OpenUCT :: Browsing by Author "Honikman, Simone"

Browsing by Author "Honikman, Simone"

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Open Access
Adapting a perinatal empathic training method from South Africa to Germany
(BioMed Central, 2018-06-19) Knapp, Caprice; Honikman, Simone; Wirsching, Michael; Husni-Pascha, Gidah; Hänselmann, Eva
Background: Maternal mental health conditions are prevalent across the world. For women, the perinatal period is associated with increased rates of depression and anxiety. At the same time, there is widespread documentation of disrespectful care for women by maternity health staff. Improving the empathic engagement skills of maternity healthcare workers may enable them to respond to the mental health needs of their clients more effectively. In South Africa, a participatory empathic training method, the “Secret History” has been used as part of a national Department of Health training program with maternity staff and has showed promising results. For this paper, we aimed to describe an adaptation of the Secret History empathic training method from the South African to the German setting and to evaluate the adapted training. Methods: The pilot study occurred in an academic medical center in Germany. A focus group (n = 8) was used to adapt the training by describing the local context and changing the materials to be relevant to Germany. After adapting the materials, the pilot training was conducted with a mixed group of professionals (n = 15), many of whom were trainers themselves. A pre-post survey assessed the participants’ empathy levels and attitudes towards the training method. Results: In adapting the materials, the focus group discussion generated several experiences that were considered to be typical interpersonal and structural challenges facing healthcare workers in maternal care in Germany. These experiences were crafted into case scenarios that then formed the basis of the activities used in the Secret History empathic training pilot. Evaluation of the pilot training showed that although the participants had high levels of empathy in the pre-phase (100% estimated their empathic ability as high or very high), 69% became more aware of their own emotional experiences with patients and the need for self-care after the training. A majority, or 85%, indicated that the training was relevant to their work as clinicians and trainers, that it reflected the German situation, and that it may be useful ultimately to address emotional distress in mothers in the perinatal phase. Conclusions: Our study suggests that it is possible to adapt an empathic training method developed in a South African setting and apply it to a German setting, and that it is well received by participants who may be involved in healthcare worker training. More research is needed to assess adaptations with other groups of healthcare workers in different settings and to assess empathic skill outcomes for participants and women in the perinatal period.
Open Access
Antenatal depressive symptoms and perinatal complications: a prospective study in rural Ethiopia
(BioMed Central, 2017-08-22) Bitew, Tesera; Hanlon, Charlotte; Kebede, Eskinder; Honikman, Simone; Fekadu, Abebaw
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.
Open Access
Antenatal depressive symptoms and utilisation of delivery and postnatal care: a prospective study in rural Ethiopia
(BioMed Central, 2017-06-29) Bitew, Tesera; Hanlon, Charlotte; Kebede, Eskinder; Honikman, Simone; Onah, Michael N; Fekadu, Abebaw
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.
Open Access
Brief problem-solving therapy for antenatal depressive symptoms in primary care in rural Ethiopia: protocol for a randomised, controlled feasibility trial
(2021-01-30) Bitew, Tesera; Keynejad, Roxanne; Myers, Bronwyn; Honikman, Simone; Medhin, Girmay; Girma, Fikirte; Howard, Louise; Sorsdahl, Katherine; Hanlon, Charlotte
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 .
Open Access
Characteristics of perinatal depression in rural central, India: a cross-sectional study
(BioMed Central, 2018-11-12) Rathod, Sujit D; Honikman, Simone; Hanlon, Charlotte; Shidhaye, Rahul
Background Perinatal depression is associated with negative effects on child behavioural, cognitive and emotional development, birth outcomes, and physical growth. In India, increased priority accorded to mental health programs mean it is now possible to reduce the population-level burden of perinatal depression. In this secondary analysis of two studies, we aimed to describe the epidemiological features of depression among community- and facility-based samples of perinatal women from rural central India, and to describe the help-seeking behaviours from those women who screened positive for depression. Methods The Community Study was a multi-round population-based cross-sectional survey (n = 6087). The Facility Study was a multi-round facility-based cross-sectional survey (n = 1577). Both studies were conducted in Sehore District, Madhya Pradesh between 2013 and 2017. Field workers conducted structured interviews with perinatal women. The questionnaire had sections relating to sociodemographic characteristics, depression screening using the Patient’s Health Questionnaire (PHQ9), treatment seeking for depression-related symptoms, and disability. Using data pooled from both studies, we tested each characteristic for association with the total screening score and with screening positive for depression. Results We identified 224 perinatal women from the Community Study and 130 perinatal women from the Facility Study, of whom 8.8% and 18.5% screened positive for depression, respectively. For the continuous PHQ9 score, there was evidence of a “U” shaped association with age, and positive associations with pregnancy, disability score, suicidality and being a health facility attendee. For the binary PHQ9 score, there was evidence of positive associations with pregnancy, disability score, suicidality and being a health facility attendee. Conclusions This study highlights where the largest population-level variations in perinatal depression symptoms are present in this Indian sample, for which mental health service provision should be made a priority. Epidemiological evidence generated by this study, as well as new evidence on peer-delivered interventions for perinatal depression, must be utilized by policy-makers to prioritize mental health services for mothers along with maternal and child health services.
Open Access
Clients' returning for cervical screening results : a focus group study exploring the reasons why women spontaneously return for their results at the Khayelitsha Cervical Cancer Screening Project
(2004) Honikman, Simone; Denny, Lynette
Cervical cancer is integrally associated with the problems of poverty in the developing world. It is the most common cancer cause of death among women in these regions. In South Africa, the lifetime risk for black African women developing this cancer is 1 in 26. Rates for white women are 1 in 80. Cervical cancer is largely preventable by screening for its precursor stages. However, cervical cancer screening in low-resource settings has only rarely been initiated and sustained. There are many barriers to the establishment of mass, organised screening programmes. This study focuses on one aspect of the screening process: the clients' receiving of their screening results. For the most part, health providers in resource-poor settings rely on the clients themselves to return to the health service to receive their results and consequent arrangements for further care. Understanding those factors that impact upon clients' returning is therefore crucial to the success of the screening. The Khayelitsha Cervical Cancer Screening Project (KCCSP) was established in 1996 to evaluate alternative screening tests to cytology. In addition, the Project has evaluated alternative screening algorithms to the traditional approach of cytology, colposcopy, biopsy and treatment, specifically, a "screen and treat" approach. This approach is expected to overcome some of the many barriers to women participating in screening programmes. This study aims to investigate the phenomenon of the high spontaneous return rate in the setting of the KCCSP. Motivating and deterring factors are sought, both logistical and psychological, in the clients' personal contexts, as well as those related to their experiences of the Project. Exploratory study in the interpretive research paradigm located in a peri-urban informal settlement outside Cape Town, South Africa. Volunteer sample of women enrolled in the KCCSP returning for their first set of screening results. Four focus groups were conducted in Xhosa, facilitated by a Xhosa-speaking social worker from Khayelitsha who has experience in focus group work. Discussion guidelines were followed. The discussions were tape recorded and later transcribed before being translated into English by the facilitator. Analysis of the data draws on elements of both the grounded theory and the systems theory paradigms. The findings reveal that, for the most part, women present to the KCCSP in order to have general gynaecological problems addressed. Returning for results represents an extension of this need. Obstacles to returning include problems with access to the clinic, the need to care for dependents at home and the competing priorities of housework and generating income. Factors that promote the returning for results are the imperative to understand the cause of, and have treatment for pre-existing gynaecological symptoms which cause high levels of anxiety. Related to this, women are motivated to have confirmed or refuted the diagnosis of a fatal disease, including cancer and HIV. Certain qualities and design features of the KCCSP facilitate women returning fOr their results. These include the perceived superior quality of interpersonal communication between Project staff and clients and the efficient manner in which results are made available to clients. Other promotive or obstructive factors that playa role in cervical screening service utilisation include; client attitudes towards traditional healers, a prevalent fear of hysterectomy, concern about privacy and gossip and a suspicious attitude toward caring health workers. Women enrolled in the KCCSP have a personal health agenda with a different focus to that of the Project. Chronic gynaecological problems are frequently experienced and give rise to levels of anxiety about their being signs of serious pathology. Women have not had these fears or the symptoms adequately addressed at other health services. The need to have these issues properly managed represents a large enough motivating force to overcome many of the practical and psychological obstacles to utilisation of the KCCSP. The Project represents for women a general women's health service.
Open Access
Developing a task-sharing psychological intervention to treat mild to moderate symptoms of perinatal depression and anxiety in South Africa: a mixed-method formative study
(2021-03-15) Boisits, Sonet; Abrahams, Zulfa; Schneider, Marguerite; Honikman, Simone; Kaminer, Debra; Lund, Crick
Background Symptoms of depression and anxiety are highly prevalent amongst perinatal women in low-resource settings of South Africa, but there is no access to standardised counselling support for these conditions in public health facilities. The aim of this study is to develop a task-sharing psychological counselling intervention for routine treatment of mild to moderate symptoms of perinatal depression and anxiety in South Africa, as part of the Health Systems Strengthening in sub-Saharan Africa (ASSET) study. Methods We conducted a review of manuals from seven counselling interventions for depression and anxiety in low- and middle-income countries and two local health system training programmes to gather information on delivery format and common counselling components used across task-sharing interventions. Semi-structured interviews were conducted with 20 health workers and 37 pregnant women from four Midwife Obstetric Units in Cape Town to explore perceptions and needs relating to mental health. Stakeholder engagements further informed the intervention design and appropriate service provider. A four-day pilot training with community-based health workers refined the counselling content and training material. Results The manual review identified problem-solving, psychoeducation, basic counselling skills and behavioural activation as common counselling components across interventions using a variety of delivery formats. The interviews found that participants mostly identified symptoms of depression and anxiety in behavioural terms, and lay health workers and pregnant women demonstrated their understanding through a range of local idioms. Perceived causes of symptoms related to interpersonal conflict and challenging social circumstances. Stakeholder engagements identified a three-session counselling model as most feasible for delivery as part of existing health care practices and community health workers in ward-based outreach teams as the best placed delivery agents. Pilot training of a three-session intervention with community-based health workers resulted in minor adaptations of the counselling assessment method. Conclusion Input from health workers and pregnant women is a critical component of adapting existing maternal mental health protocols to the context of routine care in South Africa, providing valuable data to align therapeutic content with contextual needs. Multisector stakeholder engagements is vital to align the intervention design to health system requirements and guidelines.
Open Access
Domestic and intimate partner violence among pregnant women in a low resource setting in South Africa: a facility-based, mixed methods study
(BioMed Central, 2018-07-04) Field, Sally; Onah, Michael; van Heyningen, Thandi; Honikman, Simone
Background Rates 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. Methods We 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). Results The 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. Conclusions This 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.
Open Access
HIV-infected infants born to women who tested HIV-negative during pregnancy
(2004) Nuttall, James; Eley, Brian; Honikman, Simone
The prevention of mother-to-child transmission (PMTCT) programme in the Western Cape is said to have achieved 100% coverage.1 This implies that all pregnant women who attend an antenatal health care facility in the public sector are offered voluntary counselling and testing (VCT). Uptake varies but has been reported to be as high as 90% in the Guguletu district.1 Currently, women who test HIV-positive qualify for the nevirapine-based PMTCT programme. Transmission rates below 10% have been achieved in some health districts (Médecins sans Frontières — unpublished research). Mothers of several perinatally infected infants recently diagnosed in our institution have indicated that they tested HIV-negative during their pregnancy. In some cases we have verified their statements with clinical and laboratory documentation. There is a need to determine the frequency of this phenonomen. Pregnant women are encouraged to book at their nearest antenatal clinic before 5 months’ gestation, although this frequently does not occur. We are concerned about women who do book early and test HIV-negative. Some may be in the ‘window period’ of the infection or become infected from a sexual partner during the latter stages of pregnancy. At present, there is no provision within the PMTCT programme for repeat HIV testing during pregnancy. Some women may, therefore, be denied the benefits of prevention measures including counselling on infant feeding options.
Open Access
Maternal mental health in primary care in five low- and middle-income countries: a situational analysis
(BioMed Central, 2016-02-16) Baron, Emily C; Hanlon, Charlotte; Mall, Sumaya; Honikman, Simone; Breuer, Erica; Kathree, Tasneem; Luitel, Nagendra P; Nakku, Juliet; Lund, Crick; Medhin, Girmay; Patel, Vikram; Petersen, Inge; Shrivastava, Sanjay; Tomlinson, Mark
Background: The integration of maternal mental health into primary health care has been advocated to reduce the mental health treatment gap in low- and middle-income countries (LMICs). This study reports findings of a cross-country situation analysis on maternal mental health and services available in five LMICs, to inform the development of integrated maternal mental health services integrated into primary health care. Methods: The situation analysis was conducted in five districts in Ethiopia, India, Nepal, South Africa and Uganda, as part of the Programme for Improving Mental Health Care (PRIME). The analysis reports secondary data on the prevalence and impact of priority maternal mental disorders (perinatal depression, alcohol use disorders during pregnancy and puerperal psychosis), existing policies, plans and services for maternal mental health, and other relevant contextual factors, such as explanatory models for mental illness. Results: Limited data were available at the district level, although generalizable data from other sites was identified in most cases. Community and facility-based prevalences ranged widely across PRIME countries for perinatal depression (3–50 %) and alcohol consumption during pregnancy (5–51 %). Maternal mental health was included in mental health policies in South Africa, India and Ethiopia, and a mental health care plan was in the process of being implemented in South Africa. No district reported dedicated maternal mental health services, but referrals to specialised care in psychiatric units or general hospitals were possible. No information was available on coverage for maternal mental health care. Challenges to the provision of maternal mental health care included; limited evidence on feasible detection and treatment strategies for maternal mental disorders, lack of mental health specialists in the public health sector, lack of prescribing guidelines for pregnant and breastfeeding women, and stigmatising attitudes among primary health care staff and the community. Conclusions: It is difficult to anticipate demand for mental health care at district level in the five countries, given the lack of evidence on the prevalence and treatment coverage of women with maternal mental disorders. Limited evidence on effective psychosocial interventions was also noted, and must be addressed for mental health programmes, such as PRIME, to implement feasible and effective services.
Open Access
Perinatal deaths in Lusaka, Zambia : mothers’ experiences and perceptions of care
(2014) Singogo, Irene Miti; Honikman, Simone; Mwape, Lonia
Includes abstract. Includes bibliographical references.
Open Access
Perinatal mental health care in a rural African district, Uganda: a qualitative study of barriers, facilitators and needs
(BioMed Central, 2016-07-22) Nakku, Juliet E M; Okello, Elialilia S; Kizza, Dorothy; Honikman, Simone; Ssebunnya, Joshua; Ndyanabangi, Sheila; Hanlon, Charlotte; Kigozi, Fred
Background: Perinatal mental illness is a common and important public health problem, especially in low and middle-income countries (LMICs). This study aims to explore the barriers and facilitators, as well as perceptions about the feasibility and acceptability of plans to deliver perinatal mental health care in primary care settings in a low income, rural district in Uganda. Methods: Six focus group discussions comprising separate groups of pregnant and postpartum women and village health teams as well as eight key informant interviews were conducted in the local language using a topic guide. Transcribed data were translated into English, analyzed, and coded. Key themes were identified using a thematic analysis approach. Results: Participants perceived that there was an important unmet need for perinatal mental health care in the district. There was evidence of significant gaps in knowledge about mental health problems as well as negative attitudes amongst mothers and health care providers towards sufferers. Poverty and inability to afford transport to services, poor partner support and stigma were thought to add to the difficulties of perinatal women accessing care. There was an awareness of the need for interventions to respond to this neglected public health problem and a willingness of both community- and facility-based health care providers to provide care for mothers with mental health problems if equipped to do so by adequate training. Conclusion: This study highlights the acceptability and relevance of perinatal mental health care in a rural, lowincome country community. It also underscores some of the key barriers and potential facilitators to delivery of such care in primary care settings. The results of this study have implications for mental health service planning and development for perinatal populations in Uganda and will be useful in informing the development of integrated maternal mental health care in this rural district and in similar settings in other low and middle income countries.
Metadata only
Perinatal Mental Health project
(2014-09-29) Honikman, Simone; Baron, Emily; Field, Sally; Meintjies, Ingrid; van Heyningen, Thandi
The Perinatal Mental Health Project (PMHP) addresses mental illness among pregnant and postnatal women and girls. The aim of PMHP is to ensure all women in South Africa have access to mental health care during and after pregnancy, as a routine part of their health care. Maternal mental illnesses, particularly common mental disorders such as depression and anxiety, are very common in low-income and informal settings. While maternal mental illness affects 10% to 15% of women in developed countries, prevalence is almost 40% in South Africa. Most of the women in South Africa who experience maternal mental illness are poor, from disadvantaged communities who face many challenges in accessing health services and treatment.
Open Access
Perinatal suicidal ideation and behaviour: psychiatry and adversity
(Springer, 2016) Onah, Michael Nnachebe; Field, Sally; Bantjes, Jason; Honikman, Simone
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.
Open Access
Predictors of alcohol and other drug use among pregnant women in a peri-urban South African setting
(BioMed Central, 2016-05-04) Onah, Michael N; Field, Sally; van Heyningen, Thandi; Honikman, Simone
Background: Alcohol 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. Methods: The 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. Results: Of 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. Conclusions: This 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.
Open Access
Problem solving therapy (PST) tailored for intimate partner violence (IPV) versus standard PST and enhanced usual care for pregnant women experiencing IPV in rural Ethiopia: protocol for a randomised controlled feasibility trial
(2020-06-01) Keynejad, Roxanne C; Bitew, Tesera; Sorsdahl, Katherine; Myers, Bronwyn; Honikman, Simone; Medhin, Girmay; Deyessa, Negussie; Sevdalis, Nick; Tol, Wietse A; Howard, Louise; Hanlon, Charlotte
Background In rural Ethiopia, 72% of women are exposed to lifetime intimate partner violence (IPV); IPV is most prevalent during pregnancy. As well as adversely affecting women’s physical and mental health, IPV also increases the risk of child morbidity and mortality associated with maternal depression, thus making antenatal care an important opportunity for intervention. Adapting generic, task-shared, brief psychological interventions for perinatal depression and anxiety to address the needs and experiences of women affected by IPV may improve acceptability to women and feasibility for health workers. This randomised controlled feasibility trial will compare brief problem solving therapy (PST) specifically adapted for pregnant women experiencing IPV (PST-IPV) with standard PST and enhanced usual care to determine the feasibility of a future fully powered randomised controlled trial. Methods Seventy-five pregnant women scoring five or more on the Patient Health Questionnaire, endorsing a tenth question about functional impact and reporting past-year IPV, will be recruited from antenatal care clinics in predominantly rural districts in Ethiopia. Consenting participants will be randomised to either four sessions of PST-IPV, four sessions of standard PST or information about sources of support (enhanced usual care) in a three-arm design. The interventions will be delivered by trained, supervised antenatal care staff using a task-sharing model. Assessments will be made at baseline and after 9 weeks by masked outcome assessors and will include measures of depression symptoms (primary outcome), post-traumatic stress, anxiety symptoms, functional impact, past-month IPV and hypothesised mediators (secondary outcomes). A mixed-method process evaluation will determine the feasibility of a future randomised controlled trial, assess the feasibility, acceptability, fidelity and quality of implementation of PST-IPV, generate testable hypotheses about causal mechanisms, and identify potential contextual factors influencing outcomes. Discussion Despite mental health being a critical concern for women experiencing IPV, there is limited evidence for brief, task-shared psychological interventions adapted for their needs in low- and middle-income countries. Contextually tailored interventions for pregnant women experiencing IPV in low- and middle-income countries require development and process evaluation. This randomised controlled feasibility trial will yield results on the feasibility of conducting a fully powered trial, relevant to researchers, primary and antenatal care clinicians in resource-limited settings. Trial registration Pan-African clinical trials registry: PACTR202002513482084. Prospectively registered on 13 December 2019.
Open Access
Stakeholder perspectives on antenatal depression and the potential for psychological intervention in rural Ethiopia: a qualitative study
(2020-06-22) Bitew, Tesera; Keynejad, Roxanne; Honikman, Simone; Sorsdahl, Katherine; Myers, Bronwyn; Fekadu, Abebaw; Hanlon, Charlotte
Background Psychological interventions for antenatal depression are an integral part of evidence-based care but need to be contextualised for respective sociocultural settings. In this study, we aimed to understand women and healthcare workers’ (HCWs) perspectives of antenatal depression, their treatment preferences and potential acceptability and feasibility of psychological interventions in the rural Ethiopian context. Methods In-depth interviews were conducted with women who had previously scored above the locally validated cut-off (five or more) on the Patient Health Questionnaire during pregnancy (n = 8), primary healthcare workers (HCWs; nurses, midwives and health officers) (n = 8) and community-based health extension workers (n = 7). Translated interview transcripts were analysed using thematic analysis. Results Women expressed their distress largely through somatic complaints, such as a headache and feeling weak. Facility and community-based HCWs suspected antenatal depression when women reported reduced appetite, sleep problems, difficulty bonding with the baby, or if they refused to breast-feed or were poorly engaged with antenatal care. Both women and HCWs perceived depression as a reaction (“thinking too much”) to social adversities such as poverty, marital conflict, perinatal complications and losses. Depressive symptoms and social adversities were often attributed to spiritual causes. Women awaited God’s will in isolation at home or talked to neighbours as coping mechanisms. HCWs’ motivation to provide help, the availability of integrated primary mental health care and a culture among women of seeking advice were potential facilitators for acceptability of a psychological intervention. Fears of being seen publicly during pregnancy, domestic and farm workload and staff shortages in primary healthcare were potential barriers to acceptability of the intervention. Antenatal care providers such as midwives were considered best placed to deliver interventions, given their close interaction with women during pregnancy. Conclusions Women and HCWs in rural Ethiopia linked depressive symptoms in pregnancy with social adversities, suggesting that interventions which help women cope with real-world difficulties may be acceptable. Intervention design should accommodate the identified facilitators and barriers to implementation.
Open Access
Stepped care for maternal mental health: a case study of the perinatal mental health project in South Africa
(Public Library of Science, 2012) Honikman, Simone; van Heyningen, Thandi; Field, Sally; Baron, Emily; Tomlinson, Mark
Common mental disorders such as anxiety and depression are the third leading causes of disease burden globally for women between 14 and 44 years of age [1]. By 2030, these are expected to rise to first place, ranked above heart disease and road traffic injuries [2]. A recent systematic review reveals that maternal mental disorders are approximately three times more prevalent in low- and middle-income countries (LMICs) than in high-income countries (HICs), where the related burden of disease estimates range between 5.2% and 32.9% [3],4. In HICs, maternal suicide is the leading cause of death during the perinatal period, and while there is a relative dearth of information about maternal suicide in LMICs, the estimates are similarly high [5],[6]. Untreated maternal mental illness affects infant and child growth [7] and the quality of child care [8], resulting in compromised child development [4],[9]. Community-based epidemiological studies in South Africa have shown high prevalence rates of depressed mood amongst pregnant and postnatal women. In a low-income, informal settlement outside of Cape Town, 39% of pregnant women screened positive on the Edinburgh Postnatal Depression Scale (EPDS) for depressed mood [10] and 34.7% of postnatal women were diagnosed with depression [11]. In a rural area of KwaZulu-Natal province with high HIV prevalence, 47% of women were diagnosed with depression in their third trimester of pregnancy [12].
Open Access
Task sharing of a psychological intervention for maternal depression in Khayelitsha, South Africa: study protocol for a randomized controlled trial
(BioMed Central, 2014-11-21) Lund, Crick; Schneider, Marguerite; Davies, Thandi; Nyatsanza, Memory; Honikman, Simone; Bhana, Arvin; Bass, Judith; Bolton, Paul; Dewey, Michael; Joska, John; Kagee, Ashraf; Myer, Landon; Petersen, Inge; Prince, Martin; Stein, Dan J; Thornicroft, Graham; Tomlinson, Mark; Alem, Atalay; Susser, Ezra
Background: Maternal depression carries a major public health burden for mothers and their infants, yet there is a substantial treatment gap for this condition in low-resourced regions such as sub-Saharan Africa. To address this treatment gap, the strategy of “task sharing” has been proposed, involving the delivery of interventions by non-specialist health workers trained and supervised by specialists in routine healthcare delivery systems. Several psychological interventions have shown benefit in treating maternal depression, but few have been rigorously evaluated using a task sharing approach. The proposed trial will be the first randomised controlled trial (RCT) evaluating a task sharing model of delivering care for women with maternal depression in sub-Saharan Africa. The objective of this RCT is to determine the effectiveness and cost-effectiveness of a task sharing counseling intervention for maternal depression in South Africa. Methods/Design: The study is an individual-level two-arm RCT. A total of 420 depressed pregnant women will be recruited from two ante-natal clinics in a low-income township area of Cape Town, using the Edinburgh Postnatal Depression Scale to screen for depression; 210 women will be randomly allocated to each of the intervention and control arms. The intervention group will be given six sessions of basic counseling over a period of 3 to 4 months, provided by trained community health workers (CHW)s. The control group will receive three monthly phone calls from a CHW trained to conduct phone calls but not basic counseling. The primary outcome measure is the 17-Item Hamilton Depression Rating Scale (HDRS-17). The outcome measures will be applied at the baseline assessment, and at three follow-up points: 1 month before delivery, and 3 and 12 months after delivery. The primary analysis will be by intention-to-treat and secondary analyses will be on a per protocol population. The primary outcome measure will be analyzed using linear regression adjusting for baseline symptom severity measured using the HDRS-17. Discussion: The findings of this trial can provide policy makers with evidence regarding the effectiveness and cost-effectiveness of structured psychological interventions for maternal depression delivered by appropriately trained and supervised non-specialist CHWs in sub-Saharan Africa. Trial registration Clinical Trials (ClinicalTrials.gov): NCT01977326 , registered on 24/10/2013; Pan African Clinical Trials Registry ( http://www.pactr.org ): PACTR201403000676264 , registered on 11/10/2013.
Open Access
Validation of a brief mental health screening tool for pregnant women in a low socio-economic setting
(2019-12-09) Abrahams, Zulfa; Schneider, Marguerite; Field, Sally; Honikman, Simone
Abstract Background In South Africa, the prevalence of symptoms of common mental disorders (CMD), i.e. depression, anxiety and suicidal thoughts are high. This study aimed to use a cognitive interviewing technique to validate the content and structure of a 4-item screening tool, to adapt the tool accordingly, and to use receiver operating curve (ROC) analysis to determine the optimum cut-point for identifying pregnant women with symptoms of CMD. Methods We conducted a mixed method study at a Midwife Obstetric Unit in Cape Town. Women attending the clinic for their first antenatal visit during the recruitment period, whose first language was English, Afrikaans or isiXhosa, were invited to participate. A 4-item screening tool was administered in the first language of the interviewee, after which a cognitive interviewing technique was used to examine the question-response processes and considerations used by respondents as they formed answers to the screening tool questions. The Edinburgh Postnatal Depression Scale (EPDS) was used to identify women with symptoms of CMD. Results A 2-week recall period performed well. Questions about (1) being unable to stop worrying, or thinking too much, (2) feeling down, depressed or hopeless, and (3) having thoughts and plans to harm yourself, were well understood. The question that referred to feeling little interest or pleasure in doing things, was poorly understood across all languages. Using ROC analysis with the EPDS as the reference standard, and a cut-point of ≥13, we showed that a 3-item version of the screening tool was able to correctly classify 91% of the women screened. Conclusions Cognitive interviewing enabled testing and refining of the language and constructs of an ultra-brief screening tool. The shortened, 3-item tool is well understood and effective at identifying pregnant women with symptoms of CMD, across the three most commonly spoken languages and cultures in Cape Town.