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Journal of Psychology in Africa
ISSN: 1433-0237 (Print) 1815-5626 (Online) Journal homepage: http://www.tandfonline.com/loi/rpia20
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
© 2017 Africa Scholarship Development Enterprize
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,
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
immunodeciency 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). Specically 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;
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,
*Corresponding author email: firstname.lastname@example.org
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.
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
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
(n = 3)
Records after duplicates removed
(n = 508)
(n = 505)
Abstracts excluded (Non-
Zimbabwean) (n = 460)
Full-text articles assessed
for eligibility (n = 45)
Full-text articles excluded
(non-Zimbabwean) (n =
Studies on depression
among women in
Zimbabwe (n = 14)
Studies in final analysis
(n = 5)
Figure 1. PRISMA Flow Diagram for review process
January et al.
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.
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.
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
size Study design Setting Prevalence Screening/ Diagnostic Tools
Nhiwatiwa et al., 1998 Postnatal
16% Shona Symptom
437 Cross-sectional Peri-urban
17% Shona Symptom
Chibanda et al., 2010a Postnatal
210 Cross sectional Urban-Chitungwiza 33% Edinburgh Postnatal
Depression Scale (EPDS),
January et al., 2015 Postnatal
295 Cross-sectional Urban-Harare 34.2% Edinburgh Postnatal
Depression Scale (EPDS)
Shamu et al., 2016 Postnatal
842 Cross-sectional Urban-Harare 21.4% Centre for Epidemiological
Postnatal depression screening 297
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 difcult 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.
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
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 benet more from public health
nancing compared to their rural counterparts (Shepherd
Shamu, January, & Rusakaniko, 2016).
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.
Abas, M. A., & Broadhead, J. C. (1997). Depression and
anxiety among women in an urban setting in Zimbabwe.
Psychological Medicine, 27(1), 59–71. https://doi.
Abas, M., Mbengeranwa, O. L., Chagwedera, I. V. S., Maramba, P.,
& Broadhead, J. (2003). Primary care services for depression
in Harare, Zimbabwe. Harvard Review of Psychiatry, 11(3),
157–165. https://doi.org/10.1080/10673220303952 https://
January et al.
Alder, J., Fink, N., Bitzer, J., Hösli, I., & Holzgreve, W.
(2007). Depression and anxiety during pregnancy: A
risk factor for obstetric, fetal and neonatal outcome? A
critical review of the literature. The Journal of Maternal-
Fetal & Neonatal Medicine, 20(3), 189–209. https://doi.
Burns, J. K. (2015). Poverty, inequality and a political economy of
mental health. Epidemiology and Psychiatric Sciences, 24(2),
Chibanda, D., Mangezi, W., Tshimanga, M., Woelk, G.,
Rusakaniko, P., Stranix-Chibanda, L., . . . Shetty, A. K.
(2010a). Validation of the Edinburgh Postnatal Depression
Scale among women in a high HIV prevalence area in urban
Zimbabwe. Archives of Women’s Mental Health, 13(3),
Chibanda, D., Mangezi, W., Tshimanga, M., Woelk, G.,
Rusakaniko, S., Stranix-Chibanda, L., . . . Shetty, A.
K. (2010b). Postnatal depression by HIV status among
women in Zimbabwe. Journal of Women’s Health, 19(11),
Chibanda, D., Shetty, A. K., Tshimanga, M., Woelk, G., Stranix-
Chibanda, L., & Rusakaniko, S. (2014). Group problem-
solving therapy for postnatal depression among HIV-positive
and HIV-negative mothers in Zimbabwe. [JIAPAC]. Journal
of the International Association of Providers of AIDS Care,
13(4), 335–341. https://doi.org/10.1177/2325957413495564
Ferrari, A. J., Charlson, F. J., Norman, R. E., Patten, S. B.,
Freedman, G., Murray, C. J. L., … Whiteford, H. A. (2013).
Burden of depressive disorders by country, sex, age, and
year: Findings from the Global Burden of Disease Study
2010. PLOS Med, 10(11), 1-12. https://doi.org/10.1371/
Gentile, S. (2017). Untreated depression during pregnancy:
Short-and long-term effects in offspring. A systematic review.
Neuroscience, 342, 154–166. https://doi.org/10.1016/j.
Grant, M. J., & Booth, A. (2009). A typology of reviews: An
analysis of 14 review types and associated methodologies.
Health Information and Libraries Journal, 26(2), 91–108.
January, J., Chivanhu, H., Chiwara, J., Denga, T., Dera, K.,
Dube, T., … Chikwanha, T. M. (2015). Prevalence and the
correlates of postnatal depression in an urban high density
suburb of Harare. Central African Journal of Medicine,
61(1–4), 1–4. https://doi.org/10.4314/cajm.v61i1-4
Moher, D., Liberati, A., Tetzlaff, J., & Altman, D. G. (2009).
Preferred reporting items for systematic reviews and
meta-analyses: The PRISMA statement. Annals of Internal
medicine, 151(4), 264-269. https://doi.org/10.1136/bmj.
Nhiwatiwa, S., Patel, V., & Acuda, W. (1998). Predicting
postnatal mental disorder with a screening questionnaire:
A prospective cohort study from Zimbabwe. Journal of
Epidemiology and Community Health, 52(4), 262–266.
O’Connor, T. G., Monk, C., & Burke, A. S. (2016). maternal
affective illness in the perinatal period and child development:
findings on developmental timing, mechanisms, and
intervention. Current Psychiatry Reports, 18(3), 1–5. https://
Patel, V., Simunyu, E., Gwanzura, F., Lewis, G., & Mann,
A. (1997). The Shona Symptom Questionnaire: The
development of an indigenous measure of common mental
disorders in Harare. Acta Psychiatrica Scandinavica,
95(6), 469–475. https://doi.org/10.1111/j.1600-0447.1997.
Patel, V., Todd, C., Winston, M., Gwanzura, F., Simunyu, E.,
Acuda, W., & Mann, A. (1997). Common mental disorders
in primary care in Harare, Zimbabwe: Associations and risk
factors. The British Journal of Psychiatry, 171(1), 60–64.
Paulden, M., Palmer, S., Hewitt, C., & Gilbody, S. (2009).
Screening for postnatal depression in primary care: Cost
effectiveness analysis. BMJ, 339. https://doi.org/10.1136/
Shamu, S., January, J., & Rusakaniko, S. (2016). Who benefits
from public health financing in Zimbabwe? Towards
universal health coverage. Global Public Health: An
International Journal for Research, Policy and Practice, 4,
Shamu, S., Zarowsky, C., Roelens, K., Temmerman, M., &
Abrahams, N. (2016). High-frequency intimate partner
violence during pregnancy, postnatal depression and
suicidal tendencies in Harare, Zimbabwe. General Hospital
Psychiatry, 38, 109–114. https://doi.org/10.1016/j.
Siu, A. L., & US Preventive Services Task Force (USPSTF).
(2016). Screening for depression in adults: US preventive
services task force recommendation statement. JAMA,
315(4), 380–387. https://doi.org/10.1001/jama.2015.18392
Stranix-Chibanda, L., Chibanda, D., Chingono, A., Montgomery,
E., Wells, J., Maldonado, Y., . . . Shetty, A. K. (2005).
Screening for psychological morbidity in HIV-infected
and HIV-uninfected pregnant women using community
counselors in Zimbabwe. [JIAPAC]. Journal of the
International Association of Physicians in AIDS Care, 4(4),
Todd, C., Patel, V., Simunyu, E., Gwanzura, F., Acuda, W.,
Winston, M., & Mann, A. (1999). The onset of common
mental disorders in primary care attenders in Harare,
Zimbabwe. Psychological Medicine, 29(1), 97–104. https://
Wittkowski, A., Gardner, P. L., Bunton, P., & Edge, D. (2014).
Culturally determined risk factors for postnatal depression
in Sub-Saharan Africa: A mixed method systematic review.
Journal of Affective Disorders, 163, 115–124. https://doi.