Postnatal Depression by HIV Status Among Women in Zimbabwe

Abstract

Background:

Postnatal depression (PND) is a serious public health problem in resource-limited countries. Research is limited on PND affecting HIV-infected women in sub-Saharan Africa. Zimbabwe has one of the highest antenatal HIV infection rates in the world. We determined the prevalence and risk factors of PND among women attending urban primary care clinics in Zimbabwe.

Methods:

Using trained peer counselors, a simple random sample of postpartum women (n = 210) attending the 6-week postnatal visit at two urban primary care clinics were screened for PND using the Shona version of the Edinburgh Postnatal Depression Scale (EPDS). All women were subsequently subjected to mental status examination using the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for major depression by two psychiatrists who had no knowledge of the EPDS test results.

Results:

Of the 210 mothers (31 HIV positive, 148 HIV negative, 31 unknown status) enrolled during the postpartum period, 64 (33%) met DSM-IV criteria for depression. The HIV prevalence was 14.8%. Of the 31 HIV-infected mothers, 17(54%) met DSM-IV criteria for depression. Univariate analysis showed that multiparity (prevalent odds ratio [OR] 2.22, 95% confidence intervals [CI] 1.15-4.31), both parents deceased (OR 2.35, 95% CI 1.01-5.45), and having experienced a recent adverse life event (OR 8.34, CI 3.77-19.07) were significantly associated with PND. Multivariate analysis showed that PND was significantly associated with adverse life event (OR 7.04, 95% CI 3.15-15.76), being unemployed (OR 3.12, 95% CI 1.23-7.88), and multiparity (OR 2.50, 95% CI 1.00-6.24).

Conclusions:

Our data indicate a high burden of PND among women in Zimbabwe. It is feasible to screen for PND in primary care clinics using peer counselors. Screening for PND and access to mental health interventions should be part of routine antenatal care for all women in Zimbabwe.

Introduction

Postnatal depression (PND) is an important public health problem that affects many women globally.^1,2 The adverse consequences of PND are well documented for mothers and infants.³ PND is associated with insecure mother-child attachment and problems in child cognitive, behavioral, and emotional development.⁴ Recent studies from South Asia indicate that PND is also associated with adverse infant growth outcomes.^5,6

PND affects 10%–15% of women in resource-rich countries.⁷ In contrast, the prevalence of PND is higher in low-income and middle-income countries.¹ In a study from India, maternal depression was found in 23% of women at 6–8 weeks after childbirth.⁸ Likewise, a South African periurban survey reported a high rate (35%) of PND.⁹ Data on PND are limited in Zimbabwe.¹⁰ In one published study on PND in Zimbabwe, the prevalence of postnatal mental disorders was 16%.¹⁰ In that study, the investigators used the Shona Symptom Questionnaire (SSQ), an indigenous psychiatric questionnaire used in the antenatal period to detect depression.¹¹ Although the SSQ has been used extensively in Zimbabwe as a screening tool for common mental illness (CMD),^12,13 it was not designed for detection of PND.

Women who are both pregnant and HIV infected may be at higher risk of developing CMD,^14
–16 but the burden of CMD among HIV-infected pregnant women in sub-Saharan Africa is not well studied.^17

–21 In addition, there is very little research on perinatal CMD, especially among HIV-infected women participating in prevent mother-to-child transmission of HIV (PMTCT) programs in sub-Saharan Africa.^18,19 In a recent study from rural South Africa, depression among pregnant women undergoing HIV testing as measured by the Edinburgh Postnatal Depression Scale (EPDS) was high (41%).¹⁹ In another study from Tanzania, depressive symptoms were common (57%) among HIV-infected pregnant women and increased the risk of disease progression.¹⁸

Zimbabwe has one of the highest HIV infection rates in the world, with up to 16% of pregnant women being HIV infected.²² In a recent study conducted at our site, the prevalence of psychological morbidity among pregnant women attending an urban primary care clinic was 17%.²³ Depression was the most frequent illness among women with psychological morbidity; 79% of women were evaluated by the psychiatrist and met the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for clinical depression.²³ Studies have shown that depressive symptoms increase the risk of HIV disease progression and mortality among pregnant women, suboptimal compliance to antiretroviral therapy, and poor use of antenatal care.^6,18,24,25

The objective of this study is to determine the risk factors associated with PND in a cohort of HIV-infected and HIV uninfected women who came for postpartum follow-up to two urban antenatal clinics in Zimbabwe.

Materials and Methods

Sample

This study was conducted at two urban postnatal clinics in Chitungwiza, a periurban community with a population of 1.5 million located on the outskirts of the city of Harare, Zimbabwe. Shona is the most common spoken language in Zimbabwe. The prevalence of HIV infection among antenatal attendees in Chitungwiza antenatal clinics was around 16%.²² At both clinics, pregnant women are offered HIV testing as part of routine antenatal care.²⁶ Single-dose intrapartum/neonatal nevirapine prophylaxis is used to PMTCT.²⁷

To be eligible for the study, all women had to be aged ≥18 years, have attended the routine postnatal clinic 6 weeks postdelivery with her baby between 6 and 7 weeks of age, and resided within the Chitungwiza catchment area. The 6-week window period used as an inclusion criterion was based on the DSM-IV definition of postpartum depression (i.e., onset within 4–6 weeks of birth).²⁸ Excluded were women who did not reside in Chitungwiza township or were unable to give informed consent. Simple random sampling was used with the clinic registry as the sampling frame. Computer-generated random numbers were used to enroll participants into the study.

Written informed consent was obtained from each participant, and the study was approved by the Institutional Review Boards at Wake Forest University Health Sciences, the Medical Research Council of Zimbabwe, and Chitungwiza City Health Department.

Measures

Depressive symptoms

A two-stage screening procedure was performed to determine the prevalence of PND. During the first stage, we validated the Shona version of the EPDS among postpartum women at our site using trained community counselors.²⁹ The community counselors were HIV-infected women who had previously participated in a PMTCT program at our site, were currently enrolled in support groups, and had disclosed their positive HIV status to partner or family member. The peer counselors were employed by Zimbabwe AIDS Prevention Project, worked full-time, and were paid a salary.

The EPDS is a widely used questionnaire developed specifically to screen women in many different cultures for PND.³⁰ The EPDS consists of 10 self-reported items, each response rated 0–3 based on severity and summed to yield the total score (0–30). The scale has items related to anxiety (3 items) and depressive symptoms (7 items), such as inability to laugh and look forward to things with enjoyment, blaming oneself unnecessarily, anxious or worried, scared or panicky, inability to cope, difficulty sleeping, sad or miserable, tearfulness, and thoughts of harming oneself. All the sampled subjects were literate and able to comprehend the 10-item EPDS. Using a cutoff score of 11/12 on the Shona version of the EPDS, the sensitivity of the EPDS was 88% and the specificity was 87%, with a positive predictive value of 74% and a negative predictive value of 94% and an area under the curve (AUC) of 0.82. Cronbach's alpha coefficient for the whole scale was 0.87.²⁹

During the second stage, each participant was interviewed by two trained psychiatrists who were blinded to the participant's EPDS scores. Diagnosis of PND was made by using a Structured Clinical Interview for DSM-IV, Clinician Version (SCID).³¹ Two experienced and trained psychiatrists administered the SCID to eligible women in the postpartum period. The kappa coefficient was used to calculate interrater reliability between the two psychiatrists. A pretest of the clinical interview administered by the clinicians showed a kappa coefficient of 0.89, thereby showing good concordance between the two psychiatrists.

Adverse events

Adverse events were measured by asking about the occurrence of four negative social and economic events in the last 3 months before delivery (relationship issues, death, illness, and financial difficulties). Adverse life events were defined through a focus group discussion (FGD), which included community counselors and mothers attending the postnatal clinic. The last 3 months before delivery were defined as an important period in the prevention of Kufungisisa. The term Kufungisisa literally means “thinking too much” and is a Shona idiom for CMD.³² Several studies in Zimbabwe have shown that Kufungisisa is closely linked to depression.^33,34 Based on the FGDs, the most likely causes of Kufungisisa 3 months before delivery included relationship issues (abandonment by spouse/partner, refusal of paternity, domestic violence), death of spouse or family members, illness of a person close to them, and insufficient money for basic necessities. Descriptive statistics are recorded on the percentage of participants who reported each adverse event in the 3 months before delivery.

Procedures

Before study initiation, staff at the two clinic sites attended a 2-day training session conducted by investigators (D.C. and L.S.-C), in which the study procedures were discussed and explained in detail, including data collection and interview techniques. All mothers were initially provided with information about the study while they were receiving their clinic review cards from the nurses. They were then selected on the basis of computer-generated random numbers that were matched to their review cards. Upon selection, the participants were provided with further information about the study in a written format.

After informed consent, six trained community counselors administered the EPDS to eligible postpartum women. In addition to sociodemographic data, information about adverse events and HIV testing was documented using a predesigned questionnaire. The interview was conducted in a quiet, private setting in the local language, Shona. All study participants were subsequently subjected to mental status examination using DSM-IV criteria for major depression by two psychiatrists who were blinded to the subject's EPDS test results until the study was completed.

Study participants with psychosis, severe depression, and suicidal ideation and attempts were referred to a specialized psychiatric unit located at Harare Central Hospital for treatment.

Statistical analysis

The data were analyzed using Epi-Info software 2002 (Centers for Disease Control and Prevention [CDC], Atlanta, GA). Descriptive statistics (including means, standard deviations [SD], frequencies, and percentage) were calculated for the sociodemographic variables. Group comparison was determined using chi-square test, t test, and odds ratio (OR) (95% confidence interval [CI]). Stepwise logistic regression was used to evaluate independent associations. All tests were 2-tailed, and p < 0.05 was considered statistically significant.

Results

Demographic characteristics

A total of 210 women completed the study. Table 1 shows the sociodemographic characteristics of the study population. There were no differences in findings by study clinic. All study participants were black Zimbabwean women with a mean age of 25 years. One hundred sixty-five women (79%) were married, 36 (17%) were in a cohabiting relationship, and 9 (4%) were single. All enrolled participants had received some level of education, with the majority (74%) having achieved secondary education. The majority of women (75%) were unemployed. The majority (93%) of the mothers reported having a confidant with whom they could share their problems. Ninety-seven women (46%) were primiparous, and 54% (113) had more than one child; 99% breastfed their babies. The mean birth weight of babies was 3.9 kg (SD 1.2); 58% of infants were female.

Table 1.

Sociodemographic Characteristics of Study Participants (n = 210)

Characteristic	n	%
Age, years
18–24	121	58
25–34	67	32
≥35	22	10
Education
None	0
Primary	48	23
Secondary	155	74
More than secondary	7	3
Martial status
Married	165	79
Cohabiting	36	17
Single	9	4
Occupation
Employed	6	3
Unemployed	204	97
Parity
Primiparous	97	46
Multiparous	113	54
Living with partner/spouse	187	89
Both parents deceased	42	20
DSM-IV defined depression	64	30
Prevalence of HIV	31	15
Adverse events^a	111	53

Adverse events (n = 111) reported include insufficient money for basic necessities, such as food and clothing (n = 27), illness (n = 25), death of partner or close family member (n = 22), domestic violence (n = 15), abandonment by male partner (n = 13), and refusal of paternity (n = 9).

DSM-IV, Diagnostic and Statistical Manual of Mental Disorders.

Of the 201 study participants, 179 women (85%) underwent routine HIV testing (optout approach) during pregnancy, and 95% of enrolled HIV-infected women received single-dose intrapartum/neonatal nevirapine prophylaxis for PMTCT.

Frequency of adverse life events

Of the total 210 women, 111 (53%) reported adverse life events during the 3 months before delivery. Adverse events (n = 111) reported included insufficient money for such basic necessities as food and clothing (n = 27), illness (n = 25), death of partner or close family member (n = 22), problems in relationships with their partners such as domestic violence (n = 15), abandonment by male partner (n = 13), and refusal of paternity (n = 9).

Prevalence of postnatal depression

Of the 210 mothers (31 HIV positive, 148 HIV negative, 31 unknown HIV status) enrolled during the postpartum period, 64 (33%) were depressed postnatally. The HIV prevalence was 14.8%; of the 31 HIV-infected mothers, 17(54%) met DSM-IV criteria for depression. Of the 148 HIV-negative women, 36 (24%) were depressed. Of the 31 women with unknown HIV status, 11 (35%) met DSM-IV criteria for depression.

Associated factors of postnatal depression

Table 2 presents the univariate analysis of factors associated with PND. Multiparity (prevalent OR 2.22, 95% CI 1.15-4.31), both parents deceased (OR 2.35, 95% CI 1.01-5.45), and having experienced a recent adverse life event (OR 8.34, 95% CI 3.77-19.07) were significantly associated with PND. In a multivariate analysis, PND was significantly associated with adverse life event (OR 7.04, 95% CI 3.15-15.76), being unemployed (OR 3.12, 95% CI 1.23-7.88), and multiparity (OR 2.50, 95% CI 1.00-6.24) (Table 3). Table 4 shows a comparison of demographic characteristics, adverse events, and mental health between HIV-infected and HIV-uninfected women.

Table 2.

Univariate Risk Factors Associated with Postnatal Depression (n = 210)

Variable	DSM-IV-defined depression present n = 64 (%)	DSM-IV-defined depression absent n = 146 (%)	OR (95% CI)
Age, years
18–24	39 (61)	82 (56)	1.22 (0.64-2.32)
≥25 (Ref )	25 (39)	64 (44)	-
Marital status
Single	5 (8)	4 (3)	1.45 (0.705-3.00)
Married/cohabiting (Ref )	59 (92)	142 (97)	-
Education, years
0–7	18 (28)	31 (21)	1.45 (0.70-3.00)
8+ (Ref )	46 (72)	115 (79)	-
Employment
Unemployed	54 (84)	104 (72)	2.18 (0.96-5.04)
Employed (Ref )	10 (16)	42 (28)	-
Parity
Multiparous	43 (67)	70 (48)	2.22 (1.15-4.31)*
Primiparous (Ref )	21 (33)	76 (52)	-
Partner age^a
<30 (Ref )	27 (42)	85 (58)	-
≥30	33 (51)	58 (40)	1.79 (0.93-3.44)
Partner around
No	10 (16)	13 (8)	1.89 (0.72-4.96)
Yes (Ref )	54 (84)	133 (92)
Both parents deceased
Yes	18 (28)	24 (16)	2.35 (1.01-5.45)*
One living	23 (36)	50 (34)	1.18 (0.64-2.20)
Both living (Ref )	23 (36)	72 (49)	-
HIV status
Positive	17 (26)	14 (9)	3.78 (1.58-9.08)*
Negative (Ref )	36 (57)	112 (77)	-
Unknown	11 (17)	20 (14)	1.71 (0.69-4.20)
Adverse life event
Yes	54 (84)	57 (39)	8.34 (3.77-19.07)*
No (Ref )	10 (16)	88 (61)	-

The ages of 4 (7%) cases and 2 (2%) noncases were unknown.

*Significant association.

CI, confidence interval; OR, odds ratio; Ref, reference group; cases, DSM-IV-defined depression present; noncases, DSM-IV-defined depression absent.

Table 3.

Multivariate Analysis of Factors of Postnatal Depression Among Zimbabwean Women

Characteristic	Adjusted OR	95% CI	p value
Adverse events	7.04	3.15-15.76	p < 0.001*
Unemployed	3.12	1.23-7.88	0.02*
Multiparity	2.50	1.00-6.24	0.05*
HIV-positive status	1.95	0.76-4.99	0.16
HIV-unknown status	1.59	0.59-4.25	0.36
Both parents deceased	2.13	0.92-4.93	0.07
Age (<18–24 years)	1.46	0.56-3.79	0.44
Marital status (single)	4.45	0.54-36.51	0.16
Education (0–7 years)	1.38	0.61-3.11	0.44
Husband/partner age (<30 years)	0.69	0.29-1.63	0.40
Husband/partner around	0.66	0.17-2.51	0.54

*Statistically significant.

Table 4.

Comparison of Demographic Characteristics, Adverse Events, and Mental Health Between HIV-Infected and HIV-Uninfected Women (n = 210)

Variable	HIV-positive n = 31 (%)	HIV-negative n = 148 (%)	HIV status unknown n = 31 (%)
Mean age, years	27	25	27
Mean EPDS score	12.8	9.7	10.9
Age of partner, years
<30	10 (32)	89 (58)	14 (45)
≥30	21 (67)	54 (36)	16 (51)
Unknown	-	5 (3)	1 (3)
Parity
Primiparous	7 (22)	77 (52)	14 (45)
Multiparous	24 (88)	71	27
Marital status
Married	27 (87)	113 (76)	24 (77)
Cohabiting	4 (12)	27 (18)	6 (19)
Single	0 (0)	8 (5)	1 (3)
Husband/partner physically around	27 (87)	131 (89)	29 (93)
Both parents deceased	8 (25)	29 (19)	6 (19)
Mother only deceased	4 (12)	40 (27)	8 (25)
Father only deceased	4 (12)	13 (8)	3 (9)
Both parents alive	15 (48)	66 (49)	14 (45)
Educational status
High school	22 (71)	110 (74)	24 (77)
Junior school	9 (29)	32 (21)	7 (22)
Tertiary school	0	6 (4)	0
Employment
Formal	1 (3)	5 (3)	0
Informal	6 (19)	36 (24)	5 (16)
Unemployed	24 (77)	107 (72)	26 (83)
Adverse events	26 (83)	70 (47)	15 (48)
Death in family	4 (12)	15 (10)	3 (10)
Financial issues	4 (12)	18 (12)	5 (16)
Illness	8 (25)	14 (9)	3 (10)
Relationship issues^a	10 (32)	23 (15)	4 (12)
No adverse events	5 (16)	78 (53)	16 (52)
DSM-IV-defined depression	17 (55)	36 (24)	11 (35)

Relationship issues include domestic violence, abandonment by male partner, and refusal of paternity.

EPDS, Edinburgh Postnatal Depression Scale.

Discussion

To our knowledge, this study is among the first to investigate PND among HIV-infected postpartum women in Zimbabwe. The findings of this study indicate that PND is very prevalent among postpartum women attending primary care clinics in Zimbabwe. In our study, the diagnosis of PND was made by psychiatrists using DSM-IV criteria. Our findings are consistent with those of other published reports from sub-Saharan Africa.^18,19

In the present study, women's experience of recent adverse life events, such as death or illness of husband/partner or close family member or being abandoned by a partner or partner refusal of paternity, was associated with PND. Many factors have been associated with PND, such as young age, high parity, low education and illiteracy, unemployment, and financial difficulties.^35

–41 In published studies, the most frequently reported factors include marital conflict, lack of partner's support, and child health issues.^35

–38 Sociocultural factors, such as relationship with mother-in-law and desire for a male infant, were important factors in recent studies from South Asia and sub-Saharan Africa.^8,39
–41

The overall HIV prevalence in our sample was 15%. This finding is consistent with the national estimates of HIV seroprevalence rates among pregnant women attending antenatal clinics.²² In the present study, positive HIV serostatus was not significantly associated with depressive symptoms among postpartum mothers. This is consistent with findings from a study conducted in four cities in the United States, which showed that HIV serostatus was less important than socioenvironmental factors in predicting depressive symptoms.⁴² In contrast, a Zambian study showed that women who discovered their positive HIV status during pregnancy were more prone to develop depression.⁴³ A study from Thailand found evidence of depressive symptoms and HIV-related worry in HIV-infected women at 18–24 months postpartum.¹⁵

There is evidence that women who experience antenatal depression are vulnerable to PND.⁴⁴ Two thirds of cases of PND begin before the birth of the baby, typically during the third trimester of pregnancy.⁴⁵ In addition, perinatal depression can begin later than 6 weeks postpartum, and some women may have clinical depression, which can persist long term after the postnatal follow-up period.⁴⁶ This is relevant in the context of prenatal and long-term depression management services for this vulnerable population.

Detection of maternal depression in primary care clinics remains a challenge, as women often are reluctant to express their feelings.² Our study demonstrated that the Shona version of the EPDS is a useful tool to detect depression among postpartum mothers and to support further clinical evaluation. In addition, this study demonstrated the feasibility of screening PND in primary care clinics using trained community counselors. This is particularly important in view of the recent political instability, economic hardships, severely limited resources, and shortage of healthcare workers in Zimbabwe. A recent landmark trial conducted in rural Pakistan showed that perinatal depression can be effectively treated by community health workers using a cognitive behavioral intervention, resulting in significant benefits for both mother and baby.⁴⁷

The cultural perspective of psychiatry in Zimbabwe needs to be considered while interpreting the study results, as the characterization of symptoms and women's responses to psychiatrists could be affected by the cultural viewpoint of mental health and mental health treatment. In Zimbabwe, sociocultural factors play an important role in the presentation of CMD. Therefore, it is critical to understand the local idioms and concepts of nonpsychotic mental illness. Kufungisisa, which literally means “thinking too much,” is used to mean both a cause and a symptom of illness and is strongly related to biomedical constructs of nonpsychotic mental illness, but it is not specifically related to either depression or anxiety.^33,34 Some experts have suggested that the use of the term Kufungisisa may increase the awareness and recognition of nonpsychotic mental disorders by the community and healthcare providers.⁴⁸ In our study, only Shona idioms of distress were used in the interviews, based on previous studies in Zimbabwe.⁴⁸

Our study has several limitations. The sample size was relatively small. Our study was conducted in an urban setting, and results may not be generalizable to rural settings. This study relied on the diagnosis of depression based on DSM-IV criteria. The SCID interviews in Shona were administered by two experienced and trained psychiatrists. The peer counselors who screened mothers for PND in our setting were highly motivated and well-trained and received supervision. Depressive symptoms were measured only in the postpartum period and not antenatally. We did not determine the percent of newborns who acquired perinatal HIV infection because early infant diagnosis by HIV DNA/RNA PCR testing was unavailable at our site. All these factors could strongly impact the findings of the current study and should be explored in future research. Despite these limitations, our study results offer significant insight into the burden of perinatal depression and highlight the importance of screening and treatment of depression as an integral component of maternal postpartum care.

Given the high prevalence of PND in our setting, we recommend that screening for antenatal and postpartum depression and provision of psychosocial support should be part of routine perinatal care in Zimbabwe. Future studies should evaluate the feasibility, acceptability, and efficacy of treating perinatal depression using community counselors in routine antenatal care settings in Zimbabwe.

Footnotes

Acknowledgments

This study was funded by Elsie E. and Robert B. Lawson Funds. We thank Dr. Mike Simoyi (Chitungwiza Health Department, ZW), nursing staff and peer counselors (Seke North and St Mary's clinics, Chitungwiza, ZW), UZ-UCSF Collaborative Program in Women's Health, Departments of Psychiatry, Pediatrics and Community Medicine, University of Zimbabwe College of Health Sciences, Zimbabwe Ministry of Health and Child Welfare, and all the mothers who participated in the study.

Disclosure Statement

The authors have no conflicts of interest to report.

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