Antenatal predictors of incident and persistent postnatal depressive symptoms in rural Ethiopia:a population-based prospective study

Background: There have been few studies to examine antenatal predictors of incident postnatal depression, particularly in low- and middle-income countries (LMICs). The aim of this study was to investigate antenatal predictors of incident and persistent maternal depression in a rural Ethiopian community in order to inform development of antenatal interventions. Method: A population-based prospective study was conducted in Sodo district, south central Ethiopia. A locally validated version of the Patient Health Questionnaire (PHQ-9) was used to assess antenatal (second and third trimesters) and postnatal (4-12 weeks after childbirth) depressive symptoms, with a PHQ-9 cut-off of five or more indicating high depressive symptoms. Poisson regression with robust standard errors was used to identify independent predictors of persistence and incidence of postnatal depressive symptoms from a range of antenatal, clinical and psychosocial risk factors. Result: Out of 1311 women recruited antenatally, 1240 (356 with and 884 without antenatal depressive symptoms) were followed up in the postnatal period. Among 356 women with antenatal depressive symptoms, the elevated symptoms persisted into postnatal period in 138 women (38.8%). Out of 884 women without antenatal depressive symptoms, 136 (15.4%) experienced incident elevated depressive symptoms postnatally. The prevalence of high postnatal depressive symptoms in the follow-up sample was 274 (22.1%). Higher intimate partner violence scores in pregnancy were significantly associated with greater risk of incident depressive symptoms [adjusted Risk Ratio (aRR) = 1.06, 95% CI: 1.00, 1.12]. Each 1-point increment in baseline PHQ-9 score predicted an increased risk of incidence of postnatal depressive symptoms (aRR = 1.29, 95% CI: 1.15, 1.45). There was no association between self-reported pregnancy complications, medical conditions or experience of threatening life events with either incidence or persistence of depressive symptoms. Conclusion: Psychological and social interventions to address intimate partner violence during pregnancy may be the most important priorities, able to address both incident and persistent depression

Antenatal depressive symptoms and maternal health care utilisation:a population-based study of pregnant women in Ethiopia

BACKGROUND: Depressive symptoms during pregnancy can have multiple adverse effects on perinatal outcomes, including maternal morbidity and mortality. The potential impact of antenatal depressive symptoms on maternal health care use, however, has been little explored in low and middle-income countries (LMICs). This paper investigates whether maternal health care utilisation varies as a function of antenatal depressive symptoms.METHODS: In a population-based cross-sectional survey, 1311 women in the second or third trimesters of pregnancy were recruited in Sodo district, Gurage Zone, southern Ethiopia. Depressive symptoms were measured using a locally validated version of the Patient Health Questionnaire (PHQ-9). The association between antenatal depressive symptoms and number of antenatal care (ANC) visits was examined using Poisson regression and the association of depression symptoms with emergency health care visits using negative binomial regression. Binary logistic regression was used to investigate the association of depressive symptoms with initiation, frequency and adequacy of antenatal care.RESULTS: At PHQ-9 cut off of five or more, 29.5 % of participants had depressive symptoms. The majority (60.5 %) of women had attended for one or more ANC visits. Women with depressive symptoms had an increased risk of having more non-scheduled ANC visits (adjusted Risk Ratio (aRR) = 1.41, 95 % CI: 1.20, 1.65), as well as an increased number of emergency health care visits to both traditional providers (aRR = 1.64, 95 % CI: 1.17, 2.31) and biomedical providers (aRR = 1.31, 95 % CI: 1.04, 1.69) for pregnancy-related emergencies. However, antenatal depressive symptoms were not significantly associated with initiation of ANC.CONCLUSIONS: Increased non-scheduled ANC and emergency health care visits may be indicators of undetected depression in antenatal women, and have the potential to overwhelm the capacity and resources of health care systems, particularly in LMICs. Establishment of a system for detection, referral and treatment of antenatal depression, integrated within existing antenatal care, may reduce antenatal morbidity and treatment costs and promote efficiency of the health care system.</p

Pregnant women and health workers’ perspectives on perinatal mental health and intimate partner violence in rural Ethiopia: a qualitative interview study

BackgroundMental health conditions are common during the perinatal period and associated with maternal, foetal, and neonatal morbidity and mortality. There is an established bidirectional relationship between mental health conditions and intimate partner violence (IPV), including during and after pregnancy. Mean lifetime prevalence of physical, sexual or emotional IPV exposure among women in rural Ethiopia is estimated to be 61% and may be even higher during the perinatal period. We aimed to explore the perspectives of women and antenatal care (ANC) health workers on the relationship between all types of IPV and perinatal mental health, to inform the adaptation of a psychological intervention for pregnant women experiencing IPV in rural Ethiopia.MethodsWe conducted in-depth qualitative interviews with 16 pregnant women and 12 health workers in the Gurage zone of the Southern Nations, Nationalities and People’s Region of Ethiopia, between December 2018 and December 2019. We conducted thematic analysis of English-translated transcripts of audio-recorded Amharic-language interviews.ResultsParticipants contextualised IPV as the primary form of abusive treatment women experienced, connected by multiple pathways to emotional and bodily distress. Patriarchal norms explained how the actions of neighbours, family, community leaders, law enforcement, and government agents in response to IPV often reinforced women’s experiences of abuse. This created a sense of powerlessness, exacerbated by the tension between high cultural expectations of reciprocal generosity and severe deprivation. Women and health workers advocated a psychological intervention to address women’s powerlessness over the range of difficulties they faced in their daily lives.ConclusionsWomen and health workers in rural Ethiopia perceive multiple, interconnected pathways between IPV and perinatal emotional difficulties. Contrary to expectations of sensitivity, women and health workers were comfortable discussing the impact of IPV on perinatal mental health, and supported the need for brief mental health interventions integrated into ANC

Antenatal depressive symptoms and perinatal complications:a prospective study in rural Ethiopia

BACKGROUND: Antenatal depressive symptoms affect around 12.3% of women in in low and middle income countries (LMICs) and data are accumulating about associations with adverse outcomes for mother and child. Studies from rural, low-income country community samples are limited. This paper aims to investigate whether antenatal depressive symptoms predict perinatal complications in a rural Ethiopia setting.METHODS: A population-based prospective study was conducted in Sodo district, southern Ethiopia. A total of 1240 women recruited in the second and third trimesters of pregnancy were followed up until 4 to 12 weeks postpartum. Antenatal depressive symptoms were assessed using a locally validated version of the Patient Health Questionnaire (PHQ-9) that at a cut-off score of five or more indicates probable depression. Self-report of perinatal complications, categorised as maternal and neonatal were collected by using structured interviewer administered questionnaires at a median of eight weeks post-partum. Multivariate analysis was conducted to examine the association between antenatal depressive symptoms and self-reported perinatal complications.RESULT: A total of 28.7% of women had antenatal depressive symptoms (PHQ-9 score ≥ 5). Women with antenatal depressive symptoms had more than twice the odds of self-reported complications in pregnancy (OR=2.44, 95% CI: 1.84, 3.23), labour (OR= 1.84 95% CI: 1.34, 2.53) and the postpartum period (OR=1.70, 95% CI: 1.23, 2.35) compared to women without these symptoms. There was no association between antenatal depressive symptoms and pregnancy loss or neonatal death.CONCLUSION: Antenatal depressive symptoms are associated prospectively with self-reports of perinatal complications. Further research is necessary to further confirm these findings in a rural and poor context using objective measures of complications and investigating whether early detection and treatment of depressive symptoms reduces these complications.</p

Adapting an intervention of brief problem-solving therapy to improve the health of women with antenatal depressive symptoms in primary healthcare in rural Ethiopia

Background: Evidence-based brief psychological interventions are safe and effective for the treatment of antenatal depressive symptoms. However, the adaptation of such interventions for low- and middle-income countries has not been prioritised. This study aimed to select and adapt a brief psychological intervention for women with antenatal depressive symptoms attending primary healthcare (PHC) in rural Ethiopia. Methods: We employed the Medical Research Council (MRC) framework for the development and evaluation of complex interventions. Alongside this, we used the ADAPT-ITT model of process adaptation and the ecological validity model (EVM) to guide content adaptation. We conducted formative work, comprising a qualitative study, a series of three participatory theories of change workshops and an expert adaptation workshop to assess the needs of the target population and to select an intervention for adaptation. The adaptation process followed a series of steps: (1) training Ethiopian mental health experts in the original South African problem-solving therapy (PST version 0.0) and an initial adaptation workshop leading to PST Version 1.0. (2) Version 1.0 was presented to perinatal women and healthcare professionals in the form of a ‘theatre test’, leading to further adaptations (version 2.0). (3) Local and international stakeholders reviewed version 2.0, leading to version 3.0, which was used to train 12 PHC staff using clinical cases. (4) Finally, feedback about PST version 3.0 and its delivery was obtained from PHC staff. Results: In the first step, we modified case examples and terminology from the South African model, introduced an in-session pictorial flipchart for this low literacy setting, and added strategies to facilitate women’s engagement before translating into Amharic. In the second step, adaptations included renaming of the types of problems and inclusion of more exercises to demonstrate proposed coping strategies. In the third step, the components of motivational interviewing were dropped due to cultural incongruence. In the final step, refresher training was delivered as well as additional training on supporting control of women’s emotions to address PHC staff training needs, leading to the final version (version 4.0). Conclusion: Using a series of steps, we have adapted the content and delivery of brief PST to fit the cultural context of this setting. The next step will be to assess the feasibility and acceptability of the intervention and its delivery in antenatal care settings

Training antenatal care providers to deliver brief problem-solving therapy in rural Ethiopia::a developmental evaluation

Background: Task-sharing is the redistribution of tasks usually performed by specialists, to staff with less training and fewer qualifications. Despite the established clinical efficacy of task-shared brief psychological interventions in low and middle-income countries, training and supervision models are infrequently reported and rarely evaluated.Methods: From the interpretive paradigm, we conducted a developmental evaluation of training, supervision, and task-sharing of antenatal care providers (ANCPs) to deliver problem-solving therapy for antenatal depression in rural Ethiopia. We triangulated 18 qualitative interviews with women intervention recipients, ANCPs, mental health specialist trainer/supervisors and research staff, with documentary data. We employed reflexive thematic analysis before ‘peer review’ of our interpretations by a female Ethiopian research assistant.Findings: Four over-arching themes encompassed the developmental journey, impacts, factors influencing success, and improvements. The complex adaptive healthcare system exerted unforeseen effects on the iterative development of training, supervisory and task-sharing plans. High quality communication skills (‘common elements’) training was most valued by ANCPs, while women especially appreciated psychological intervention ‘specific elements.’ An apprenticeship cascade model could balance the need for frequent, in-person specialist supervision against logistical barriers to travel from the capital. Fostering peer ‘communities of practice’ could support ANCPs' well-being and enhance their continued professional development.Conclusions: This study contributes to sparse literature evaluating task-sharing training and supervisory approaches in resource-restricted settings, from an interpretive paradigm. Developmental evaluation proved a flexible methodological approach for exploring perspectives of stakeholders occupying diverse roles. We demonstrate the importance of embedding in-depth pedagogical consideration and qualitative evaluation into trials which depend on high quality clinical education

Perinatal mental health around the world: priorities for research and service development in Africa

Africa is a diverse and changing continent with a rapidly growing population, and the mental health of mothers is a key health priority. Recent studies have shown that: perinatal common mental disorders (depression and anxiety) are at least as prevalent in Africa as in high-income and other low- and middle-income regions; key risk factors include intimate partner violence, food insecurity and physical illness; and poor maternal mental health is associated with impairment of infant health and development. Psychological interventions can be integrated into routine maternal and child healthcare in the African context, although the optimal model and intensity of intervention remain unclear and are likely to vary across settings. Future priorities include: extension of research to include neglected psychiatric conditions; large-scale mixed-method studies of the causes and consequences of perinatal common mental disorders; scaling up of locally appropriate evidence-based interventions, including prevention; and advocacy for the right of all women in Africa to safe holistic maternity care

Brief problem-solving therapy for antenatal depressive symptoms in primary care in rural Ethiopia:protocol for a randomised, controlled feasibility trial

BACKGROUND: Despite a high prevalence of antenatal depression in low- and middle-income countries, there is very little evidence for contextually adapted psychological interventions delivered in rural African settings. The aims of this study are (1) to examine the feasibility of procedures for a future fully powered efficacy trial of contextually adapted brief problem solving therapy (PST) for antenatal depression in rural Ethiopia, and (2) to investigate the acceptability, fidelity and feasibility of delivery of PST in routine antenatal care.METHODS: Design: A randomised, controlled, feasibility trial and mixed method process evaluation.PARTICIPANTS: Consecutive women attending antenatal clinics in two primary care facilities in rural Ethiopian districts. Eligibility criteria: (1) disabling levels of depressive symptoms (Patient Health Questionnaire (PHQ-9) score of five or more and positive for the 10th disability item); (2) gestational age 12-34 weeks; (3) aged 16 years and above; (4) planning to live in the study area for at least 6 months; (5) no severe medical or psychiatric conditions.INTERVENTION: Four sessions of adapted PST delivered by trained and supervised antenatal care staff over a maximum period of eight weeks.CONTROL: enhanced usual care (EUC).SAMPLE SIZE: n = 50. Randomisation: individual randomisation stratified by intimate partner violence (IPV). Allocation: central phone allocation. Outcome assessors and statistician masked to allocation status. Primary feasibility trial outcome: dropout rate. Primary future efficacy trial outcome: change in PHQ-9 score, assessed 9 weeks after recruitment.SECONDARY OUTCOMES: anxiety symptoms, trauma symptoms, intimate partner violence, disability, healthcare costs at 9 weeks; postnatal outcomes (perinatal and neonatal complications, onset of breast feeding, child health) assessed 4-6 weeks postnatal. Other trial feasibility indicators: recruitment, number and duration of sessions attended. Audio-recording of randomly selected sessions and in-depth interviews with purposively selected participants, healthcare providers and supervisors will be analysed thematically to explore the acceptability and feasibility of the trial procedures and fidelity of the delivery of PST.DISCUSSION: The findings of the study will be used to inform the design of a fully powered efficacy trial of brief PST for antenatal depression in routine care in rural Ethiopia.TRIAL REGISTRATION: The protocol was registered in the Pan-African clinical trials registry, (PACTR): registration number: PACTR202008712234907 on 18/08/2020; URL: https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=9578

Antenatal depressive symptoms and utilisation of delivery and postnatal care: a prospective study in rural Ethiopia

Background: Uptake of delivery and postnatal care remains low in Low and Middle-Income Countries (LMICs), where 99% of global maternal deaths take place. However, the potential impact of antenatal depression on use of institutional delivery and postnatal care has seldom been examined. This study aimed to examine whether antenatal depressive symptoms are associated with use of maternal health care services. Methods: A population-based prospective study was conducted in Sodo District, Southern Ethiopia. Depressive symptoms were assessed during pregnancy with a locally validated, Amharic version of the Patient Health Questionnaire (PHQ-9). A cut off score of five or more indicated possible depression. A total of 1251 women were interviewed at a median of 8 weeks (4–12 weeks) after delivery. Postnatal outcome variables were: institutional delivery care utilization, type of delivery, i.e. spontaneous or assisted, and postnatal care utilization. Multivariate logistic regression was used to examine the association between antenatal depressive symptoms and the outcome variables. Results: High levels of antenatal depressive symptoms (PHQ score 5 or higher) were found in 28.7% of participating women. Nearly two-thirds, 783 women (62.6%), delivered in healthcare institutions. After adjusting for potential confounders, women with antenatal depressive symptoms had increased odds of reporting institutional birth [adjusted Odds Ratio (aOR) =1.42, 95% Confidence Interval (CI): 1.06, 1.92] and increased odds of reporting having had an assisted delivery (aOR = 1.72, 95% CI: 1.10, 2.69) as compared to women without these symptoms. However, the increased odds of institutional delivery among women with antenatal depressive symptoms was associated with unplanned delivery care use mainly due to emergency reasons (aOR = 1.62, 95% CI: 1.09, 2.42) rather than planning to deliver in healthcare institutions. Conclusion: Improved detection and treatment of antenatal depression has the potential to increase planned institutional delivery and reduce perinatal complications, thus contributing to a reduction in maternal morbidity and mortality

Brief problem-solving therapy (PST) for women experiencing antenatal depressive symptoms:a randomised, controlled feasibility trial in an antenatal care setting in rural Ethiopia

BackgroundWe adapted non-specialist healthcare worker (HCW) delivered problem-solving therapy (PST) to support improved treatment of antenatal depression in maternal healthcare platforms in rural Ethiopia. In this study, we aimed to evaluate the feasibility, fidelity and acceptability of PST for antenatal depression and the procedures required for the implementation of a fully-powered randomised controlled trial (RCT).MethodsParticipants were consecutive antenatal care (ANC) attendees in two primary healthcare (PHC)-based healthcare facilities, based on pre-established eligibility criteria. We employed a randomised, controlled feasibility trial design with two parallel groups. Participants in the intervention arm received four sessions of a contextually adapted version of PST; the control group received enhanced usual care (EUC) that involved routine antenatal care and information about sources of support. Assessments were conducted at baseline (T0) and at nine weeks after randomisation (T1). Assessment at T1 mainly comprised of preliminary clinical outcomes and hypothesized mediators. At T2, feasibility parameters were assessed in addition to T1 assessments. A recruitment rate of 80% of the expected sample size within a month, retention rate of ≥50%, provider competence of ≥60%, less than 10% adverse events and mean session duration of 30 minutes were assumed for feasibility success. We summarised participant characteristics, feasibility outcomes and preliminary clinical outcomes using descriptive statistics. Results:After screening and the consent process, we randomised 50 eligible women to PST and EUC arms. Trial procedures such as participant recruitment and allocation concealment were feasible. Most (64%) completed all four sessions of the intervention. About 58% of HCWs attained expected scores on Enhancing Assessment of Common Therapeutic factors (ENACT) scale. No adverse events occurred during the trial. Supervision reports indicated that HCWs appreciated skills gained from PST and adhered to most of the PST content, except challenging women who reported not having problems or worries. However, they recommended pre-recorded videos of role play demonstrations and shorter trainer demonstrations, to increase trainees’ opportunities to practise skills. ConclusionsParticipant recruitment, screening, randomisation, masking, as well as the intervention delivery process, were feasible. Future training should prioritise opportunities for HCWs to practise skills as much as possible. Trial registrationThe protocol was registered in the Pan-African clinical trials registry, (PACTR): registration number: PACTR202008712234907 on 18/08/2020; URL: https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=9578. The protocol has also been published: https://pilotfeasibilitystudies.biomedcentral.com/articles/10.1186/s40814-021-00773-8<br/