Reviewer's report
Title:The "MENTAL" in maternal health care: Perceptions of postnatal
depression and health care needs in a South African sample.
Version:2Date:25 February 2014
Reviewer: oriana vesga
Reviewer's report:
This is an interesting article, which used qualitative methods to explore
participants´ understanding of the nature and causes of depressive
symptomatology in the postpartum period, as well as participants´ attitudes
towards available treatment options. Postpartum depression affects a large
proportion of women worldwide, and the treatment gap found in low and middle
income countries make this article a relevant contribution to the literature.
Nevertheless, a number of issues will need to be addressed before the article is
ready to be accepted for publication.
1. Major revisions
a. The abstract needs to be revised to better reflect the purpose and scope of the
present study:
b. The clarity and content of the introduction can be strengthened:
The authors do a good job at summarizing the literature supporting the high
burden of disease in LAMIC attributed to postpartum depression, as well as the
adverse childhood outcomes associated with untreated maternal depressive
symptoms. However, little is said about the relevant gaps in the literature and
how the present qualitative study will help address some of those gaps.
If the authors would consider summarizing the review of the epidemiological
literature (limit the review of this data to one or two paragraphs) and expand
more on how qualitative studies in general, and this study in particular, are
needed to inform the development of feasible and sustainable interventions for
management of postpartum depression in low income settings, the clarity of the
introduction would be strengthened.
Specific questions to consider include: How is qualitative research relevant in this
particular context? Why is the understanding of individuals´ perceptions and
attitudes towards illness and health care relevant for the development of feasible
and sustainable interventions? How will this study make novel contribution to the
existing literature?
c. More detail is required in the methods section. The following questions require
clarification:
i. When did the study take place?
ii. How was the interview guide designed? What are the main questions? Were
the interviews conducted face-to-face?
iii. Were the subjects compensated for their time?
iv. What were the study´s eligibility (inclusion/exclusion) criteria?
v. Was this a convenience sample? or did the authors stopped recruitment once
theoretical saturation was reached?
vi. Was the SCID administered to confirm the diagnosis of MDD or a MDE? If it
was to confirm diagnosis of MDD, it is not clear why having a history of antenatal
depression was an exclusion criterion.
d. Results section: There are two major issues with the results of the study:
i. The themes reported are not consistent with the stated goal to explore “how
women diagnosed with a postpartum depressive episode understood the causes,
course and treatment options available for their depressive symptoms, as well as
their attitudes toward task sharing of counseling interventions.”
Rather, the authors present data on psychosocial stressors associated with
depressive symptomatology, impact of depressive symptoms, a brief overview of
reported symptoms, and attitudes towards mental health services. Please
reconcile and revise the introduction or the results section accordingly to be
consistent with each other.
ii. Data collection included ten follow up interviews at the participants ´home to
“confirm earlier findings, gain a better understanding of their home environments
and social contexts, and observe their interactions with other family members
and infants.” No data from this second wave of interviews appears to be
presented, or at least is not clear in the current report. Furthermore, if the
purpose of interviewing participants at their homes was additional data collection
as stated in the methods section, rather than convenience, then these
observations/data need to be presented in the results section.
iii. Lastly, please clarify the following questions:
• What was the protocol for participants who endorsed suicidal or homicidal
ideation?
• The authors report themes of “unhealthy thinking” and “unhealthy behavior” to
be considered symptoms of depression. How was unhealthy defined and by
whom, the authors or the participants?
e. The discussion of the findings needs to be consistent with the stated purpose
of the manuscript, namely “to inform the development of a context appropriate
counseling intervention based on the needs and socioeconomic contexts of the
target population.”
The current discussion is a bit disjointed and difficult to read, as it lacks a clear
flow or direction. One way to address this would be by summarizing one more
time the key themes observed in the data, and then discussing how those
themes (psychosocial stressors, symptoms, impact on functioning, and attitudes
towards services) specifically inform the development of a context appropriate
intervention.
In addition, the authors could simply guide the readers through the discussion,
noting how they will first discuss the cultural or contextual background to some of
the themes (e.g. financial insecurity, male migration and family structure, female
disempowerment) and then discuss how the key themes inform the development
of appropriate interventions. Whatever the case, the flow of the argument needs
to be more linear.
f. There is no discussion of the main limitations. One of the main limitations,
briefly outlined in the results section, is the fact that some participants did not
understood the term “depression” and were therefore not able to verbalize or
relate their understanding or experience of symptoms or other behaviors. Please
discuss this, and other limitations in more detail in the discussion.
2. Minor revisions
a. Use terms consistently throughout the manuscript. For example, it appears
that the terms task-shifting and task-sharing are being used interchangeably.
3. Discretionary revisions
a. Consider including the interview guide as an appendix.
Level of interest: An article whose findings are important to those with closely
related research interests
Quality of written English: Needs some language corrections before being
published
Statistical review: No, the manuscript does not need to be seen by a statistician.
Declaration of competing interests:
I declare that I have no competing interests.