived fair or poor health were significantly less likely to use PNC within 7 days and less likely to complete the continuum of care. As for effect modification, we found that for women with probable moderate or severe antenatal depression (a score of 10 or greater), those with perceived fair or poor health used fewer ANC visits and were less likely to use PNC within 7 days than those with perceived excellent, very good or good health.

CONCLUSIONS

Women experiencing moderate or severe antenatal depression and/or who self-perceive as having poor health should be identified and targeted for additional support to access and utilize maternal health services.

Intimate Partner Violence and Food Insecurity Predict Early Behavior Problems Among South African Children over 5-years Post-Birth

Households experiencing intimate partner violence (IPV) and food insecurity are at high risk of lifelong physical and behavioral difficulties. Longitudinal data from a perinatal home-visiting cluster-randomized controlled intervention trial in South Africa townships were used to examine the relationships between household settings and mothers' histories of risk and children's behavior problems at 3 and 5 years of age. IPV, food insecurity, maternal depressed mood, and geriatric pregnancy (at age of 35 or older) were consistently associated with children's internalizing and externalizing behavior problems. Aggressive behavior was more prevalent among 3- and 5-year olds boys, and was associated with maternal alcohol use. The effects of these factors on child behavior were more prominent than maternal HIV status. There is a continuing need to reduce IPV and household food insecurity, as well as supporting older, depressed, alcohol using mothers in order to address children's behavioral needs.

Depression prevalence based on the Edinburgh Postnatal Depression Scale compared to Structured Clinical Interview for DSM DIsorders classification: Systematic review and individual participant data meta-analysis

OBJECTIVES

Estimates of depression prevalence in pregnancy and postpartum are based on the Edinburgh Postnatal Depression Scale (EPDS) more than on any other method. We aimed to determine if any EPDS cutoff can accurately and consistently estimate depression prevalence in individual studies.

METHODS

We analyzed datasets that compared EPDS scores to Structured Clinical Interview for DSM (SCID) major depression status. Random-effects meta-analysis was used to compare prevalence with EPDS cutoffs versus the SCID.

RESULTS

Seven thousand three hundred and fifteen participants (1017 SCID major depression) from 29 primary studies were included. For EPDS cutoffs used to estimate prevalence in recent studies (≥9 to ≥14), pooled prevalence estimates ranged from 27.8% (95% CI: 22.0%-34.5%) for EPDS ≥ 9 to 9.0% (95% CI: 6.8%-11.9%) for EPDS ≥ 14; pooled SCID major depression prevalence was 9.0% (95% CI: 6.5%-12.3%). EPDS ≥14 provided pooled prevalence closest to SCID-based prevalence but differed from SCID prevalence in individual studies by a mean absolute difference of 5.1% (95% prediction interval: -13.7%, 12.3%).

CONCLUSION

EPDS ≥14 approximated SCID-based prevalence overall, but considerable heterogeneity in individual studies is a barrier to using it for prevalence estimation.

Protocol for assessing feasibility, acceptability and fidelity of screening for antenatal depression (FAFSAD) by midwives in Blantyre District, Malawi

Background

Depression is often underdiagnosed by treating health professionals. This is a situation in Malawi where there is no routine screening of depression at antenatal clinics. Recently, a Screening Protocol for Antenatal Depression (SPADe) that can be used by midwives to screen for antenatal depression was developed in Blantyre District. SPADe proposes multistage screening of antenatal depression by midwives which may enable early detection and treatment of pregnant women with depression. Proper treatment of antenatal depression can assist in achieving Sustainable Development Goals (SDGs). However, utilisation of SPADe in clinical practice to screening for depression in antenatal clinics has not been established yet. Therefore, the primary aim of this study is to assess feasibility of screening for depression by midwives using SPADe in antenatal clinics in Blantyre District. The secondary aim was to assess acceptability and fidelity of screening for depression by midwives using SPADe in antenatal clinics in Blantyre District.

Methods

This will be a feasibility study which will consist of scientific investigations that will support movement of evidence-based, effective health care approach, SPADe, from the clinical knowledge base into routine use. This study will consist three phases: phase 1 will introduce SPADe in antenatal clinics in Blantyre District where screening of depression is almost none existent; phase 2 will implement screening of depression using SPADe in antenatal clinics in Blantyre District; and phase 3 will evaluate the screening of antenatal depression using SPADe to establish its feasibility, acceptability and fidelity in antenatal clinics in Blantyre District.

Discussion

This study will establish and document feasibility, acceptability and fidelity of screening for depression by midwives using SPADe in antenatal clinics in Blantyre District. It is expected that midwives will develop more confidence in detecting and dealing with antenatal depression. Consequently, there will be increased numbers of pregnant women detected with depression by midwives and increased accessibility to mental health care by pregnant women in antenatal clinics.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00775-6.

Does resilience moderate the effect of intimate partner violence on signs of depression among Tanzanian pregnant women: A cross-sectional study

INTRODUCTION

Exposure to intimate partner violence (IPV) has been found to be associated with a multitude of poor health and quality of life outcomes. Among the risks exacerbated by IPV is prenatal depression. Resilience is hypothesized to protect against psychopathology after exposure to a traumatic influence. The present study aims to investigate resilience as a moderator of the effect of exposure to IPV on prenatal depression among pregnant women in Moshi, Tanzania.

MATERIAL AND METHODS

In this cross-sectional study, nested within a larger longitudinal study, pregnant women receiving antenatal care were interviewed about exposure to IPV, signs of depression using the Edinburgh Postpartum Depression Scale, and resilience using the abbreviated Connor-Davidson Resilience Scale. Logistic regression was used to test the effect of the interaction term of resilience and exposure to IPV during pregnancy on the risk of high level of signs of depression.

RESULTS

In total, 1013 women completed all interviews, 300 women reported exposure to IPV, and 113 had high levels of signs of depression. Mean resilience score was 14.26 (SD 9.45). Exposure to IPV was correlated with signs of depression (adjusted odds ratio 6.49, 95% CI 3.75-11.24). Resilience was not correlated with signs of depression, nor was the interaction term of resilience and exposure to IPV.

CONCLUSIONS

The study did not find that resilience acted as a moderator of the effect of exposure to IPV during pregnancy on the risk of prenatal depression. The cross-sectional design of the study may not be well suited to investigate resilience, which could take time to manifest. The abbreviated Connor-Davidson Resilience Scale has not been validated in a Tanzanian setting, or in the Swahili version. Practitioners should take note that all women and families affected by IPV should be afforded relevant assistance from social services, law enforcement, healthcare practitioners, and other relevant services, regardless of their apparent level of resilience.

Addressing the interaction between food insecurity, depression risk and informal work: findings of a cross-sectional survey among informal women workers with young children in South Africa

Background

There is a high burden of depression globally, including in South Africa. Maternal depression is associated with poverty, unstable income, food insecurity, and lack of partner support, and may lead to poor outcomes for mothers and children. In South Africa one-third of working women are in informal work, which is associated with socioeconomic vulnerability.

Methods

A cross sectional survey explored work setting and conditions, food security and risk of depression among informal working women with young children (0–3 years). Depression risk was assessed using the Edinburgh Postnatal Depression Score (EPDS) and Whooley score. Food insecurity was evaluated using Household Food Insecurity Access Scale. Data was analysed using SPSS and Stata.

Results

Interviews were conducted with 265 informal women workers. Types of work included domestic work, home-based work, informal employees and own account workers, most of whom were informal traders. Most participants (149/265; 56.2%) earned between US$70–200 per month, but some participants (79/265; 29.8%) earned < US$70 per month, and few earned > US$200 per month (37/265; 14.0%). Many participants experienced mild (38/267; 14.3%), moderate (72/265; 27.2%) or severe (43/265; 16%) food insecurity. Severe food insecurity was significantly higher among participants with the lowest income compared to those with the highest income (p = 0.027). Women who received financial support from the baby’s father were less likely to be food insecure (p = 0.03). Using EPDS scores, 22/265 (8.3%) women were designated as being at risk of depression. This was similar among postnatal women and women with older children. Household food insecurity was significantly associated with depression risk (p < 0.001).

Conclusions

Informal women workers were shown to be vulnerable with low incomes and high rates of food insecurity, thus increasing the risk for poor maternal health. However, levels of depression risk were low compared to previous estimates in South Africa, suggesting that informal workers may have high levels of resilience. Interventions to improve social protection, access to health services, and support for safe childcare in the workplace could improve the health and wellbeing of these mothers and support them to care for their children.

Antenatal depression and anxiety across pregnancy in urban South Africa

BACKGROUND

Depression and anxiety in pregnancy have negative consequences for women and their offspring. High adversity places pregnant women at increased mental health risk, yet there is a dearth of longitudinal research in these settings. Little is known about the pathways by which these problems emerge or persist in pregnancy.

METHODS

Women were enrolled in a prospective pregnancy cohort in Soweto, South Africa (2014-2016) and assessed using validated measures (Edinburgh Postnatal Depression Scale EPDS ≥13; State Trait Anxiety Index STAI ≥12) in early (T1) and later pregnancy (T2). Data was available for n = 649 women. Multinominal regression modelling was used to determine factors associated with transient versus persistent depression and anxiety across pregnancy. Cross-lagged panel modelling explored direction of effect between depression and anxiety, and stressors.

RESULTS

We found high rates of depression (T1: 27%; T2: 25%) and anxiety (T1: 15%; T2: 17%). Perceiving a partner made one's life harder increased risk of persistent depression (RR 5.92 95% CI [3.0-11.8] p<0.001); family stress increased risk for persistent anxiety (RR 1.71 95% CI [1.1-2.7] p = 0.027). We find evidence of a direct effect of early depression (T1) on later family stress (T2); and early family stress (T1) on later anxiety (T2).

LIMITATIONS

We used screening measures of depression and anxiety rather than clinical interviews.

CONCLUSIONS

Studies which focus only on late pregnancy may underestimate risk. Early identification, in the first trimester, is critical for prevention and treatment. Partner and family stressors are a key intervention target.

Overestimation of Postpartum Depression Prevalence Based on a 5-item Version of the EPDS: Systematic Review and Individual Participant Data Meta-analysis

OBJECTIVE

The Maternal Mental Health in Canada, 2018/2019, survey reported that 18% of 7,085 mothers who recently gave birth reported "feelings consistent with postpartum depression" based on scores ≥7 on a 5-item version of the Edinburgh Postpartum Depression Scale (EPDS-5). The EPDS-5 was designed as a screening questionnaire, not to classify disorders or estimate prevalence; the extent to which EPDS-5 results reflect depression prevalence is unknown. We investigated EPDS-5 ≥7 performance relative to major depression prevalence based on a validated diagnostic interview, the Structured Clinical Interview for DSM (SCID).

METHODS

We searched Medline, Medline In-Process & Other Non-Indexed Citations, PsycINFO, and the Web of Science Core Collection through June 2016 for studies with data sets with item response data to calculate EPDS-5 scores and that used the SCID to ascertain depression status. We conducted an individual participant data meta-analysis to estimate pooled percentage of EPDS-5 ≥7, pooled SCID major depression prevalence, and the pooled difference in prevalence.

RESULTS

A total of 3,958 participants from 19 primary studies were included. Pooled prevalence of SCID major depression was 9.2% (95% confidence interval [CI] 6.0% to 13.7%), pooled percentage of participants with EPDS-5 ≥7 was 16.2% (95% CI 10.7% to 23.8%), and pooled difference was 8.0% (95% CI 2.9% to 13.2%). In the 19 included studies, mean and median ratios of EPDS-5 to SCID prevalence were 2.1 and 1.4 times.

CONCLUSIONS

Prevalence estimated based on EPDS-5 ≥7 appears to be substantially higher than the prevalence of major depression. Validated diagnostic interviews should be used to establish prevalence.

Clinical and Obstetric Risk Factors for Postnatal Depression in HIV Positive Women: A Cross Sectional Study in Health Facilities in Rural KwaZulu-Natal

Postnatal depression (PND) remains underdiagnosed and undertreated in different socio-economic backgrounds in South Africa. This study determined the prevalence of and clinical and obstetric risk factors for PND symptoms among HIV positive women in health facilities in a rural health district in South Africa. The Edinburgh Postnatal Depression Scale was used to measure PND from 386 women who had delivered a live infant. More than half (58.5%) tested HIV positive during the current pregnancy. The prevalence of PND symptoms was 42.5%. Logistic regression analysis yielded significant associations between clinical and obstetric variables of pre-term baby (p-value < 0.01), baby health status p-value < 0.01), baby hospitalization, (p-value < 0.01), and knowing the baby’s HIV status (p-value = 0.047). Maternal variables associated with PND were level of education (p-value < 0.01), monthly income (p-value < 0.01), and source of income (p-value = 0.05). At multivariate analysis, none of the clinical and obstetrical risk factors were independently associated with the PND. The high prevalence of PND symptoms underscore the need to integrate routine screening for PND in prevention of mother to child transmission of HIV programmes to enable early diagnosing and treatment of PND.

Home visits by community health workers in rural South Africa have a limited, but important impact on maternal and child health in the first two years of life

BACKGROUND

More than 50% of Africa's population lives in rural areas, which have few professional health workers. South Africa has adopted task shifting health care to Community Health Workers (CHWs) to achieve the Sustainable Development Goals, but little is known about CHWs' efficacy in rural areas.

METHODS

In this longitudinal prospective cohort study, almost all mothers giving birth (N = 470) in the Zithulele Hospital catchment area of the OR Tambo District were recruited and repeatedly assessed for 2 years after birth with 84.7-96% follow-up rates. During the cohort assessment we found that some mothers had received standard antenatal and HIV care (SC) (n = 313 mothers), while others had received SC, supplemented with home-visiting by CHWs before and after birth (HV) (n = 157 mothers, 37 CHWs). These visits were unrelated to the cohort study. Multiple linear and logistic regressions evaluated maternal comorbidities, maternal caretaking, and child development outcomes over time.

RESULTS

Compared to mothers receiving SC, mothers who also received home visits by CHWs were more likely to attend the recommended four antenatal care visits, to exclusively breastfeed at 3 months, and were less likely to consult traditional healers at 3 months. Mothers in both groups were equally likely to secure the child grant, and infant growth and achievement of developmental milestones were similar over the first 2 years of life.

CONCLUSION

CHW home visits resulted in better maternal caretaking, but did not have direct benefits for infants in the domains assessed. The South African Government is planning broad implementation of CHW programmes, and this study examines a comprehensive, home-visiting model in a rural region.

The Secret History method and the development of an ethos of care: Preparing the maternity environment for integrating mental health care in South Africa

South Africa, like many low-and-middle-income countries, is integrating mental health services into routine Primary Health Care (PHC) through a task-shifting approach to reduce the gaps in treatment coverage. There is concern, however, that this approach will exacerbate nurses' abuse of patients currently common within PHC in the country. To address this concern, the Perinatal Mental Health Project developed its Secret History method, a critical pedagogical intervention for care-providers working within maternity settings. This article describes the method's theoretical underpinnings and practical application amongst nurses. Drawing on Augusto Boal's Theatre of the Oppressed and contrary to traditional nursing training in South Africa, the method creates a space for nurses to interrogate and reimagine nurse-patient relations. By introducing nurses to a counter ideology of empathic care, the method seeks to prepare the maternity environment for mental health task-shifting initiatives and ensure these initiatives are more democratic, responsive and humane.

The development of an ultra-short, maternal mental health screening tool in South Africa

PURPOSE

The burden of common perinatal mental disorders (CPMD) in low-and-middle-income countries is substantially higher than high-income countries, with low levels of detection, service provision and treatment in resource-constrained settings. We describe the development of an ultra-short screening tool to detect antenatal depression, anxiety disorders and maternal suicidal ideation.

METHODS

A sample of 376 women was recruited at a primary-level obstetric clinic. Five depression and anxiety symptom-screening questionnaires, demographics and psychosocial risk questionnaires were administered. All participants were assessed with the Mini-International Neuropsychiatric Interview (MINI), a structured, diagnostic interview. Screening tool items were analysed against diagnostic data using multiple logistic regression and receiver operating curve (ROC) analysis.

RESULTS

The prevalence of MINI-defined major depressive episode (MDE) and/or anxiety disorders was 33%. Overall, 18% of participants expressed suicidal ideation and behaviour, 54% of these had no depression or anxiety diagnosis. Multiple logistic regression identified four screening items that were independently predictive of MDE and anxiety disorders, investigating depressed mood, anhedonia, anxiety symptoms and suicidal ideation. ROC analysis of these combined items yielded an area under the curve of 0.83 (95% CI 0.78-0.88). A cut-off score of 2 or more offered a sensitivity of 78% and specificity of 82%.

CONCLUSION

This novel screening tool is the first measure of CPMD developed in South Africa to include depressed mood, anxiety symptoms and suicidal ideation. While the tool requires further investigation, it may be useful for the early identification of mental health symptoms and morbidity in the perinatal period.

Course of perinatal depressive symptoms among South African women: associations with child outcomes at 18 and 36 months

PURPOSE

Latent modelling was used to identify trajectories of depressive symptoms among low-income perinatal women in South Africa. Predictors of trajectories and the association of trajectories with child outcomes were assessed.

METHODS

This is a secondary analysis of data collected among women living in Cape Town settlements (N = 446). Participants were eligible if pregnant and 18 years or older, and included in the analysis if allocated to the control arm (routine perinatal care). Participants were excluded in case of non-singleton birth and baby death. Follow-up assessments were at 2 weeks, 6-, 18-, and 36-month postpartum. Trajectories of depressive symptoms were based on the Edinburgh Postnatal Depression Scale scores until 18-month postpartum, using latent class growth analysis. Child physical, cognitive, socio-emotional, and behavioural outcomes were assessed at 18 and/or 36 months. Univariate and multivariate regressions were used to identify predictors of trajectories and differences in child outcomes.

RESULTS

Four trajectories were identified: chronic low (71.1%), late postpartum (10.1%), early postpartum (14.4%), and chronic high (4.5%). Low social support, unwanted pregnancy, and risky drinking were associated with the chronic high trajectory; unemployment and HIV-positive status with the early postpartum trajectory; and intimate partner violence with the late postpartum trajectory. Weight-to-length and weight-for-age z-scores at 18 months, and weight-for-age z-scores, length-for-age z-scores, emotional symptom, and peer problem scores at 36 months differed across trajectories.

CONCLUSIONS

Severe depressive symptoms in postpartum period have a lasting effect on child physical and socio-emotional outcomes. Multiple screening throughout pregnancy and 1-year postpartum is essential.

Maternal depression treatment in HIV (M-DEPTH): Study protocol for a cluster randomized controlled trial

INTRODUCTION

Over one-third of human immunodeficiency virus (HIV)-infected pregnant women are clinically depressed, increasing the risk of mother-to-child transmission (MTCT) of HIV, as well as negative birth and child development outcomes. This study will evaluate the efficacy and cost-effectiveness of an evidence-based stepped care treatment model for perinatal depression (maternal depression treatment in HIV [M-DEPTH]) to improve adherence to prevention of MTCT care among HIV+ women in Uganda.

METHODS

Eight antenatal care (ANC) clinics in Uganda will be randomized to implement either M-DEPTH (n=4) or usual care (n=4) for perinatal depression among 400 pregnant women (n=50 per clinic) between June 2019 and August 2022. At each site, women who screen positive for potential depression will be enrolled and followed for 18 months post-delivery, assessed in 6-month intervals: baseline, within 1 month of child delivery or pregnancy termination, and months 6, 12, and 18 following delivery. Primary outcomes include adherence to the prevention of mother-to-child transmission (PMTCT) care continuum-including maternal antiretroviral therapy and infant antiretrovial prophylaxis, and maternal virologic suppression; while secondary outcomes will include infant HIV status, post-natal maternal and child health outcomes, and depression treatment uptake and response. Repeated-measures multivariable regression analyses will be conducted to compare outcomes between M-DEPTH and usual care, using 2-tailed tests and an alpha cut-off of P <.05. Using a micro-costing approach, the research team will relate costs to outcomes, examining the incremental cost-effectiveness ration (ICER) of M-DEPTH relative to care as usual.

DISCUSSION

This cluster randomized controlled trial will be one of the first to compare the effects of an evidence-based depression care model versus usual care on adherence to each step of the PMTCT care continuum. If determined to be efficacious and cost-effective, this study will provide a model for integrating depression care into ANC clinics and promoting adherence to PMTCT.

TRIAL REGISTRATION

NIH Clinical Trial Registry NCT03892915 (clinicaltrials.gov).

Prevalence and predictors of postpartum depression by HIV status and timing of HIV diagnosis in Gauteng, South Africa

Background

Postpartum depression (PPD) is a common mental health condition that can compromise the quality of life and functional capacity of mothers and cause health and developmental problems in children born to affected mothers.

Objectives

We set out to measure the prevalence of PPD comparing postpartum HIV-1 infected women with pre-pregnancy HIV care experience, newly diagnosed (in latest pregnancy) HIV-1 infected women and HIV negative women, and to identify predictors of major PPD among these women in a peri-urban clinic in South Africa.

Methods

We conducted a cross-sectional survey of 1151 adult (≥18 years) postpartum HIV-1 infected (690) and HIV negative (461) women who delivered up to 30 days before study enrolment, interviewed after their first post-natal visit (3–6 days post- delivery) at Midwife Obstetric Units in Gauteng, South Africa. PPD was categorised into no depression (CES-D 10 total score <5), low to medium depression (CES-D 10 total score ≥5 and <10) and major depressive symptoms (CES-D 10 total score≥10). We used ordered logistic regression to identify predictors of postpartum depression and report adjusted odds ratio (aOR) and 95% confidence intervals (CIs).

Results

Overall 288 (25.0%) women screened positive for postpartum depression, a total of 168 (14.6%) women had low to medium PPD and 120 (10.4%) had major PPD. A higher proportion of HIV negative women experienced PPD, 129/461 (28.0%) among HIV negative vs. 159/690 (23.0%) among HIV-1 infected. Among HIV positive women, there was no meaningful difference in PPD between newly HIV diagnosed and those diagnosed before the most recent pregnancy (aOR 1.3, 95% confidence interval (CI): 0.9–1.8). Predictors of PPD among HIV positive women were living with friends/in a house-share (aOR 0.5 for house-share vs. own home, 95% CI: 0.3–0.9), and attending antenatal care (ANC) for the most recent pregnancy (aOR 0.2 for ANC attendance vs. no ANC attendance, 95% CI: 0.0–0.5). Living with friends/in a house-share was also a predictor of PPD among HIV negative women (aOR 0.4 for house-share vs. own home, 95% CI: 0.2–0.8).

Conclusions and recommendations

Targeted symptom screening based on identified risk factors should be considered for postpartum women to increase PPD case-finding and referral to specialised social support services.

Perinatal maternal depression in rural South Africa: Child outcomes over the first two years

AIMS

To examine child outcomes over time among mothers with perinatally depressed mood in rural South Africa (SA).

METHODS

A representative sample of consecutive births (470/493) in the OR Tambo District of the Eastern Cape of South Africa (SA) were recruited and were reassessed at five points over the course of the next two years: 85% were reassessed at 3 months, 92% at 6 months, 88% at 9 months, 91% at 12 months, and 88% at 2 years post-birth. Over time, the children of mothers with perinatally depressed mood (16%) were compared to children of mothers without depressed mood using multiple linear and logistic regressions.

RESULTS

Mothers with perinatal depressed mood are significantly less likely to live with the child's father or their in-laws (23% vs 35%), have household incomes above 2000 ZAR (154 USD) (31% vs 51%), and significantly more likely to have experienced IPV prior (19% vs 9%) and during (32% vs 20%) pregnancy compared to mothers without depressed mood. There are no differences in age, education, primipara, HIV status (29% seropositive), or alcohol use. Growth and developmental delays and motor and speech milestones through 24 months post-birth are similar for mothers with and without perinatal depressed mood.

CONCLUSIONS

Despite increased economic and partner difficulties associated with perinatal depressed mood, infant outcomes are similar in mothers with and without depressed mood in rural South Africa.

Depression among HIV positive pregnant women in Zimbabwe: a primary health care based cross-sectional study

BACKGROUND

Depression is a common psychiatric disorder that is highly prevalent among people living with HIV (PLWH). Depression is linked to poor adherence to anti-retroviral medication while in the peri-natal period may affect birth outcomes. Intimate partner violence (IPV) has been linked to depression. Little is known about the factors associated with depression in HIV positive pregnant women in Zimbabwe.

METHODS

We carried out a cross-sectional study in 4 busy primary care clinics offering antenatal services during the months of June through to September in 2016. Simple random sampling was used to screen HIV positive pregnant women while they waited to be attended to at each clinic. Eligible women who gave written informed consent were screened using a locally validated screening tool-the Edinburgh Postnatal Depression Scale (EPDS).

RESULTS

A total of 198(85%) participants were recruited out of 234 that were approached. The mean age of participants was 26.6(SD 4.5), of these, 176 (88.9%) had secondary education or more. A total of 78 (39.4%) (95% CI 32.5-46.3) met criteria for antenatal depression according to the local version of the EPDS. Factors associated with antenatal depression after multivariate analysis were intimate partner violence (IPV) [OR 3.2 (95% CI 1.5-6.7)] and previous history of depression OR 4.1 (95% CI 2.0-8.0)].

CONCLUSION

The prevalence of antenatal depression among HIV positive pregnant women in primary care clinics is high. Factors associated with antenatal depression in pregnant HIV positive women are IPV and previous history of depression. There is need for routine screening for depression during the antenatal period and interventions targeting depression in this population should include components to address IPV.

Accessible continued professional development for maternal mental health

Background

Changing global health and development trends have resulted in a need for continued professional development (CPD) within the health and development sectors. In low-resource settings, where the need for training and CPD may be highest, there are significant challenges for disseminating information and skills. There is a need to improve mental health literacy and reduce levels of stigma about maternal mental illness. The Bettercare series of distance learning books provides a peer-based format for CPD. We aimed to evaluate the Bettercare Maternal Mental Health book as a format for CPD.

Aim

The aim of this study was to determine whether the Bettercare Maternal Mental Health book significantly improves knowledge and decreases stigma around mental health for care providers from the health and social development sectors.

Setting

One hundred and forty-one participants (social workers, nursing students and health professionals) were provided with the Bettercare Maternal Mental Health book to study.

Methods

Before and after studying the book, the same multiple-choice knowledge test and the Mental Illness Clinicians’ Attitude Scale were used to assess cognitive knowledge and mental health stigma, respectively.

Results

Participants’ knowledge showed a statistically significant (p < 0.001) improvement between the pre- and post-test results, for all six chapters of the book. However, participants’ attitudes towards mental illness did not show a statistically significant change between the pre- and post-test results.

Conclusion

We found that this method of learning elicited significant improvement in mental health knowledge for care providers. Continued professional development policy planners and curriculum developers may be interested in these findings.

A cross-sectional study of depression among women attending antenatal clinics in Blantyre district, Malawi

Background

Pregnancy is a period associated with major psychological and social changes in the life of a woman and can be associated with anxiety and depression.

Aim

To describe demographic, clinical and risk profile of antenatal depression among pregnant women attending antenatal clinics in Blantyre district, Malawi.

Setting

The study was conducted in eight antenatal clinics in Blantyre district, Malawi.

Methods

A cross-sectional study of 480 randomly selected pregnant women attending antenatal clinics was conducted. Prevalence was determined using the Edinburgh Postnatal Depression Scale (EPDS) which was validated against a sub-sample using the Mini International Neuropsychiatric Interview. The risk factors of depression were assessed using the Pregnancy Risk Questionnaire. Data were analysed using descriptive statistics, Pearson chi-square test and binary logistic regression.

Results

Prevalence of antenatal depression using the EPDS was 19% (95% CI 15.5% – 22.5%, n = 91) and was comparable to the Mini International Neuropsychiatric Interview (25.8% [95% CI = 17.5–34], n = 25). The key risk factors that predicted antenatal depression were: ‘being distressed by anxiety or depression for more than 2 weeks during this pregnancy’ (OR = 4.1 [2.1–7.9], p ≤ 0.001); ‘feeling that a relationship with partner is not an emotionally supportive one’ (OR = 3.5 [1.4–8.4], p = 0.01); ‘having major stresses, changes or losses in the course of this pregnancy’ (OR = 3.2 [1.7–6.2], p = 0.01); ‘feeling that father was critical of her when growing up’ (OR = 3.2 [1.4–7.6], p = 0.01); and ‘having history of feeling miserable or depressed for ≥2 weeks before this pregnancy’ (OR = 2.4 [1.3–4.4], p = 0.01).

Conclusion

This study confirmed the high-prevalence rate of depression in this group and illustrated that antenatal depression was associated with being distressed by anxiety or depression; support from partner; major stresses during pregnancy; and history of feeling miserable or depressed before pregnancy. This study also found a history of poor relationship between pregnant women and their fathers during childhood.

A pilot study evaluating depression in mothers with children diagnosed with Down syndrome in state health care

BACKGROUND

Parenting a child who has an intellectual disability has been shown to increase the risk for developing depression. The purpose of this study was to screen for depression and to determine if there is an association between depressive symptoms and certain sociodemographic factors in mothers with a child diagnosed with Down syndrome in state health care facilities in Johannesburg.

METHODS

The study included 30 biological mothers of children between 6 months and 3 years diagnosed with Down syndrome postnatally. The Edinburgh Postnatal Depression Scale (EPDS) was used to assess depression in participants. A 10-item sociodemographic questionnaire was concurrently administered. Data analysis was conducted using descriptive and inferential statistical analysis.

RESULTS

The 30 mothers had a mean EPDS score of 9.1 (SD = 5.89) with scores ranging between 0 and 26. Eight mothers (26.7%) screened positive for depression with an EPDS score of 13 or greater. A statistically significant association was found between an HIV-positive status and mothers who had an EPDS score of 13 or greater (P = 0.01). No significant association between depression and various other sociodemographic factors was identified.

CONCLUSIONS

Mothers with a child diagnosed with Down syndrome may be vulnerable to developing depression. A significant association was found between a positive HIV status and symptoms of depression, in mothers with a child diagnosed with Down syndrome. This study indicates the need for further investigations assessing the causes and risk factors resulting in postnatal depression in mothers with a child diagnosed with Down syndrome.

Prevalence and factors associated with antenatal depressive symptoms among women enrolled in Option B+ antenatal HIV care in Malawi: a cross-sectional analysis

BACKGROUND

Option B+ has increased the number of pregnant women initiating antiretroviral therapy for HIV, yet retention in HIV care is sub-optimal. Retention may be affected by antenatal depression. However, few data exist on antenatal depression in this population.

AIM

Describe the prevalence and factors associated with antenatal depression among Malawian women enrolled in Option B+.

METHOD

At their first antenatal visit, women with HIV provided demographic and psychosocial information, including depression as measured with the locally validated Edinburgh Postnatal Depression Scale (EPDS). Prevalence ratios (PR) for factors associated with probable depression (EPDS ≥6) were estimated with log binomial regression.

RESULTS

9.5% (95% CI: 7.5-11.9%) of women screened positive for current depression, and 46% self-reported a history of depression or anxiety. Women were more likely to screen positive for current depression if they reported a history of depression (adjusted PR: 2.42; 95% CI: 1.48-3.95) or had ever experienced intimate partner violence (1.77; 1.11-2.81). Having an unintended current pregnancy (1.78; 0.99-3.21), being unmarried (1.66; 0.97-2.84), or employed (1.56; 1.00-2.44) had potential associations with probable depression.

CONCLUSIONS

Probable antenatal depression affected a notable proportion of women living with HIV, comparable to other global regions. Screening for antenatal depression in HIV care should be considered.

Comparison of mental health screening tools for detecting antenatal depression and anxiety disorders in South African women

BACKGROUND

Antenatal depression and anxiety disorders are highly prevalent in low and middle-income countries. Screening of pregnant women in primary care antenatal settings provides an opportunity for entry to care, but data are needed on the performance of different screening tools. We compared five widely-used questionnaires in a sample of pregnant women in urban South Africa.

METHOD

Pregnant women attending a primary care antenatal clinic were administered five tools by trained research assistants: the Edinburgh Postnatal Depression Scale (EPDS), the Patient Health Questionnaire (PHQ-9), the Kessler Psychological Distress scale (K10) and a shortened 6-item version (K6), the Whooley questions and the two-item Generalised Anxiety Disorder scale (GAD-2). Following this, a registered mental health counsellor administered the MINI Plus, a structured clinical diagnostic interview. The Area Under the Curve (AUC) from Receiver Operator Characteristic curve analysis was used to summarise screening test performance and Cronbach's α used to assess internal consistency.

RESULTS

Of 376 participants, 32% were diagnosed with either MDE and/or anxiety disorders. All five questionnaires demonstrated moderate to high performance (AUC = 0.78-0.85). The EPDS was the best performing instrument for detecting MDE and the K10 and K6 for anxiety disorder. For MDE and/or anxiety disorders, the EPDS had the highest AUC (0.83). Of the short instruments, the K10 (AUC = 0.85) and the K6 (AUC = 0.85) performed the best, with the K6 showing good balance between sensitivity (74%) and specificity (85%) and a good positive predictive value (70%). The Whooley questions (AUC = 0.81) were the best performing ultra-short instrument. Internal consistency ranged from good to acceptable (α = 0.89-0.71). However, the PPV of the questionnaires compared with the diagnostic interview, ranged from 54% to 71% at the optimal cut-off scores.

CONCLUSIONS

Universal screening for case identification of antenatal depression and anxiety disorders in low-resource settings can be conducted with a number of commonly used screening instruments. Short and ultra-short screening instruments such as the K6 and the Whooley questions may be feasible and acceptable for use in these settings.

Changes in mood after screening for antenatal anxiety and depression

BACKGROUND

Screening programmes with referral are a valuable strategy for mitigating consequences of perinatal depression on mothers and their families. The effectiveness of these screening programmes needs to be measured. One potential problem in assessing outcomes is measurement reactivity where the actual measure results in changes in the people being measured.

AIM

The aim of this article is to explain the mechanisms and circumstances by which measurement reactivity occurred in a sample of antenatal women who participated in a screening interview.

METHODS

Fifty-five women who participated in an antenatal screening interview in their second trimester were re-interviewed in their third trimester. These qualitative interviews were conducted between September 2015 and April 2016.

RESULTS

The qualitative data suggested that measurement reactivity occurred through mechanisms such as the disclosure, gaining self-knowledge, validation of experiences, and personal agency which resulted in them seeking out support from others.

CONCLUSION

Although the screening interview appeared to improve women's outcomes, this may have occurred through measurement reactivity. This needs to be considered when designing studies that aim to assess the effectiveness of screening with intervention for antenatal depression.

Maternal patterns of antenatal and postnatal depressed mood and the impact on child health at 3-years postpartum

OBJECTIVE

The consequences of maternal depressed mood on children's growth, health, and cognitive and language development are examined over the first 3 years of life.

METHOD

Pregnant women in 24 periurban township neighborhoods in Cape Town, South Africa (N = 1,238 mothers) were randomized by neighborhood to a home visiting intervention or a standard care condition. Reassessments were conducted for 93%-85% of mothers at 2-weeks, 6-, 18-, and 36-months postbirth. Regressions were conducted on measures of children's growth, behavior, language, and cognition to examine the impact of four patterns of depressed mood: antenatal only (n = 154, 13.8%), postnatal only (n = 272, 24.3%), antenatal and postnatal (n = 220, 19.7%), and no depressed mood on any assessment (n = 473, 42.3%).

RESULTS

Patterns of depressed mood were similar across intervention conditions. Depressed mothers were significantly less educated, had lower incomes, were less likely to be employed or to have electricity; were more likely to report problematic drinking of alcohol, experience food insecurity, interpersonal partner violence, and to be HIV seropositive. At 36 months, the pattern of maternal depressed mood over time was significantly associated with children's compromised physical growth, both in weight and height, and more internalizing and externalizing symptoms of behavior problems. Measures of language and cognition were similar across maternal patterns of depressed mood.

CONCLUSIONS

Mothers who report depressed mood face significantly more life challenges, both environmental stressors related to poverty and other problematic behaviors. More proximal, postnatal depressed mood appears to have a larger influence on their children, compared with antenatal depressed mood. (PsycINFO Database Record

First trimester antenatal depression and anxiety: prevalence and associated factors in an urban population in Soweto, South Africa

Depression and anxiety in the antenatal period are of public health concern given potential adverse effects for both mother and infant. Both are under-researched in the first trimester of pregnancy, especially in Africa. We examine the prevalence of first trimester antenatal depression and anxiety in a cohort of South African women and investigate associated risk factors. Data were collected from 946 women (2014-2016) in the Soweto First 1000 Days Cohort, a prospective pregnancy cohort in Soweto, South Africa. Antenatal depression was assessed using the Edinburgh Postnatal Depression Scale with a score of ⩾13 indicating probable depression. Anxiety was assessed using the short form of the State-Trait Anxiety Index with a score ⩾12 indicating probable anxiety. Prevalence of antenatal depression was 27% [95% confidence interval (CI) 24.2-29.8] and anxiety 15.2% (95% CI 12.9-17.5). Factors associated with antenatal depression and anxiety were predominantly relationship- and family-centred. Women who perceived that their partner made life harder for them had three-fold increased odds for depression [(odds ratio (OR) 3.33 [2.28-4.85] P<0.001], whereas those with family stressors had almost double the odds for depression (OR 1.78 [1.22-2.59] P=0.003) and anxiety (OR 1.75 [1.44-2.69] P=0.0011). Antenatal depression and anxiety are common in the first trimester of pregnancy, and partner and family relationship stressors are central. Longitudinal analysis is needed to determine if this is a phase of adjustment to pregnancy or onset of persistent symptomology. Early intervention may have secondary preventative effects and should involve the partner and family.

Screening for Antepartum Depression Through Community Health Outreach in Swaziland

Maternal depression, including antepartum and postpartum depression, is a neglected public health issue with potentially far-reaching effects on maternal and child health. We aimed to measure the burden of antepartum depression and identify risk factors among women in a peri-urban community in Swaziland. We conducted a cross-sectional study within the context of a community outreach peer support project involving "Mentor Mothers". We used of the Edinburgh Postnatal Depression Scale (EPDS) to screen women for depression during the third trimester of pregnancy, using a cut-off score of ≥13 to indicate depression. We also collected demographic and socioeconomic factors, and assessed the association of these factors with EPDS score using logistic regression models. A total of 1038 pregnant women were screened over a period of 9 months. Almost a quarter (22.7 %) had EPDS scores ≥13 and 41.2 % were HIV positive. A fifth, 17.5 % were teenagers and 73.7 % were unemployed. Depression was not associated with HIV status, age or employment status. However, women with multiple socioeconomic stressors were found to be more likely to score highly on the EPDS. Depression was common among pregnant women in the peri-urban areas of Swaziland. Screening for depression using the EPDS is feasible and can be included in the community health worker standard tool box as a way to improve early detection of depression and to highlight the importance of maternal mental health as a core public health concern.

Depressive scores in newly diagnosed HIV-infected and HIV-uninfected pregnant women

Background

Prevalence rates of HIV infection in KwaZulu-Natal are high, with a significant amount of those infected being women of reproductive age. A diagnosis of HIV infection has been associated with an increased risk for the development of depression. Antenatal depression is a serious health concern, having the potential to cause wide-reaching adverse consequences for mother and unborn child.

Aim

To compare depressive scores between newly diagnosed HIV-infected and HIV-uninfected pregnant women.

Setting

Antenatal clinics at two regional hospitals in KwaZulu-Natal, South Africa.

Methods

A cross-sectional questionnaire-based analysis of 102 newly HIV-tested black African pregnant women (HIV infected: n = 40; HIV uninfected: n = 62) was conducted. Women’s socio-demographic and clinical data were recorded, before being assessed for depressive symptomology using an isiZulu version of the Edinburgh Depression Scale.

Results

About 9.8% of women suffered from significant depressive symptoms, irrespective of HIV status. Prevalence rates of antenatal depressive symptoms did not differ significantly between HIV-infected and HIV-uninfected cohorts (p = 0.79). A new diagnosis of HIV infection (p < 0.0001) and maternal age (p = 0.03) were risk factors for antenatal depression. Unemployment was a borderline risk factor (p = 0.09) for the development of antenatal depression.

Conclusion

Prevalence rates of depressive symptoms were low. Knowledge of a new diagnosis of HIV infection at the first antenatal visit places women at an increased risk for the development of depression during pregnancy. Younger age and unemployment influence depression. This study provides an important step in documenting the need for screening for antenatal depression in HIV-associated pregnancies in a South African population group.

Patterns of Alcohol Abuse, Depression, and Intimate Partner Violence Among Township Mothers in South Africa Over 5 Years

Alcohol is a major contributor to the global burden of disease. In South Africa, alcohol abuse is hypothesized to correlate with women's HIV status, mental health, and partner relationships over time. All pregnant women in 12 urban, low-income, Cape Town neighborhoods were interviewed at baseline, post-birth, and at 6, 12, 36, and 60 months following delivery with retention rates from 82.5 to 94%. Women were assessed for any alcohol use, problematic drinking, depression, intimate partner violence, and HIV status. Prior to pregnancy discovery and 5 years after giving birth, alcohol use was 25.8 and 24.7%, respectively. Most women decreased their alcohol use during pregnancy. Twenty-one percent reported alcohol use on two or more assessments, and only 15% of the mothers drinking alcohol at 5 years were also drinking at baseline. Mothers with depression had a higher likelihood of drinking alcohol compared to mothers who were not depressed only at baseline and 6 months post-birth. Mothers who experienced IPV had more than twice the likelihood of drinking alcohol compared to non-IPV mothers at all assessments. HIV positive mothers were more likely to drink alcohol compared to mothers without HIV prior to pregnancy discovery and at 5 years post-birth. These longitudinal trends in alcohol use among young women in South Africa represent a large economic, social, and health burden and must be addressed in a comprehensive manner.

Psychological morbidity and parenting stress in mothers of primary school children by timing of acquisition of HIV infection: a longitudinal cohort study in rural South Africa

Longitudinal maternal mental health data are needed from high HIV prevalence settings. The Siyakhula Cohort (SC) is a population-based cohort of HIV-positive and negative mothers (n=1506) with HIV-negative children (n=1536) from rural South Africa. SC includes 767 HIV-negative mothers; 465 HIV-positive in pregnancy; 272 HIV-positive since pregnancy (n=2 missing HIV status). A subgroup (n=890) participated in a non-randomized breastfeeding intervention [Vertical Transmission Study (VTS)]; the remaining (n=616) were resident in the same area and received antenatal care at the time of the VTS, but were not part of the VTS, instead receiving the standard of care Prevention of Mother-to-Child Transmission (PMTCT) Programme. In secondary analysis we investigated the prevalence of, and factors associated with, psychological morbidity amongst mothers who were still the primary caregiver of the child (1265 out of 1506) at follow-up (7-11 years post-birth). We measured maternal depression (Patient Health Questionnaire-9), anxiety (General Anxiety Disorder Scale-7) and parenting stress (Parenting Stress Index-36), using standardized cut-offs and algorithms. In total, 75 (5.9%) mothers met criteria for depression, 37 (2.9%) anxiety and 134 (10.6%) parenting stress. Using complete case logistic regression (n=1206 out of 1265 mothers) as compared to being HIV-negative, testing HIV-positive in pregnancy doubled odds of depression [adjusted odd ratios (aOR)=1.96 [1.0-3.7] P=0.039]. Parenting stress was positively associated with acquisition of HIV after pregnancy (aOR=3.11 [1.9-5.2] P<0.001) and exposure to household crime (aOR=2.02 [1.3-3.2] P=0.003); negatively associated with higher maternal education (aOR=0.29 [0.1-0.8] P=0.014), maternal employment (aOR=0.55 [0.3-0.9] P=0.024). Compared with the standard of care PMTCT, VTS mothers had reduced odds of parenting stress (aOR=0.61 [0.4-0.9] P=0.016). Integrating parental support into mostly bio-medical treatment programmes, during and beyond pregnancy, is important.