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Primary care screening and risk factors for postnatal depression in Zimbabwe: A scoping review of literature

June 2017
Journal of Psychology in Africa 27(3):294-298

DOI:10.1080/14330237.2017.1321866

Authors:

Jonathan Kenneth Burns

University of Exeter

Moses J Chimbari

University of KwaZulu-Natal

Postnatal depression (PND) exerts a significant burden on the global public health system, globally affecting approximately 10 to 20% of women Despite the recently reported high prevalence of PND in Zimbabwe, it is rarely diagnosed or appropriately managed in primary care settings This review scopes evidence on PND from studies on screening for PND and the associated risk factors conducted in Zimbabwe over the past 20 years We searched electronic databases for published articles and checked reference lists of studies relating to depression among women in Zimbabwe We used the following key words: postnatal, depression, women, screening, risk-factors, and Zimbabwe A total of 14 studies were retrieved as follows: postnatal depression (4), postnatal mental disorders (1), mental disorders among pregnant women (1), and depression and women in general (8) Reported prevalence of PND ranged from 16% to 34 2% Studies on PND enrolled women from urban and peri-urban settings Significant risk factors for PND identified among women in Zimbabwe included multi parity, having a spouse who was older than 35years, poorer relations with spouses or partners, having had experienced an adverse event, being unemployed, and having had experienced intimate partner violence Psychosocial factors are implicated in PND occurrence among Zimbabwean women There is need to explore the burden of PND among rural communities

PRISMA Flow Diagram for review process

…

. Prevalence of PND and depressive symptomatology among women in Zimbabwe

…

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Primary care screening and risk factors for

postnatal depression in Zimbabwe: A scoping

review of literature

James January, Jonathan Burns & Moses Chimbari

To cite this article: James January, Jonathan Burns & Moses Chimbari (2017) Primary care

screening and risk factors for postnatal depression in Zimbabwe: A scoping review of literature,

Journal of Psychology in Africa, 27:3, 294-298, DOI: 10.1080/14330237.2017.1321866

To link to this article: https://doi.org/10.1080/14330237.2017.1321866

Published online: 29 Jun 2017.

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The Journal of Psychology in Africa is co-published by Informa UK Limited (trading as Taylor & Francis Group) and NISC (Pty) Ltd

Journal of Psychology in Africa, 2017

Vol. 27, No. 3, 294–298, http://dx.doi.org/10.1080/14330237.2017.1321866

Introduction

Postnatal depression (PND) exerts a significant public

mental health burden on women and impacts negatively

on their overall quality of life (Gentile, 2017; O’Connor,

Monk, & Burke, 2016; Siu & US Preventive Services

Task Force, 2016). The World Health Organization and

various mental health practitioners have made numerous

calls to introduce screening for PND in primary health

care. The United States Preventive Services Task Force

(USPSTF) has also recommended that the general adult

population, including pregnant and postpartum women,

should be screened for depression in primary care settings

(Siu & USPSTF, 2016). Knowledge of risk factors for, and

screening procedures for PND currently employed would

be important for shaping appropriate, culture specific, and

targeted public health interventions aimed at reducing

psychological morbidity among women during the

perinatal period (Wittkowski, Gardner, Bunton, & Edge,

2014).

Compared to high resource settings, there have

been comparatively few studies on risk factors for PND

and screening procedures for the health condition in

low resource settings (Alder, Fink, Bitzer, Hösli, &

Holzgreve, 2007; Ferrari et al., 2013; Wittkowski et al.,

2014). Consequently, the guidelines on the provision of

appropriate support for women with PND in these socio-

economically disadvantaged settings are either lacking or

poorly implemented. For instance, very few studies have

addressed PND in the low-resource country of Zimbabwe

(e.g., Chibanda et al., 2010a; January et al., 2015; Shamu,

Zarowsky, Roelens, Temmerman, & Abrahams, 2016).

However, the few related studies suggest PND prevalence

rates exceeding 30% (Chibanda et al., 2010; January et

al., 2015). Higher rates (54%) for PND have also been

reported among postnatal women living with human

immunodeciency virus (HIV) (Chibanda et al., 2010b).

This scoping review of literature aimed to collate

evidence of studies which have focused on screening for

depression in primary care settings within Zimbabwe.

Scoping reviews are particularly useful when collating

emerging evidence and conducting preliminary assessment

of available literature on a topic of interest (Grant &

Booth, 2009). Whilst scoping reviews may inform

policymakers and researchers as to whether full systematic

reviews are warranted, their weakness lies in the lack of

quality assessment which may in turn bias ndings (Grant

& Booth, 2009). Specically this review was aimed to

answer the following research questions: (a) What is

the prevalence of PND in Zimbabwe? (b) What are the

documented risk factors for PND among Zimbabwean

populations? and (c) What is the extent of primary care

screening for PND in Zimbabwe?

Maternal mental health problems also directly and

indirectly impact on maternal morbidity and mortality. A

larger number of studies which have been conducted on

depression, anxiety, and common mental disorders (CMD)

among women in Zimbabwe (Abas & Broadhead, 1997;

Nhiwatiwa, Patel, & Acuda, 1998; Patel et al., 1997;

PROFESSIONAL ISSUES

Primary care screening and risk factors for postnatal depression in Zimbabwe: A scoping

review of literature

James January1,*, Jonathan Burns1 and Moses Chimbari2

1Department of Psychiatry, Nelson R. Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal,

Durban, South Africa

2School of Nursing and Public Health, Howard Campus, College of Health Sciences, University of KwaZulu-Natal, Durban,

South Africa

*Corresponding author email: miranda.january@gmail.com

Postnatal depression (PND) exerts a significant burden on the global public health system, globally affecting approximately

10 to 20% of women. Despite the recently reported high prevalence of PND in Zimbabwe, it is rarely diagnosed or

appropriately managed in primary care settings. This review scopes evidence on PND from studies on screening for

PND and the associated risk factors conducted in Zimbabwe over the past 20 years. We searched electronic databases for

published articles and checked reference lists of studies relating to depression among women in Zimbabwe. We used the

following key words: postnatal, depression, women, screening, risk-factors, and Zimbabwe. A total of 14 studies were

retrieved as follows: postnatal depression (4), postnatal mental disorders (1), mental disorders among pregnant women

(1), and depression and women in general (8). Reported prevalence of PND ranged from 16% to 34.2%. Studies on

PND enrolled women from urban and peri-urban settings. Significant risk factors for PND identified among women in

Zimbabwe included multi parity, having a spouse who was older than 35years, poorer relations with spouses or partners,

having had experienced an adverse event, being unemployed, and having had experienced intimate partner violence.

Psychosocial factors are implicated in PND occurrence among Zimbabwean women. There is need to explore the burden

of PND among rural communities.

Keywords: postnatal depression, review, Zimbabwe

Postnatal depression screening 295

Stranix-Chibanda et al., 2005; Todd et al., 1999), and fewer

on PND. This current review will help identify existing

gaps in literature on risk factors for PND and screening

for PND in primary health care settings in Zimbabwe.

Understanding the associated risk factors for PND is

crucial as it informs appropriate and targeted public health

interventions aimed at reducing psychological morbidity

among women during the perinatal period.

Methods

This scoping review was guided by the Preferred

Reporting Items for Systematic Reviews and Meta-

Analyses (PRISMA) statement (Moher, Liberati, Tetzlaff,

& Altman, 2009). The PRISMA statement provides a set

of items which can guide reporting in systematic reviews

and meta-analyses. In this study we used the PRISMA

flow diagram (see Figure 1) to clearly show the flow of

information through the various stages of the scoping

review.

Search strategy

Three electronic research databases were utilised in

this review. In the initial phase of the search, we used

the PubMed Medical Subject Headings (MeSH) terms:

postnatal depression, and postpartum depression. This

was followed by electronic searches of English language

literature on postnatal depression published between

1995 and 2016 using the following keywords: postnatal/

postpartum depression, women, risk-factors, screening,

prevalence, and Zimbabwe. The searches were conducted

on Medline/PubMed, African Journals Online (AJOL),

and Google Scholar electronic databases. These three

electronic databases were chosen for their public health

relevance and, in the case of AJOL, also for its focus on

RUNNING HEAD: POSTNATAL DEPRESSION SCREENING

Figure 1: PRISMA Flow Diagram for review process

Records identified through

Medline/PubMed (n = 4)

AJOL (n = 1)

Google Scholar (n = 512)

Additional records identified

through mining of reference

lists/bibliographies

(n = 3)

Records after duplicates removed

(n = 508)

Abstracts screened

(n = 505)

Abstracts excluded (Non-

Zimbabwean) (n = 460)

Full-text articles assessed

for eligibility (n = 45)

Full-text articles excluded

(non-Zimbabwean) (n =

31)

Studies on depression

among women in

Zimbabwe (n = 14)

Studies in final analysis

(perinatal depression/

mental illness)

(n = 5)

Figure 1. PRISMA Flow Diagram for review process

January et al.

296

research from Africa. A reference list of all identified

articles was produced and duplicates were removed

resulting in 508 papers. These were further reduced to 14

after excluding studies not conducted in Zimbabwe.

Inclusion criteria

Studies were included if they were published in English

language journals between January 1995 and February

2016. All studies should have been conducted in

Zimbabwe and focused on depression or CMD among

women. For the final analysis, we included only studies

that focused on perinatal depression or mental disorders

(see Figure 1). Articles that did not report prevalence of

depression or associated risk factors were excluded.

Results

Fourteen articles were found which focused on depression

among women in Zimbabwe for the 20 year period. Of

the 14 articles, four were on PND and postnatal mental

disorders, another focused on CMD among pregnant

women, and the rest on depression and women in general.

These five articles were included in the final scoping

review (see Table 1). One study focused on the validation

of the Edinburgh Postnatal Depression Scale (EPDS)

among women in an urban area with high HIV prevalence

(Chibanda et al., 2010a).

Prevalence of PND in Zimbabwe

Prevalence for PND in Zimbabwe ranged from 16%

(Nhiwatiwa et al., 1998) to 34.2% (January et al., 2015).

The differences in the prevalence of PND among different

studies are presented in Table 1. Two studies which used

the 14-item Shona Symptom Questionnaire to assess for

common mental disorders during the perinatal period

reported prevalence of 16% (Nhiwatiwa et al., 1998) and

17% (Stranix-Chibanda et al., 2005) respectively. Studies

which used the EPDS reported prevalence of PND among

postnatal women to be 33% (Chibanda et al., 2010a) and

34.2% (January et al., 2015). A recent study by Shamu et

al. (2016) reported the prevalence of PND to be 21.4%.

PND screening at primary care level

We could not retrieve any studies that focused on routine

screening for PND among women in primary care in

Zimbabwe. However, most studies have recommended

that there is need to introduce screening for depression at

primary care level in light of the high prevalence of PND

in the country. In a study by Abas et al. (2003), from 1997

to 1998 only 0.12% of the total primary care visits in

Harare city health facilities were diagnosed for depression

and the diagnosis was only done by psychiatric nurses or

psychiatrists who had seen some of the patients at tertiary

institutions (Abas, Mbengeranwa, Chagwedera, Maramba,

& Broadhead, 2003).

PND screening tools

The studies which reported on PND prevalence in

Zimbabwe have utilised a variety of assessment tools.

Another two studies by Chibanda and colleagues and

January and others (Chibanda et al., 2010a; January et al.,

2015) used the validated Shona version of the EPDS to

determine the prevalence of PND. Shamu and colleagues

(Shamu et al., 2016) utilised the CES-D, a 20-item

depression screening tool which has been used extensively

in countries within Africa. Two studies on postnatal

mental disorder carried out by Nhiwatiwa and others and

Stranix-Chibanda et al

.(Nhiwatiwa et al., 1998; Stranix-

Chibanda et al., 2005) used the SSQ. The SSQ is a brief

Zimbabwean indigenous measure of common mental

disorders in primary healthcare settings (Patel, Simunyu,

Gwanzura, Lewis, & Mann, 1997). The EPDS is the most

commonly used screening tool for PND and has been used

in a variety of settings all over the world. The tool has

been validated in Zimbabwe and has been shown to be

reliable and valid in screening for PND among women in

the country (Chibanda et al., 2010a).

Risk-factors for PND in Zimbabwe

Significant risk factors for PND from the reviewed studies

included having a spouse who was older than 35years

(Stranix-Chibanda et al., 2005), multi-parity (Chibanda

et al., 2010b; Nhiwatiwa et al., 1998), poorer relations

with spouses or partners (Nhiwatiwa et al., 1998), having

had experienced an adverse event, being unemployed

(Chibanda et al., 2010b), and experiencing intimate partner

violence (Shamu et al., 2016). Although studies reported a

high prevalence of psychiatric morbidity in HIV positive

women of 19.4% (Stranix-Chibanda et al., 2005) and 54%

(Chibanda et al., 2010b), no significant associations were

established between HIV serostatus and PND.

Table 1. Prevalence of PND and depressive symptomatology among women in Zimbabwe

Author and year Main outcome

variable

Sample

size Study design Setting Prevalence Screening/ Diagnostic Tools

Nhiwatiwa et al., 1998 Postnatal

mental disorders

500 Prospective

Cohort study

Peri-urban-Epworth,

Harare

16% Shona Symptom

Questionnaire (SSQ)

*Stranix-Chibanda et

al., 2005

Common mental

disorders

437 Cross-sectional Peri-urban

Chitungwiza

17% Shona Symptom

Questionnaire (SSQ)

Chibanda et al., 2010a Postnatal

depression

210 Cross sectional Urban-Chitungwiza 33% Edinburgh Postnatal

Depression Scale (EPDS),

DSM IV

January et al., 2015 Postnatal

depression

295 Cross-sectional Urban-Harare 34.2% Edinburgh Postnatal

Depression Scale (EPDS)

Shamu et al., 2016 Postnatal

depression

842 Cross-sectional Urban-Harare 21.4% Centre for Epidemiological

Studies—Depression

Scale (CES-D)

*Antenatal women

Postnatal depression screening 297

Discussion

This scoping literature review summarises the evidence on

the risk-factors for and the extent of screening for PND

in primary care settings in Zimbabwe. Findings suggest

lack of routine screening for PND in Zimbabwean primary

care settings. Lack of screening for PND in primary

healthcare settings may be due to a number of factors;

firstly, there may be low awareness of the extent of the

burden of PND to policy makers which calls for advocacy

and sensitisation to be scaled up. Secondly, there may be

reluctance to introduce this type of screening as it may be

perceived to require trained expertise despite evidence that

lay health workers and community counsellors are able

to screen for CMD and administer effective interventions

(Chibanda et al., 2014; Stranix-Chibanda et al., 2005).

Thirdly, pregnancy and childbearing usually bring about

changes within the woman and these may be perceived

by caregivers and significant others as normal processes.

Thus, in some cases, only the most severe cases of PND

are noticed and given due attention.

Some studies in developed countries have found that

screening for PND may not be cost effective in primary

care settings (Paulden, Palmer, Hewitt, & Gilbody, 2009).

Of concern however, is the fact that studies carried out on

PND in Zimbabwe have focused solely on women in urban

and peri-urban areas and have left out women in rural areas

where the problem might be more widespread.

Evidence on PND screening is constrained by the

limitations associated with the instruments that are used.

For instance the EPDS has been used widely in different

settings without using uniform cut-off scores. Some studies

have used cut-off scores of eleven or twelve (Chibanda

et al., 2010a), whilst others have used a cut-off score of

twelve (January et al., 2015). These discrepancies may

overestimate or underestimate the prevalence of PND

among women. Moreover, use of different screening tools

makes it difcult to compare ndings as some tools may be

more sensitive than others. For example, the EPDS and the

SSQ have been used for research purposes in Zimbabwe

although not validated for clinical use in primary care

settings (Chibanda et al., 2010a).

Psychosocial factors are primary risk factors for PND

among Zimbabwean women. This nding is consistent

with those from a previous study (Chibanda et al., 2010b).

This suggests a need to address social inequalities among

women in low and middle income countries at risk for

PND. Poverty and social inequalities have been shown to

have profoundly negative impacts on mental health (Burns,

2015). Poor social relations have also been demonstrated to

be a risk factor for postnatal mental disorders in Zimbabwe

(Nhiwatiwa et al., 1998). There is also evidence suggesting

that women who experience intimate partner violence tend

to be socially and economically disempowered and hence

improving their economic and social well-being may bring

about better mental health outcomes.

Implications for Maternal Health Support Practices

Numerous calls have been made on the need to integrate

mental health into antenatal and postnatal care for women

in Zimbabwe using cost effective methods, such as the

use of community counsellors to screen for psychological

morbidity. Community oriented interventions targeted at

assisting women with mental health problems will serve

to reduce incidence of PND, as well as maternal and child

morbidity. In view of this, it is crucial to examine the

extent to which screening for PND is conducted in primary

care settings and explore the factors which put women at

risk for PND in Zimbabwe.

Limitations

Our review only included published articles and this

may have biased the results. We did not include studies

published before 1995 and those which were not in English

language. Future studies should look at published papers

and also grey literature. The prevalence rates for PND were

largely drawn from studies which used small sample sizes

which could have underestimated the burden of PND in the

absence of large population-based epidemiological studies.

Another limitation of this review is that due to the diversity

of screening tools used for PND in Zimbabwe, it was

difficult to pool prevalence rates to get a true estimation

of the prevalence of PND and this also precluded meta-

analysis. The one study that was conducted on mental

disorder among postnatal women within a peri-urban area

was done close to 20 years ago (Nhiwatiwa et al., 1998)

and the results may not be applicable to the present day

situation.

Given that studies reviewed in this paper enrolled

women from a mostly urban population, the results may

not be applicable to rural populations who, in the case of

Zimbabwe, are even more economically disadvantaged.

Furthermore, primary healthcare services differ markedly

between urban and rural areas; with rural health facilities

receiving less funding than their urban counterparts.

Recent evidence from the country has shown that richer

households tend to benet more from public health

nancing compared to their rural counterparts (Shepherd

Shamu, January, & Rusakaniko, 2016).

Conclusion

Evidence from Zimbabwe indicates that prevalence

for PND ranges between 21.4% and 34%. However,

prevalence studies for PND have focused on urban and

peri-urban areas and there is paucity of studies among rural

populations within the country. Psychosocial factors such

as unemployment, prior experiencing of an adverse event

such as intimate partner violence, multi-parity, having a

spouse who was older than 35 years and poorer relations

with spouses or partners were reported as significant risk

factors for PND among women in Zimbabwe.

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Associations between depressive symptoms, socio-economic factors, traumatic exposure and recent intimate partner violence experiences among women in Zimbabwe: a cross-sectional study

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Jun 2022
BMC Wom Health

Background Population-based research on the cumulative effects of socio-economic conditions and trauma exposures, particularly women’s experiences of intimate partner violence (IPV) on their mental health in Zimbabwe, has been limited. Aim Our study aimed to determine the associations between depressive symptoms and socio-economic factors, IPV, and traumatic exposures among a nationally representative sample of women from Zimbabwe. Methods Data was collected from 2905 women who volunteered to participate in a survey that had a multi-stage random sampling design. Depression was measured using the Centre for Epidemiologic Studies Depression Scale (CESD). Traumatic exposures included childhood trauma, life events, and experiences of IPV in the past year. We compared mean depression scores for different categories of variables, conducted linear regression modelling to investigate the bivariate and multivariate associations between variables and depressive symptoms’ outcomes, and applied Structural Equation Modelling (SEM) to investigate the inter-relationships between variables and depressive symptoms’ outcomes. Results Fifteen percent of women self-reported depressive symptoms (CESD score ≥ 21). Higher depressive symptomatology was associated with lower socio-economic status, experiencing IPV, history of childhood and other traumatic events, experiencing non-partner rape, and HIV positive status. Women who could find money in an emergency and sought informal or professional emotional support were less at risk of severe depressive symptoms. Conversely, seeking informal and formal social support was positively associated with more severe depressive symptoms. Conclusion This study contributes evidence showing that economic hardship, exposure to traumas including IPV, living with HIV, and low social support have a cumulative negative toll on mental health among Zimbabwean women from the general population. Programmes and services that respond to the mental ill-health effects reported by Zimbabwean women and prevention interventions that tackle the multiple risk factors for depression that we have identified must be prioritised.

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Article

Jan 2022

Postpartum depression is a mood disorder that occurs in some women after childbirth. It is one of the most frequent postpartum complications which usually appears 4-6 weeks after delivery and can persist for up to a year. Consequently, this study looked into the predictors of postpartum depression among nursing mothers in Calabar South Cross River State. A cross-sectional study was conducted among 254 mothers in Calabar South Local Government Area of Cross River State, Nigeria, attending seven primary health centers for infant immunization from four weeks to eleven months postpartum. A standardized questionnaire administered by an interviewer was used to gather the data. Data were analyzed using IBM SPSS 23.0 to generate descriptive and inferential statistics at a p < 0.05 level of significance. The mean score for knowledge was 5.93 ± 2.86. More than half (52.0%) of the respondents had a negative attitude toward postpartum depression, (52.4%) of the respondents had a high perception, and (53.1%) of respondents had high self-esteem. More than half (56.1%) of the respondents had low media influence, (53.1%) of the respondents had social support, and (65.4%) of the respondents had low enabling factors. There was a significant relationship (p= 0.000) between each respondent’s independent variables and level of postpartum depression except for enabling factors. Social support was a predictor of postpartum depression among this study population. It is suggested that family members should be made more aware of the need for supporting nursing mothers so as to improve their mental health by reducing postpartum depression. Keywords: Social Support, Postpartum Depression, Knowledge, Attitude, Media.

ANTENATAL ASSESSMENT OF THE PSYCHOSOCIAL WELLBEING OF PREGNANT WOMEN: A CASE OF MPILO LOZIKEYI MATERNITY HOSPITAL, BULAWAYO, ZIMBABWE

Article

Full-text available

Jul 2022

Introduction: Women have psychosocial challenges but perinatal interventions are not making much impact on their mental status hence the interventions need scaling up. This study involved measuring and analysing the extent to which levels of the psychosocial markers reflect effectiveness of the mental health interventions offered by midwives. Methods: The study was conducted at Mpilo Central Hospital Maternity Bulawayo, for the main reason that it receives women referrals from 5 out of the 10 provinces in the country with a total catchment of almost 50% of the country’s population. The maternity hospital has a full complement of all the five maternity units. A quantitative approach administrating a Quality-of-Life Enjoyment and Satisfaction Short form (Q-LES-SF) scale was used. The scale ranged from “very poor” to “very good” with “poor”, “fair”, “good” components in between was used to measure the psychosocial scores on a purposive sample of 300 women in the third trimester of pregnancy. The participants had attended at least three antenatal reviews where psychosocial interventions and mental health assessment, monitoring and evaluations are normally carried. The quantitative data was analysed using descriptive statistics on SPSS Version 23 package. Results: The Q-LES-Q-SF psychosocial scale which was revealed that women had psychosocial challenges without adequate mental health interventions to ameliorate these challenges. The study demonstrated a bimodal sample with peaks at the “Good” and “Poor” set points. The relationships of the psychosocial and satisfaction scores along the scale continuum showed that “Poor” (33%) Q-LES-Q-SF was higher, followed by “Good” (29%), followed by “Fair” (25%), followed by “Very Poor” and “Very Poor” and “Very Good” being equal (6.5%) in a normal distribution pattern. The likelihood of the demographic variables influencing the Q-LES-Q-F scale were not necessarily linked to the quality-of-life enjoyment and satisfaction of the expectant women during prenatal period. However, age, education level acquired and marital status showed a linearity towards the “Good” when individually rated against the Q-LES-Q-F. Discussion: The psychosocial scores were generally both poor and good indicating that perinatal interventions are needed are needed to making much impact on the mental and social wellbeing of women in the third trimester of pregnancy. The good to very good Q-LES-Q-F scores are a requirement in expectant mothers as this has a strong bearing on the wellbeing of the foetus and mother post parturition. Apparently, the need for scaling up psychosocial support, monitoring, evaluation and interventions to third trimester pregnant women by midwives cannot be overemphasized.

Food insecurity and common mental disorders in perinatal women living in low socio-economic settings in Cape Town, South Africa during the COVID-19 pandemic: a cohort study

Article

Full-text available

Feb 2022
GMH

Background Common mental disorders (CMDs), i.e. depression and anxiety, are highly prevalent during the perinatal period, and is associated with poverty, food insecurity and domestic violence. We collected data from perinatal women at two time-points during the COVID-19 pandemic to test the hypotheses that (1) socio-economic adversities at baseline would be associated with CMD prevalence at follow-up and (2) worse mental health at baseline would be associated with higher food insecurity prevalence at follow-up. Methods Telephonic interviews with perinatal women attending healthcare facilities in Cape Town, South Africa. Multivariable (multilevel) regression analysis was used to model the associations of baseline risk factors with the prevalence of household food insecurity and probable CMD at 3 months follow-up. Results At baseline 859 women were recruited, of whom 217 (25%) were pregnant, 631 (73%) had given birth in the previous 6 months, 106 (12%) had probable CMD, and 375 (44%) were severely food insecure. At follow-up ( n = 634), 22 (4%) were still pregnant, 603 (95%) had given birth, 44 (7%) had probable CMD, and 207 (33%) were severely food insecure. In the multivariable regression model, after controlling for confounders, unemployment [incidence rate ratio (IRR) 1.19 (1.12–2.27); p < 0.001] and had higher scores on the Edinburgh Postnatal Depression Scale [IRR 1.05 (1.03–1.09); p < 0.001] at baseline predicted food insecurity at follow-up; and experiencing domestic violence [OR 2.79 (1.41–5.50); p = 0.003] at baseline predicted CMD at follow-up. Conclusions This study highlights the complex bidirectional relationship between mental health and socio-economic adversity among perinatal women during the COVID-19 pandemic.

Food insecurity and common mental disorders in perinatal women living in low socio-economic settings in Cape Town, South Africa during the COVID-19 pandemic: a cohort study

Preprint

Full-text available

Jul 2021

Background Common mental disorders (CMDs) such as depression and anxiety are highly prevalent during the perinatal period, and are associated with poverty, food insecurity and domestic violence. We used data collected from perinatal women at two time-points during the COVID-19 pandemic to test the hypotheses that (1) socio-economic adversities at baseline would be associated with higher CMD prevalence at follow-up and (2) worse mental health at baseline would be associated with higher food insecurity prevalence at follow-up. Methods Telephonic interviews were conducted with perinatal women attending healthcare facilities in Cape Town, South Africa. Multivariable logistic regression analysis was used to model the associations of baseline risk factors with the prevalence of household food insecurity and CMD at 3 months follow-up. Results At baseline 859 women were recruited, of whom 217 (25%) were pregnant, 106 (12%) had probable CMD, and 375 (44%) were severely food insecure. At follow-up (n=634), 22 (4%) were still pregnant, 44 (7%) had probable CMD, and 207 (33%) were severely food insecure. In the multivariable regression model, after controlling for confounders, the odds of being food insecure at follow-up were greater in women who were unemployed [OR=2.05 (1.46-2.87); p<0.001] or had probable CMD [OR=2.37 (1.35-4.18); p=0.003] at baseline; and the odds of probable CMD at follow-up were greater in women with psychological distress [OR=2.81 (1.47-5.39); p=0.002] and abuse [OR=2.47 (1.47-4.39); p=0.007] at baseline. Conclusions This study highlights the complex bidirectional relationship between mental health and socioeconomic adversity among perinatal women during the COVID-19 pandemic.

Food insecurity and common mental disorders in perinatal women living in low socio-economic settings in Cape Town, South Africa during the COVID-19 pandemic: a cohort study

Preprint

Full-text available

Jul 2021

Objective: Common mental disorders (CMDs) such as depression and anxiety are highly prevalent during the perinatal period, and are associated with food insecurity, domestic violence and lack of social support. This study explores the relationship between household food insecurity, mental health status and several adverse social and economic factors experienced by perinatal women during the COVID-19 pandemic. Design: Cohort study, using telephonic interviews at two time-points, three months apart. Logistic regression analysis was used to model the associations of several baseline risk factors with the occurrence of household food insecurity at follow-up as the outcome. Setting: Midwife obstetric units or basic antenatal care units in Cape Town, South Africa. Participants: The sample comprised of 880 perinatal women at baseline and 660 women at follow-up. Results: At baseline 23% were pregnant, 54% were unemployed, 13% had a probable CMD, 43% were severely food insecure and 21% experienced domestic abuse in the past year. Of the 660 women interviewed at follow-up, 71% were unemployment, 3.5% were pregnant, 7% had a probable CMD, and 32% were severely food insecure. In the multivariate regression model, after controlling for ethnicity, number of children, being HIV-infected, and having a planned pregnancy, the odds of being food insecure were greater in women who were unemployed (OR=1.88; p=0.001) or had probable CMD (OR=2.20; p=0.019) at baseline. Conclusions: This study highlights a range of socio-demographic and mental health related variables that predict food insecurity among perinatal women during the COVID-19 pandemic.

Social and Demographic Factors Associated with Postnatal Depression Symptoms among HIV-Positive Women in Primary Healthcare Facilities, South Africa

Article

Full-text available

Jan 2021

Background: Mothers living with HIV are at risk for mental health problems, which may have a negative impact on the management of their HIV condition and care of their children. Although South Africa has a high prevalence of HIV, there is a dearth of studies on sociodemographic predictors of postnatal depression (PND) among HIV-positive women in South Africa, even in KwaZulu Natal, a province with the highest prevalence of HIV in the country. Objective: The objective of the study was to determine sociodemographic factors associated with the prevalence of postnatal depression symptoms among a sample of HIV-positive women attending health services from primary healthcare facilities in Umhlathuze District, KwaZulu Natal. Methods: A quantitative cross-sectional survey was used to collect data from 386 HIV-positive women who had infants aged between 1 and 12 weeks. The Edinburgh Postnatal Depression Scale (EPNDS), to which sociodemographic questions were added, was used to collect data. Results: The prevalence of PND symptoms among this sample of 386 HIV-positive women was 42.5%. The age of the mothers ranged from 16 to 42 years, with a mean of 29 years. The majority of the mothers were single or never married (85.5%; n = 330), living in a rural setting (81.9%; n = 316%), with a household income of less than R 2000 (estimated 125 USD) per month (64.9%; n = 120). The government child support grant was the main source of income for most of the mothers (53%; n = 183). PND symptoms were significantly associated with the participant's partner having other sexual partners (p-value < 0.001), adverse life events (p-value = 0.001), low monthly income (p-value = 0.015), and being financially dependent on others (p-value = 0.023). Conclusion: The prevalence of PND symptoms among the sample is high, with a number of social and demographic factors found to be significantly associated with PND. This requires the consideration of sociodemographic information in the overall management of both HIV and postnatal depression. Addressing the impact of these factors can positively influence the health outcomes of both the mother and the baby.

Prevalence and predictors of postpartum depression among postnatal women in Lagos, Nigeria

Article

Full-text available

Dec 2020
Afr Health Sci

Background: Globally, postpartum depression is one of the most common but often unrecognized complications of childbirth, yearly affecting about 10-15% of postnatal women. This study aimed to determine the prevalence of postpartum depression and its predictors among postnatal women in Lagos. Methods: A descriptive cross-sectional study was conducted among 250 mothers in Eti-Osa Local Government Area of Lagos State, Nigeria, attending six Primary Health Care centers for infant immunization at six weeks post-delivery. Data was collected using a pretested semi-structured interviewer administered questionnaire which included the Edinburgh Postnatal Depression Scale. Analysis was carried out using SPSS version 23TM. Chi-square and logistic regression analyses were used to determine associations and predictive relationships between various factors and the presence of postpartum depression. The level of significance was set at <0.05. Results: The prevalence of postpartum depression was 35.6%. Multiparity, delivery by cesarean section, mother being unwell after delivery, and not exclusively breastfeeding the baby were the factors linked with postpartum depression. Following multiple logistic regression, having postpartum blues (p=0.000; OR=32.77; 95%CI=7.23-148.58)., not getting help with caring for the baby (p=0.008; OR=2.64; 95%CI=1.29-5.42), experiencing intimate partner violence (p=0.000; OR=5.2; 95%CI=2.23-11.91) and having an unsupportive partner (p=0.018; OR=2.6; 95%CI=1.17-5.78) were identified as predictors of postpartum depression. Conclusion: This study revealed a high prevalence of postpartum depression, identifying both the obstetric and psychosocial predictors. Social support for women both in the pre- and postnatal periods and routine screening of women for postpartum depression should be encouraged for early detection and immediate intervention.

Prevalence and Coping Strategies of Postnatal Depression among Women in Bayelsa State, Nigeria

Article

Aug 2022

This study examined the prevalence and coping strategies of Postnatal Depression (PND) among mothers in Bayelsa, the state of Nigeria. The general aim was to describe the level of PND experienced by women and the methods they adopt to cope with this syndrome. This study was a cross-sectional survey of 345 women with babies between 1-6 weeks old. The women were selected purposively at health and maternity centres and clinics in Bayelsa state. A structured questionnaire was used in data collection. The data gathered were analysed using univariate, bivariate and multivariate analyses at a p≤0.05 level of significance. The prevalence rate of PND ranged from mild depression (37.7%), moderate depression (3.5%) to severe depression (3.2%). There is a statistically significant relationship between socio-demographic variables and PND among mothers (p=0.000). PND prevalent among the study population exerts adverse effects on the health and cognitive development of the mother and child. However, the strategies adopted by mothers to cope with PND ranged from social support to music therapy. This study recommended that counselling of mothers during and after childbirth should be carried out as part of the routine for mothers and childcare.

Validated Tools to Identify Common Mental Disorders in the Perinatal Period: A Systematic Review of Systematic Reviews

Article

Jan 2021

Maternal Affective Illness in the Perinatal Period and Child Development: Findings on Developmental Timing, Mechanisms, and Intervention

Article

Full-text available

Feb 2016
Curr Psychiatr Rep

Maternal mental illness is one of the most reliable risks for clinically significant child adjustment difficulties. The research literature in this area is very large and broad and dates back decades. In this review, we consider recent research findings on maternal mental illness and child development by focusing particularly on affective illness the perinatal period. We do this because maternal affective illness in the perinatal period is common; recent evidence suggests that pre- and postpartum maternal depression may have lasting effects on child behavioral and somatic health; research in the perinatal period raises acute and compelling questions about mechanisms of transmission and effect; and perinatal-focused interventions may offer distinct advantages for benefitting mother and child and gaining insights into developmental mechanisms. Throughout the review, we attend to the increasing integration of psychological and biological models and the trans-disciplinary approach now required for clinical investigation.

Who benefits from public health financing in Zimbabwe? Towards universal health coverage

Article

Full-text available

Jan 2016
Global Publ Health

Zimbabwe's public health financing model is mostly hospital-based. Financing generally follows the bigger and higher-level hospitals at the expense of smaller, lower-level ones. While this has tended to perpetuate inequalities, the pattern of healthcare services utilisation and benefits on different levels of care and across different socioeconomic groups remains unclear. The purpose of this study was therefore to assess the utilisation of healthcare services and benefits at different levels of care by different socioeconomic groups. We conducted secondary data analysis of the 2010 National Health Accounts survey, which had 7084 households made up of 26,392 individual observations. Results showed significant utilisation of health services by poorer households at the district level (concentration index of -0.13 [CI:-0.2 to -0.06; p < .05]), but with mission hospitals showing equitable utilisation by both groups. Provincial and higher levels showed greater utilisation by richer households (0.19; CI: 0.1-0.29; p < .05). The overall results showed that richer households benefited significantly more from public health funds than poorer households (0.26; CI: 0.2-0.4; p < .05). Richer households disproportionately benefited from public health subsidies overall, particularly at secondary and tertiary levels, which receive more funding and provide a higher level of care.

Untreated Depression During Pregnancy: Short- and Long-term Effecs in Offspring. A Systematic Review

Article

Full-text available

Sep 2015

Salvatore Gentile

Aim of this systematic review is to assess short- and long-lasting effects of antenatal exposure to untreated maternal depressive symptoms. Pertinent articles were identified through combined searches of Science.gov, Cochrane library, and PubMed databases (through August 2015). Forty-three, selected articles revealed that untreated gestational depression and even depressive symptoms during pregnancy may have untoward effects on the developing fetus (hyperactivity, irregular fetal heart rate), newborns (increased cortisol and norepinephrine levels, decreased dopamine levels, altered EEG patterns, reduced vagal tone, stress/depressive-like behaviors, and increased rates of premature deaths and Neonatal Intensive Care Unit admission), and children (increased salivary cortisol levels, internalizing and externalizing problems, and central adiposity). During adolescence, an independent association exists between maternal antenatal mood symptoms and a slight increase in criminal behaviors. In contrast, the relationship between gestational depression and increased risks of prematurity and low birth weight remains controversial. Given this background, when making clinical decisions, clinicians should weigh the growing evidences suggesting the detrimental and prolonged effects in offspring of untreated antenatal depression and depressive symptoms during pregnancy against the known and emerging concerns associated with in utero exposure to antidepressants.

Poverty, inequality and a political economy of mental health

Article

Full-text available

Mar 2015

Jonathan Kenneth Burns

The relationship between poverty and mental health is indisputable. However, to have an influence on the next set of sustainable global development goals, we need to understand the causal relationships between social determinants such as poverty, inequality, lack of education and unemployment; thereby clarifying which aspects of poverty are the key drivers of mental illness. Some of the major challenges identified by Lund (2014) in understanding the poverty-mental health relationship are discussed including: the need for appropriate poverty indicators; extending this research agenda to a broader range of mental health outcomes; the need to engage with theoretical concepts such as Amartya Sen's capability framework; and the need to integrate the concept of income/economic inequality into studies of poverty and mental health. Although income inequality is a powerful driver of poor physical and mental health outcomes, it features rarely in research and discourse on social determinants of mental health. This paper interrogates in detail the relationships between poverty, income inequality and mental health, specifically: the role of income inequality as a mediator of the poverty-mental health relationship; the relative utility of commonly used income inequality metrics; and the likely mechanisms underlying the impact of inequality on mental health, including direct stress due to the setting up of social comparisons as well as the erosion of social capital leading to social fragmentation. Finally, we need to interrogate the upstream political, social and economic causes of inequality itself, since these should also become potential targets in efforts to promote sustainable development goals and improve population (mental) health. In particular, neoliberal (market-oriented) political doctrines lead to both increased income inequality and reduced social cohesion. In conclusion, understanding the relationships between politics, poverty, inequality and mental health outcomes requires us to develop a robust, evidence-based 'political economy of mental health.'

Methods of systematic reviews and meta-analysis preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement

Article

Jan 2009
J CLIN EPIDEMIOL

Screening for Depression in Adults

Article

Jan 2016

Description Update of the 2009 US Preventive Services Task Force (USPSTF) recommendation on screening for depression in adults.Methods The USPSTF reviewed the evidence on the benefits and harms of screening for depression in adult populations, including older adults and pregnant and postpartum women; the accuracy of depression screening instruments; and the benefits and harms of depression treatment in these populations.Population This recommendation applies to adults 18 years and older.Recommendation The USPSTF recommends screening for depression in the general adult population, including pregnant and postpartum women. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. (B recommendation)

Prevalence and correlates of postnatal depression in an urban high density suburb of Harare

Article

Apr 2015
Cent Afr J Med

Introduction: Postnatal depression is a common cause of morbidity but is rarely diagnosed or managed in busy primary care settings in most resource limited countries like Zimbabwe. Objectives: This study sought to determine the prevalence of postnatal depression and establish factors associated with postnatal depression. Methods: The study utilized a cross-sectional descriptive design where 295 consenting women (mean age=25.4 years; SD= 5.6 years) attending post natal care services at Mbare Polyclinic were recruited. Data were collected using the validated Shona version of the Edinburgh Postnatal Depression Scale (EPDS) questionnaire. Associations between variables were computed using the chi-square test statistic and where appropriate the Fisher’s exact statistic. Results: Prevalence for postnatal depression was 34.2% among women in the study. Univariate analysis revealed that there were no statistically significant associations between mother’s age (p=0.120), parity (p=0.396), marital status (p=0.523), level of education (p=0.805), and age of child (p=0.489) and postnatal depression. Conclusion: Findings from this study indicate that there is a high prevalence of postnatal depression in women in Mbare, Zimbabwe. This therefore calls for further studies to identify and address the causes of postnatal depression among women attending postnatal care in Zimbabwe.

High frequency intimate partner violence during pregnancy, post natal depression and suicidal tendencies in Harare, Zimbabwe

Article

Oct 2015

Introduction: Intimate partner violence (IPV) is a common form of violence experienced by pregnant women and is believed to have adverse mental health effects postnatally. This study investigated the association of postnatal depression (PND) and suicidal ideation with emotional, physical and sexual IPV experienced by women during pregnancy. Methods: Data were collected from 842 women interviewed postnatally in six postnatal clinics in Harare, Zimbabwe. We used the World Health Organization versions of IPV and Centre for Epidemiological Studies - Depression Scale measures to assess IPV and PND respectively. We derived a violence severity variable and combined forms of IPV variables from IPV questions. Logistic regression was used to analyse data whilst controlling for past mental health and IPV experiences. Results: One in five women [21.4% (95% CI 18.6-24.2)] met the diagnostic criteria for PND symptomatology whilst 21.6% (95% CI 18.8-24.4) reported postpartum suicide thoughts and 4% (95% CI 2.7-5.4) reported suicide attempts. Two thirds (65.4%) reported any form of IPV. Although individual forms of severe IPV were associated with PND, stronger associations were found between PND and severe emotional IPV or severe combined forms of IPV. Suicidal ideation was associated with emotional IPV. Other forms of IPV, except when combined with emotional IPV, were not individually associated with suicidal ideation. Conclusion: Emotional IPV during pregnancy negatively affects women's mental health in the postnatal period. Clinicians and researchers should include it in their conceptualisation of violence and health. Further research must look at possible indirect relationships between sexual and physical IPV on mental health.

Moher D, Liberati A, Tetzlaff J, Altman DG Group PPreferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 339: b2535

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