Background In low and middle-income countries (LMIC), common mental disorders affecting pregnant women receive low priority, despite their disabling effect on maternal functioning and negative impact on child health and development. We investigated the prevalence of risk factors for antenatal depression among women living in adversity in a low-resource, urban setting in Cape Town, South Africa. Methods The MINI Neuropsychiatric Interview (MINI Plus) was used to measure the diagnostic prevalence of depression amongst women attending their first antenatal visit at a primary-level, community-based clinic. Demographic data were collected followed by administration of questionnaires to measure psychosocial risk. Analysis examined the association between diagnosis of depression and psychosocial risk variables, and logistic regression was used to investigate predictors for major depressive episode (MDE). Results Among 376 women participating, the mean age was 26 years. The MINI-defined prevalence of MDE was 22%, with 50% of depressed women also expressing suicidality. MDE diagnosis was significantly associated with multiple socioeconomic and psychosocial risk factors, including a history of depression or anxiety, food insecurity, experience of threatening life events and perceived support from family. Limitations The use of self-report measures may have led to recall bias. Retrospective collection of clinical data limited our ability to examine some known risk factors for mental distress. Conclusions These findings confirm the high prevalence of MDE among pregnant women in LMIC settings. Rates of depression may be increased in settings where women are exposed to multiple risks. These risk factors should be considered when planning maternal mental health interventions.

Purpose Anxiety is highly prevalent in many populations; however, the burden of anxiety disorders among pregnant women in low-resource settings is not well documented. We investigated the prevalence and predictors of antenatal anxiety disorders among low-income women living with psychosocial adversity. Methods Pregnant women were recruited from an urban, primary level clinic in Cape Town, South Africa. The MINI Plus diagnostic interview assessed prevalence of anxiety disorders. Four self-report questionnaires measured psychosocial characteristics. Logistic regression models explored demographic and socioeconomic characteristics, psychosocial risk factors and psychiatric comorbidity as predictors for anxiety disorders. Results Among 376 participants, the prevalence of any anxiety disorder was 23%. Although 11% of all women had post-traumatic stress disorder, 18% of the total sample was diagnosed with other anxiety disorders. Multivariable analysis revealed several predictors for anxiety including: a history of mental health problems (Adjusted Odds Ratio [AOR]: 4.11; 95% confidence interval (CI): 2.03–8.32), MDE diagnosis (AOR: 3.83; CI 1.99–7.31), multi-gravidity (AOR: 2.87; CI: 1.17–7.07), food insecurity (AOR: 2.57; CI: 1.48–4.46), unplanned and unwanted pregnancy (AOR: 2.14; CI: 1.11–4.15), pregnancy loss (AOR: 2.10; CI: 1.19–3.75); and experience of threatening life events (AOR: 1.30; CI: 1.04–1.57). Increased perceived social support appeared to reduce the risk for antenatal anxiety (AOR: 0.95; CI: 0.91–0.99). Conclusion A range of antenatal anxiety disorders are prevalent amongst pregnant women living in low-resource settings. Women who experience psychosocial adversity may be exposed to multiple risk factors, which render them vulnerable to developing antenatal anxiety disorders.

Pregnant women are at increased risk for suicidal ideation and behaviours (SIB) compared to the general population. To date, studies have focused on the psychiatric correlates of SIB with lesser attention given to the associated contextual risk factors, particularly in low- and middle-income countries. We investigated the prevalence and associated psychiatric and socio-economic contextual factors for SIB among pregnant women living in low resource communities in South Africa. Three hundred seventy-six pregnant women were evaluated using a range of tools to collect data on socio-economic and demographic factors, social support, life events, interpersonal violence and mental health diagnoses. We examined the significant risk factors for SIB using univariate, bivariate and logistic regression analyses (p ≤ 0.05). The 1-month prevalence of SIB was 18%. SIB was associated with psychiatric illness, notably major depressive episode (MDE) and any anxiety disorder. However, 67% of pregnant women with SIB had no MDE diagnosis, and 65% had no anxiety disorder, while 54% had neither MDE nor anxiety disorder diagnoses. Factors associated with SIB included lower socio-economic status, food insecurity, interpersonal violence, multiparousity, and lifetime suicide attempt. These findings focus attention on the importance of socio-economic and contextual factors in the aetiology of SIB and lend support to the idea that suicide risk should be assessed independently of depression and anxiety among pregnant women.

BackgroundIn South Africa, community service following medical training serves as a mechanism for equitable distribution of health professionals and their professional development. Community service officers are required to contribute a year towards serving in a public health facility while receiving supervision and remuneration. Although the South African community service programme has been in effect since 1998, little is known about how placement and practical support occur, or how community service may impact future retention of health professionals.MethodsNational, cross-sectional data were collected from community service officers who served during 2009 using a structured self-report questionnaire. A Supervision Satisfaction Scale (SSS) was created by summing scores of five questions rated on a three-point Likert scale (orientation, clinical advising, ongoing mentorship, accessibility of clinic leadership, and handling of community service officers’ concerns). Research endpoints were guided by community service programmatic goals and analysed as dichotomous outcomes. Bivariate and multivariate logistical regressions were conducted using Stata 12.ResultsThe sample population comprised 685 doctors and dentists (response rate 44%). Rural placement was more likely among unmarried, male, and black practitioners. Rates of self-reported professional development were high (470 out of 539 responses; 87%). Participants with higher scores on the SSS were more likely to report professional development. Although few participants planned to continue work in rural, underserved communities (n = 171 out of 657 responses, 25%), those serving in a rural facility during the community service year had higher intentions of continuing rural work. Those reporting professional development during the community service year were twice as likely to report intentions to remain in rural, underserved communities.ConclusionsDespite challenges in equitable distribution of practitioners, participant satisfaction with the compulsory community service programme appears to be high among those who responded to a 2009 questionnaire. These data offer a starting point for designing programmes and policies that better meet the health needs of the South African population through more appropriate human resource management. An emphasis on professional development and supervision is crucial if South Africa is to build practitioner skills, equitably distribute health professionals, and retain the medical workforce in rural, underserved areas.

BackgroundRates of violence against women are reported to be highest in Africa compared to other continents. We aimed to determine associations between mental illness, demographic, psychosocial and economic factors with experience of intimate partner violence (IPV) among pregnant women in a low resource setting in Cape Town and to explore the contextual elements pertaining to domestic violence.MethodsWe recruited adult women attending antenatal services at a primary-level maternity facility. Demographic, socioeconomic and psychosocial data were collected by questionnaire. The Expanded Mini- International Neuropsychiatric Interview (MINI) Version 5.0.0 was used to assess mental health status and the Revised Conflict Tactic Scale (CTS2) used to assess IPV in the six months prior to the study. Non-parametric tests, Wilcoxon sum of rank test, Fisher Exact and two sample T test and multicollinearity tests were performed. Descriptive, bivariate and logistic regression analyses were conducted to identify associations between the outcome of interest and key predictors. A probability value of p ≤ 0.05 was selected. From counselling case notes, a thematic content analysis was conducted to describe contextual factors pertaining to forms of domestic violence (DV).ResultsThe prevalence of IPV was 15% of a sample of 376 women. Women who were food insecure, unemployed, in stable but unmarried relationships, had experienced any form of past abuse and were not pleased about the current pregnancy were more likely to experience IPV. MINI-defined mental health problems and a history of mental illness were significantly associated with IPV. Qualitative analysis of 95 counselling case notes revealed that DV within the household was not limited to intimate partners and, DV in this context was often perceived as ‘normal’ behaviour by the participants.ConclusionsThis study contributes towards a greater understanding of the risk profile for IPV amongst pregnant women in low-income settings. Adversity, including food insecurity and mental ill-health are closely associated with IPV during the antenatal period. Advocates against violence against pregnant women are advised to consider that violence in the home may be perpetrated by non-intimate partners and may by enabled by a pervasive belief in the acceptability of the violence.

Out-of-pocket (OOP) payments have severe consequences for health care access and utilisation and are especially catastrophic for the poor. Although women comprise the majority of the poor in Nigeria and globally, the implications of OOP payments for health care access from a gender perspective have received little attention. This study seeks to fill this gap by using a combination of quantitative and qualitative analysis to investigate the gendered impact of OOPs on healthcare utilisation in south-eastern Nigeria. 411 households were surveyed and six single-sex Focus Group Discussions conducted. This study confirmed the socioeconomic and demographic vulnerability of female-headed households (FHHs), which contributed to gender-based inter-household differences in healthcare access, cost burden, choices of healthcare providers, methods of funding healthcare and coping strategies. FHHs had higher cost burdens from seeking care and untreated morbidity than male-headed households (MHHs) with affordability as a reason for not seeking care. There is also a high utilisation of patent medicine vendors (PMVs) by both households (PMVs are drug vendors that are unregulated, likely to offer very low-quality treatment and do not have trained personnel). OOP payment was predominantly the means of healthcare payment for both households, and households spoke of the difficulties associated with repaying health-related debt with implications for the medical poverty trap. It is recommended that the removal of user fees, introduction of prepayment schemes, and regulating PMVs be considered to improve access and provide protection against debt for FHHs and MHHs. The vulnerability of widows is of special concern and efforts to improve their healthcare access and broader efforts to empower should be encouraged for them and other poor households.

BackgroundAlcohol and other drugs (AOD) use among pregnant women have been associated with adverse health outcomes for mother and child, during and after pregnancy. Factors associated with AOD use among women include age, poverty, unemployment, and interpersonal conflict. Few studies have looked at demographic, economic, and psychosocial factors as predictors of AOD use among pregnant women in low-income, peri-urban settings. The study aimed to determine the association between these risk factors and alcohol and drug use among pregnant women in Hanover Park, Cape Town.MethodsThe study was undertaken at a Midwife Obstetric Unit providing primary-level maternity services in a resource-scarce area of South Africa. 376 adult women attending the unit were recruited and a multi-tool questionnaire administered. Demographic, socioeconomic and life events data were collected. The Expanded Mini-International Neuropsychiatric Interview Version 5.0.0 was used to assess alcohol abuse and other drugs use, depression, anxiety, and suicidal ideation. Descriptive and bivariate analyses were conducted to examine the associations between predictor variables. Non-parametric tests, Wilcoxon sum of rank test, Fisher Exact and two sample T test and multicollinearity tests were performed. Logistic regression was conducted to identify associations between the outcome of interest and key predictors. A probability value of p ≤ 0.05 was selected.ResultsOf the total number of pregnant women sampled, 18 % reported current AOD use. Of these, 18 % were currently experiencing a major depressive episode, 19 % had a current anxiety diagnosis, and 22 % expressed suicidal ideation. Depression, anxiety, suicidality, food insecurity, interpersonal violence, relationship dynamics, and past mental health problems were predictors of AOD use.ConclusionsThis study has confirmed the vulnerability of pregnant women in low-income, peri-urban settings to alcohol abuse and other drugs use. Further, the association between diagnosed depression and anxiety, suicidality, and AOD use among these women may reflect how complex environmental factors support the coexistence of multiple mental health problems. These problems place mothers and their infants at high risk for poor health and development outcomes. The results have implications for planning appropriate interventions.

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