Depression among pregnant women testing for HIV in rural South Africa
Rochat, Tamsen Jean
ENGLISH ABSTRACT: Pregnancy is a vulnerable time in settings such as sub-Saharan Africa, and is associated
with exposure to a multitude of physiological, social and psychological risks. High HIV prevalence, and the fact that many women will test for HIV for the first time during their pregnancy, has raised concern about women‘s psychological health during pregnancy. Depression during the antenatal period is of public health concern as it has been shown to be associated with poorer foetal and delivery outcomes, risky behaviours, and poorer uptake of antenatal care. Antenatal depression is a predictor of postnatal depression, and postnatal depression has been associated with poor maternal sensitivity and attachment in mothers which is known to result in increased behavioural and developmental difficulties in children. The aim of this research was to provide a clear, in depth and culturally sensitive understanding of the manifestation of depression in pregnant women in a rural area with high HIV prevalence in South Africa. The research method included a diagnostic assessment of depression in 109 women in their third trimester of pregnancy, and an in-depth qualitative examination of the contextual framework within which HIV testing and depression are experienced with a sub-sample of 56 women. The quantitative results demonstrated that the prevalence of antenatal depression was high (46.7%), with close to half of the women being diagnosed with depression. Presentations of depression most frequently included disturbances in mood, loss of interest and suicide ideation. Symptoms which overlap with common side effects of pregnancy such as loss of energy and weight change did not result in an overestimation of depression. Likewise, very little evidence of the somatisation of depression, or particular cultural barriers to the diagnosis of depression based on DSM-IV criteria was found. Rates of suicide ideation were high and equally common among HIV positive as HIV negative women. Factors significantly associated with depression included living within a family homestead, access to a regular source of income and practical support from a partner. Both income and partner support had a negative association with depression. Living away from a family or parental home had a positive association with depression. The results showed that the Edinburgh Postnatal Depression Scale (EPDS) was effective in identifying depression and that a shorter three item version was as effective as longer versions. A positive score for depressed mood on the EPDS was significantly associated with HIV,
suggesting that the EPDS is a good screening tool for elevated psychological risks among HIV positive women post HIV testing. Qualitative results showed that having an unsupportive partner and the occurrence of relationship or familial conflict played an important role in the development of emotional distress during pregnancy and resulted in a high number of unwanted pregnancies. Partner and familial conflict was intertwined with cultural practices which govern the acceptability of childbearing among unmarried women and the social recognition of partnerships and paternal responsibilities. Testing for HIV was considered a stressful life event for all women regardless of their HIV status and was a particularly negative life event for women who tested HIV positive or for women who had concerns over partner infidelity. Disclosure among HIV positive women frequently lead to increased partnership conflict. Qualitative findings suggested that depression and emotional distress after HIV testing did interfere with women‘s ability to engage with prevention messages. Women who were coping well with learning their HIV positive status had high levels of family disclosure and subsequent family support in common. The implication of this research is that it is important that public health programmes screen for depression among childbearing women. These data suggests that a shorter three item version of the EPDS along with screening for partner and family support or conflict would effectively detect most women at high risk for depression. Likewise, public health interventions for women with depression which are implemented in primary health care facilities and in isolation of the partnership and familial context within which depression occurs are not likely to be effective. Further research is needed to establish the precise prevalence of antenatal and postnatal depression in women at high risk for HIV; to validate the effectiveness of a shorter screening tool in resource limited settings; and to establish risk and protective factors, and trimester specific risks which could inform the design of cost effective interventions in poorly resourced settings. AFRIKAANSE OPSOMMING: Swangerskap in Afrika, suid van die Sahara, is ŉ kwesbare tydperk met blootstelling aan ŉ menigte fisiologiese, sosiale en sielkundige risiko‘s. Die hoë voorkoms van HIV en die feit dat baie vrouens gedurende swangerskap vir die eerste keer vir HIV wil toets, het ‗n besorgdheid oor vrouens se sielkundige gesondheid gedurende swangerskap laat ontstaan.
Depressie gedurende die voorgeboortelike periode is van belang vir publieke gesondheid, want daar is bewyse wat dui op ‗n verband tussen depressie en swakker fetale en geboorte resultate, riskante gedrag en verminderde gebruik van voorgeboortelike sorg . Voorgeboortelike depressie is ŉ indikasie van moontlike nageboortelike depressie en nageboortelike depressie word geassosieer met swak moederlike sensitiwiteit en die gebrekkige vorming van ‗n band tussen moeder en kind; wat reeds bewys is om te lei tot verhoogde gedrags- en ontwikkelingsprobleme in kinders. Die doel van hierdie navorsing was om ŉ duidelike, indiepte en kulturele-sensitiewe begrip van die manifestasie van depressie in swanger vroue in ŉ landelike omgewing met hoë HIV voorkoms in Suid Afrika te verkry. Die navorsingsmetode sluit in ŉ simptomatiese beraming van depressie by 109 vroue in hul derde trimester van swangerskap en ŉ indiepte kwalitatiewe ondersoek na die kontekstuele raamwerk waarbinne HIV toetse en depressie ondervind word met ŉ sub-steekproef van 56 vrouens.
Die bevinding was dat die voorkoms van voorgeboortelike depressie hoog was, 46.7 %, met feitlik die helfte van die vrouens wat met depressie gediagnoseer is. In die meeste gevalle het die voorkoms van depressie gepaard gegaan met ŉ verandering in gemoedstoestand, ŉ verlies aan belangstelling en selfmoordgedagtes. Simptome wat ooreenstem met algemene newe-effekte van swangerskap, soos verlies aan energie en verandering in gewig, het nie bygedra tot ŉ oorberekening van depressie nie. Soortgelyk is baie min bewyse gevind dat somatosasie van depressie, of spesifieke kulturele grense, tot die diagnose van depressie gebaseer op DSM-IVkriteria bydra. Die oorweging van selfmoord was hoog en algemeen tussen beide HIV-positiewe en HIV-negatiewe vouens. Faktore wat aansienlik met depressie geassosieer word, sluit in om in ŉ familiegroep te bly, toegang tot ŉ vaste bron van inkomste en die praktiese ondersteuning van ŉ lewensmaat. Beide inkomste en die ondersteuning van ŉ lewensmaat het ŉ negatiewe verbintenis met depressive. Om nie by familie of in ŉ ouerhuis te bly nie het ŉ positiewe assosiasie met depressive. Alhoewel HIV-status verband hou met depressie, was dit nie uitermate die geval nie, alhoewel daar ŉ gebrek aan statistiese kragdoeltreffendheid was om die effek van HIV vas te stel, gegee die beperkte grootte van die steekproef.
Die resultate het getoon dat die EPDS graderingsinstrument effektief was om depressie te identifiseer en dat ŉ korter driepunt weergawe daarvan net so effektief was soos die langer weergawe. ŉ Positiewe telling vir ŉ depressiewe gemoedstoestand op die EPDS het ŉ betekenisvolle assosiasie met HIV en dui daarop dat die EPDS ŉ goeie graderingsinstrument is vir verhoogde sielkundige risiko by HIV-positiewe vrouens, selfs al is HIV-positiewe vrouens in dié steekproef statistieksgewys nie meer geneig tot depressie as HIV-negatiewe vrouens nie.
Kwalitatiewe resultate toon dat ŉ lewensmaat wat nie ondersteunend is nie en die voorkoms van verhoudings- of familiekonflik ŉ belangrike rol speel in die ontwikkeling van emosionele angs gedurende swangerskap en dit het gelei tot ŉ groot aantal ongewenste swangerskappe. Konflik met ŉ lewensmaat en met familie was verweefd met kulturele gebruike wat die aanvaarbaarheid van geboortes onder ongetroude vrouens beheer en die sosiale erkenning van verhoudings en die vader se verantwoordelikhede. ŉ HIV-toets is as ŉ stresvolle lewensgebeurtenis beskou deur alle vroue, ongeag van hulle HIV-status en was ŉ besondere negatiewe lewensgebeurtenis vir vroue wat HIV-positief getoets het of vir vroue wat bekommerd was oor hulle lewensmaats se getrouheid. Onthulling van die HIV-status van positiewe vrouens het gereeld tot verhoogde konflik in verhoudings gelei. Kwalitatiewe bevindings dui daarop dat depressie en emosionele angs na ŉ HIV-toets inmeng met ŉ vrou se vermoë om ag te slaan op voorkomingsboodskappe. Vroue wat die kennis van hulle HIV-positiewe status goed hanteer het, het hoë vlakke van bekendmaking van hulle status en die ondersteuning van hulle familie in gemeen.
Die implikasie van die navorsing is dat dit belangrik is vir publieke gesondheidsorgprogramme om te toets vir depressie onder swanger vroue. Die resultate dui daarop dat ŉ korter driepunt weergawe van die EPDS, saam met ŉ ondersoek na die ondersteuning van of konflik met ŉ lewensmaat en familie, effektief kan wees om vroue met ŉ hoë risiko vir depressie te identifiseer. Soortgelyk, publieke gesondheidsingryping in primêre gesondheidsorg fasiliteite vir vroue met depressie wat in isolasie van die lewensmaat en familie konteks, waar depressie voorkom geadministreer word, is onwaarskynlik om te slaag. Bevindings onderskryf die belangrikheid van ondersteuning vir die familie om effektief te kan reageer en herstel van stresvolle faktore soos onbeplande swangerskappe en HIV-diagnose, in ŉ konteks wat swaar deur HIV geaffekteer word, aangesien dit ŉ voorkomende effek op depressie kan hê.
Verdere navorsing is nodig om die presiese voorkoms van voorgeboortelike en nageboortelike depressie in vrouens met ŉ hoë blootstelling aan HIV vas te stel; om die sukses van ŉ korter graderingsinstrument in arm omgewings te staaf; en om die risiko en beskermende faktore vas te stel en trimester spesifieke risiko‘s wat die ontwerp van ŉ koste-effektiewe ingryping in gebiede met ontoereikende hulpbronne kan beïnvloed. Description:
Thesis (PhD)--University of Stellenbosch, 2011.
Doctoral Degrees (Psychology) 
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