The Open Public Health Journal




ISSN: 1874-9445 ― Volume 14, 2021
RESEARCH ARTICLE

Postnatal Depression Screening among Postpartum Women Attending Postnatal Care at Selected Community Health Centres Situated in the Nkangala District of South Africa



Perpetua Modjadji1, *, Kebogile Mokwena1
1 Department of Public Health,School of Health Care Sciences, Sefako Makgatho Health Sciences University, 1 Molotlegi Street, Ga-Rankuwa, 0208, South Africa

Abstract

Background:

The postnatal period represents a time of risk for the emergence of Postnatal Depression (PND), a common maternal mental health problem affecting the well-being of the mother, the newborn and the entire family. Previously, it was postulated that African women were not affected by PND, due to traditional rituals and other cultural factors. However, the assumption has been refuted because of the existence of empirical evidence of PND in Africa and beyond, particularly among women living in socio-economic disadvantaged regions. Despite the growing magnitude of PND reported in South Africa, the country continues to focus more on reducing maternal and infant mortality and promoting infant physical health with limited efforts made to address PND among postpartum women.

Objective:

To screen for PND and determine the associated risk factors among postpartum women in selected community health centres situated in the Nkangala District, South Africa.

Methods:

The study was cross-sectional in design and applied a quantitative approach. Random sampling was used to select the three community health centres in the Nkangala District. A sample of 228 women who had delivered a live infant within 12 weeks of the time of data collection was selected using purposive sampling from the three community health centres. Trained research assistants administered a questionnaire to obtain information on demography and obstetric history, while the Edinburgh Postnatal Depression Scale (EDPS) was used to screen for postnatal depression. An EDPS score of 13+ confirmed the probability of PND. Data was analysed using STATA 14.

Results:

The mean age of women was 28±7 years. The majority of women were single (61%), living in large households (77%), and living in households with a monthly income of less than $291.10 (63%). Most women had normal (i.e., vaginal) delivery (83%) and reported unplanned pregnancies (65%). The probability of developing PND among women was 22%. The odds of developing PND were 3.17 times more likely in women with babies aged six weeks and above (AOR=3.17, CI; 1.39 - 7.23) and 4.50 times more likely in women living in households with an income of less than $115.55 (AOR=4.50, CI; 1.03 - 19.74). Partner/husband violence increased the odds of developing PND (AOR = 6.89, CI; 1.49 - 31.93), as well as a stressful life event (AOR= 3.73, CI: 1.52 - 9.17). Having partner/husband support (AOR=0.10, CI: 0.03 - 0.37) and receiving social support (AOR=0.28, CI: 0.09 - 0.93) reduced the risk of developing PND. A chi-square test showed significant associations between the EDPS scores and partner/husband support, partner/husband having another sexual partner, receiving social support, having a person who offers social support, partner/husband violence, and stressful life events.

Conclusion:

The probability of PND was high among postpartum women in the Nkangala District of the Mpumalanga Province, South Africa. The key determinants for the probability of PND were the age of a baby, household income, partner/husband violence, partner/husband support and receiving social support. Routine screening to identify women who are at risk of PND should be integrated into postnatal care settings for immediate intervention to protect the mother and her baby from different forms of morbidity.

Keywords: Edinburg postnatal depression scale, Screening postnatal depression, Postpartum women, Community health centres, Peri-urban setting, South Africa.


Article Information


Identifiers and Pagination:

Year: 2020
Volume: 13
First Page: 696
Last Page: 704
Publisher Id: TOPHJ-13-696
DOI: 10.2174/1874944502013010696

Article History:

Received Date: 29/6/2020
Revision Received Date: 22/9/2020
Acceptance Date: 28/9/2020
Electronic publication date: 23/12/2020
Collection year: 2020

© 2020 Modjadji & Mokwena.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at Department of Public Health, Sefako Makgatho Health Sciences University, School of Health Care Sciences, PO Box 215, Ga-Rankuwa MEDUNSA, 0204, South Africa; Tel: +2712 521 3664; E-mail: Perpetua.modjadji@smu.ac.za





1. INTRODUCTION AND BACKGROUND

Postnatal Depressio (PND) is an internationally recognized public health concern, defined as a serious maternal mental health problem occurring within four to six weeks after childbirth [1Arifin SRM, Cheyne H, Maxwell M. Review of the prevalence of postnatal depression across cultures. AIMS Public Health 2018; 5(3): 260-95.
[http://dx.doi.org/10.3934/publichealth.2018.3.260] [PMID: 30280116]
-4Pearlstein T, Howard M, Salisbury A, Zlotnick C. Postpartum depression. Am J Obstet Gynecol 2009; 200(4): 357-64.
[http://dx.doi.org/10.1016/j.ajog.2008.11.033] [PMID: 19318144]
]. Globally, PND affects 15% of postnatal women, and the high burden of disease associated with PND is well documented in Low-and-middle-income Countries (LMICs) [2World Health Organization. Maternal mental health and child health and development in low and middle income countries: Report of the meeting; Geneva, Switzerland. 2008..30 January-1 February, 2008.; 2008.., 5Sawyer A, Ayers S, Smith H. Pre- and postnatal psychological wellbeing in Africa: A systematic review. J Affect Disord 2010; 123(1-3): 17-29.
[http://dx.doi.org/10.1016/j.jad.2009.06.027] [PMID: 19635636]
-7Stewart DE, Robertson E, Dennis C-L, Grace SL, Wallington T. Postpartum depression: Literature review of risk factors and interventions 2003.]. In Africa, it was previously postulated that women were protected from PND due to traditional rituals and other cultural factors [8Cox JL. Childbirth as a life event: sociocultural aspects of postnatal depression. Acta Psychiatr Scand Suppl 1988; 344(S344): 75-83.
[http://dx.doi.org/10.1111/j.1600-0447.1988.tb09005.x] [PMID: 3067533]
]. However, it is becoming evident that all women are affected, particularly those living in socio-economically disadvantaged regions [9Tomlinson M, Cooper PJ, Stein A, Swartz L, Molteno C. Post-partum depression and infant growth in a South African peri-urban settlement. Child Care Health Dev 2006; 32(1): 81-6.
[http://dx.doi.org/10.1111/j.1365-2214.2006.00598.x] [PMID: 16398794]
-11Hartley M, Tomlinson M, Greco E, et al. Depressed mood in pregnancy: Prevalence and correlates in two Cape Town peri-urban settlements. Reprod Health 2011; 8(1): 9.
[http://dx.doi.org/10.1186/1742-4755-8-9] [PMID: 21535876]
]. The overall combined prevalence of PND has been estimated to be 16.84% in Africa [12Dadi AFA, Akalu TY, Baraki AG, Wolde HF. Epidemiology of postnatal depression and its associated factors in Africa: A systematic review and meta-analysis. PLoS One 2020; 15(4)e0231940
[http://dx.doi.org/10.1371/journal.pone.0231940] [PMID: 32343736]
], while a range between 6% and 50% has been reported in Sub-Saharan Africa (SSA) [13Adama ND, Foumane P, Olen JPK, Dohbit JS, Meka ENU, Mboudou E. Prevalence and risk factors of postpartum depression in Yaounde, Cameroon. Open J Obstet Gynecol 2015; 5(11): 608.
[http://dx.doi.org/10.4236/ojog.2015.511086]
-15Odinka JI, Nwoke M, Chukwuorji JC, et al. Post-partum depression, anxiety and marital satisfaction: A perspective from Southeastern Nigeria. S Afr J Psychiatr 2018; 24(1): 1109.
[http://dx.doi.org/10.4102/sajpsychiatry.v24i0.1109] [PMID: 30263209]
] and 16.4% to 50.3% in South Africa [16Ramchandani PG, Richter LM, Stein A, Norris SA. Predictors of postnatal depression in an urban South African cohort. J Affect Disord 2009; 113(3): 279-84.
[http://dx.doi.org/10.1016/j.jad.2008.05.007] [PMID: 18571734]
, 17Stellenberg EL, Abrahams JM. Prevalence of and factors influencing postnatal depression in a rural community in South Africa. Afr J Prim Health Care Fam Med 2015; 7(1): 874.
[http://dx.doi.org/10.4102/phcfm.v7i1.874] [PMID: 26842515]
]. Several studies in South Africa have reported variations of PND prevalence among adolescents (26%) [7Stewart DE, Robertson E, Dennis C-L, Grace SL, Wallington T. Postpartum depression: Literature review of risk factors and interventions 2003.], women living with HIV (25% to 45.1%) [18Peltzer K, Shikwane M. Prevalence of postnatal depression and associated factors among HIV-positive women in primary care in Nkangala District, South Africa. South Afr J HIV Med 2011; 12(4): 24-8.
[http://dx.doi.org/10.4102/sajhivmed.v12i4.168]
, 19Mokhele I, Nattey C, Jinga N, Mongwenyana C, Fox MP, Onoya D. Prevalence and predictors of postpartum depression by HIV status and timing of HIV diagnosis in Gauteng, South Africa. PLoS One 2019; 14(4)e0214849
[http://dx.doi.org/10.1371/journal.pone.0214849] [PMID: 30947293]
], in rural settings (47% to 50.3%) [17Stellenberg EL, Abrahams JM. Prevalence of and factors influencing postnatal depression in a rural community in South Africa. Afr J Prim Health Care Fam Med 2015; 7(1): 874.
[http://dx.doi.org/10.4102/phcfm.v7i1.874] [PMID: 26842515]
, 20Robertson E, Grace S, Wallington T, Stewart DE. Antenatal risk factors for postpartum depression: A synthesis of recent literature. Gen Hosp Psychiatry 2004; 26(4): 289-95.
[http://dx.doi.org/10.1016/j.genhosppsych.2004.02.006] [PMID: 15234824]
], peri-urban settlements (30% to 34.7%) [10Cooper PJ, Tomlinson M, Swartz L, Woolgar M, Murray L, Molteno C. Post-partum depression and the mother-infant relationship in a South African peri-urban settlement. Br J Psychiatry 1999; 175(6): 554-8.
[http://dx.doi.org/10.1192/bjp.175.6.554] [PMID: 10789353]
, 11Hartley M, Tomlinson M, Greco E, et al. Depressed mood in pregnancy: Prevalence and correlates in two Cape Town peri-urban settlements. Reprod Health 2011; 8(1): 9.
[http://dx.doi.org/10.1186/1742-4755-8-9] [PMID: 21535876]
], urban areas (16.4%) [16Ramchandani PG, Richter LM, Stein A, Norris SA. Predictors of postnatal depression in an urban South African cohort. J Affect Disord 2009; 113(3): 279-84.
[http://dx.doi.org/10.1016/j.jad.2008.05.007] [PMID: 18571734]
] and different provinces (34.7% to 49.3%) [9Tomlinson M, Cooper PJ, Stein A, Swartz L, Molteno C. Post-partum depression and infant growth in a South African peri-urban settlement. Child Care Health Dev 2006; 32(1): 81-6.
[http://dx.doi.org/10.1111/j.1365-2214.2006.00598.x] [PMID: 16398794]
, 21Mokwena K, Shiba D. Prevalence of postnatal depression symptoms in a primary health care clinic in Pretoria, South Africa: management of health care services. Afr J Physic Health Edu Recreat Dance 2014; 20(Suppl. 1): 116-27.].

The aetiology of PND is complex and includes the incorporation of many factors such as integration of biochemistry, hormonal functioning and genetic history, as well as psychosocial factors such as stressful life events [20Robertson E, Grace S, Wallington T, Stewart DE. Antenatal risk factors for postpartum depression: A synthesis of recent literature. Gen Hosp Psychiatry 2004; 26(4): 289-95.
[http://dx.doi.org/10.1016/j.genhosppsych.2004.02.006] [PMID: 15234824]
]. Symptoms of PND include depressed mood, loss of interest or pleasure in activities, sleep disturbance, feelings of worthlessness or guilt, anxiety, and thoughts of suicide [3American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5®) 2013., 4Pearlstein T, Howard M, Salisbury A, Zlotnick C. Postpartum depression. Am J Obstet Gynecol 2009; 200(4): 357-64.
[http://dx.doi.org/10.1016/j.ajog.2008.11.033] [PMID: 19318144]
]. Untreated PND has negative consequences for both the infant and the mother [22Slomian J, Honvo G, Emonts P, Reginster J-Y, Bruyère O. Consequences of maternal postpartum depression: A systematic review of maternal and infant outcomes. Womens Health (Lond) 2019; 151745506519844044
[http://dx.doi.org/10.1177/1745506519844044] [PMID: 31035856]
]. In mothers, untreated PND affects physical health, psychological health, relationships, and leads to risky behaviours. In infants, it affects anthropometry, physical health, sleep and motor, cognitive, language, emotional, social and behavioural development [22Slomian J, Honvo G, Emonts P, Reginster J-Y, Bruyère O. Consequences of maternal postpartum depression: A systematic review of maternal and infant outcomes. Womens Health (Lond) 2019; 151745506519844044
[http://dx.doi.org/10.1177/1745506519844044] [PMID: 31035856]
]. Untreated PND further affects mother-child interactions through bonding, breastfeeding, and the maternal role [22Slomian J, Honvo G, Emonts P, Reginster J-Y, Bruyère O. Consequences of maternal postpartum depression: A systematic review of maternal and infant outcomes. Womens Health (Lond) 2019; 151745506519844044
[http://dx.doi.org/10.1177/1745506519844044] [PMID: 31035856]
]. In addition, PND victims are twice as likely to experience future episodes of depression over a five year period [23Vigod SN, Villegas L, Dennis CL, Ross LE. Prevalence and risk factors for postpartum depression among women with preterm and low-birth-weight infants: A systematic review. BJOG 2010; 117(5): 540-50.
[http://dx.doi.org/10.1111/j.1471-0528.2009.02493.x] [PMID: 20121831]
].

The risk factors for PND reported in LMICs include socio-economic disadvantage, unintended pregnancy, being younger, being unmarried, lacking intimate partner empathy and support, experiencing intimate partner violence, having insufficient emotional and practical support and, in some settings, giving birth to a female baby, and having a history of mental health problems [24Fisher J, Mello MCd, Patel V, Rahman A. Prevalence and determinants of common perinatal mental disorders in women in low-and lower-middle-income countries: a systematic review. Bulletin of the World Health Organization 2012; 90: 139-49.]. In Africa, the unique risk factors for PND include poor infant nutritional status, low infant birth weight, shorter duration of breastfeeding, diarrhoeal diseases, poor self-rated health, respiratory illness, home delivery, reduced quality of interaction between mothers and infants [25Gold KJ, Spangenberg K, Wobil P, Schwenk TL. Depression and risk factors for depression among mothers of sick infants in Kumasi, Ghana. Int J Gynaecol Obstet 2013; 120(3): 228-31.
[http://dx.doi.org/10.1016/j.ijgo.2012.09.016] [PMID: 23228821]
], and poor HIV care [26Målqvist M, Clarke K, Matsebula T, Bergman M, Tomlinson M. Screening for antepartum depression through community health outreach in Swaziland. J Community Health 2016; 41(5): 946-52.
[http://dx.doi.org/10.1007/s10900-016-0175-9] [PMID: 26942766]
]. In South Africa, researchers have reported associated PND factors to be level of education, financial support by the baby’s father, whether the baby was planned, baby’s health status, partner/husband support, social support, partner/husband being violent, partner/husband alcohol use, and partner/husband having other sexual partners [9Tomlinson M, Cooper PJ, Stein A, Swartz L, Molteno C. Post-partum depression and infant growth in a South African peri-urban settlement. Child Care Health Dev 2006; 32(1): 81-6.
[http://dx.doi.org/10.1111/j.1365-2214.2006.00598.x] [PMID: 16398794]
, 16Ramchandani PG, Richter LM, Stein A, Norris SA. Predictors of postnatal depression in an urban South African cohort. J Affect Disord 2009; 113(3): 279-84.
[http://dx.doi.org/10.1016/j.jad.2008.05.007] [PMID: 18571734]
, 17Stellenberg EL, Abrahams JM. Prevalence of and factors influencing postnatal depression in a rural community in South Africa. Afr J Prim Health Care Fam Med 2015; 7(1): 874.
[http://dx.doi.org/10.4102/phcfm.v7i1.874] [PMID: 26842515]
, 21Mokwena K, Shiba D. Prevalence of postnatal depression symptoms in a primary health care clinic in Pretoria, South Africa: management of health care services. Afr J Physic Health Edu Recreat Dance 2014; 20(Suppl. 1): 116-27.].

The postnatal period represents a time of risk for the emergence of PND, affecting the well-being of the mother, the newborn and the entire family [27Cristescu T, Behrman S, Jones S, Chouliaras L, Ebmeier K. Be vigilant for perinatal mental health problems. The Practitioner 2015; 259(1780): 19-23, 2-3., 28Steen M, Francisco AA. Maternal mental health and wellbeing. Acta Paul Enferm 2019; 32(4): III-VI.
[http://dx.doi.org/10.1590/1982-0194201900049]
]. However, newly birthed mothers are not identified when at risk of having a poor state of well-being, and often the opportunities to detect anxiety, stress and coping problems are missed [28Steen M, Francisco AA. Maternal mental health and wellbeing. Acta Paul Enferm 2019; 32(4): III-VI.
[http://dx.doi.org/10.1590/1982-0194201900049]
]. In South Africa, maternal mental health care, particularly for PND, remains a neglected area [17Stellenberg EL, Abrahams JM. Prevalence of and factors influencing postnatal depression in a rural community in South Africa. Afr J Prim Health Care Fam Med 2015; 7(1): 874.
[http://dx.doi.org/10.4102/phcfm.v7i1.874] [PMID: 26842515]
, 21Mokwena K, Shiba D. Prevalence of postnatal depression symptoms in a primary health care clinic in Pretoria, South Africa: management of health care services. Afr J Physic Health Edu Recreat Dance 2014; 20(Suppl. 1): 116-27., 29Kathree T, Selohilwe OM, Bhana A, Petersen I. Perceptions of postnatal depression and health care needs in a South African sample: the “mental” in maternal health care. BMC Womens Health 2014; 14(1): 140.
[http://dx.doi.org/10.1186/s12905-014-0140-7] [PMID: 25389015]
] and the country continues to focus more on reducing maternal and infant mortality and promoting infant physical health [29Kathree T, Selohilwe OM, Bhana A, Petersen I. Perceptions of postnatal depression and health care needs in a South African sample: the “mental” in maternal health care. BMC Womens Health 2014; 14(1): 140.
[http://dx.doi.org/10.1186/s12905-014-0140-7] [PMID: 25389015]
]. This is despite the growing magnitude of PND reported in South Africa [18Peltzer K, Shikwane M. Prevalence of postnatal depression and associated factors among HIV-positive women in primary care in Nkangala District, South Africa. South Afr J HIV Med 2011; 12(4): 24-8.
[http://dx.doi.org/10.4102/sajhivmed.v12i4.168]
, 19Mokhele I, Nattey C, Jinga N, Mongwenyana C, Fox MP, Onoya D. Prevalence and predictors of postpartum depression by HIV status and timing of HIV diagnosis in Gauteng, South Africa. PLoS One 2019; 14(4)e0214849
[http://dx.doi.org/10.1371/journal.pone.0214849] [PMID: 30947293]
, 21Mokwena K, Shiba D. Prevalence of postnatal depression symptoms in a primary health care clinic in Pretoria, South Africa: management of health care services. Afr J Physic Health Edu Recreat Dance 2014; 20(Suppl. 1): 116-27.]. Thus, this study aimed to screen for PND and further determine the associated risk factors in selected health centres in the peri-urban Nkangala District of the Mpumalanga Province, South Africa. This study identified cases that required referral and further intended to add value to the minimal existing baseline information on PND in the Mpumalanga Province, necessary to influence policy. In South Africa, failing to address PND is regarded as equivalent to a human rights violation [6Wachs TD, Black MM, Engle PL. Maternal depression: A global threat to children’s health, development, and behavior and to human rights. Child Dev Perspect 2009; 3(1): 51-9.
[http://dx.doi.org/10.1111/j.1750-8606.2008.00077.x]
].

2. MATERIALS AND METHODS

2.1. Study Design, Sample Size and Setting

The study used a cross-sectional design with a quantitative approach. This study is part of a larger study in the Department of Public Health at Sefako Makgatho Health Sciences University, titled “Prevalence of postnatal symptoms in primary health care clinics in South Africa”, which was conducted in several provinces of the country. Arrangements to conduct the current study commenced in March 2019, and the study was concluded in December 2019. The study population consisted of women who had delivered a live infant within 12 weeks (three months) of the time of data collection and were attending postnatal care in the Community Health Centres (CHCs) in the Thembisile Hani local municipality, located in the Nkangala District of the Mpumalanga Province, South Africa. The local municipality having seven CHCs and three CHCs, situated in a peri-urban setting, were randomly selected. The database for deliveries in these three CHCs showed that 878 babies were born during the period of March 2019 and April 2020. Rao soft calculator [30Raosoft calulator.. 2020. http://www.raosoft.com/samplesize.html. Accessed on the 15 October 2020.] estimated a minimum representative sample of 209. Purposive sampling was used to select postpartum women and a final sample of 228 was obtained for PND screening.

2.2. Data Collection

Trained research assistants collected data using an adapted questionnaire consisting of demographic and obstetric characteristics, together with a version of the Edinburgh Postnatal Depression Scale (EPDS) [21Mokwena K, Shiba D. Prevalence of postnatal depression symptoms in a primary health care clinic in Pretoria, South Africa: management of health care services. Afr J Physic Health Edu Recreat Dance 2014; 20(Suppl. 1): 116-27.]. Interviews were conducted in the three languages (i.e., English, IsiZulu and Northern Sotho) preferred by the participants. Demographic data collected included age, marital status, education level, employment status, household family size and income, and child grant status. Age in years was classified into two groups, namely below 30 years and ≥ 30 years. Marital status was categorised according to single, cohabiting and ever married. The level of educational status was classified into low literacy (i.e., primary school) and high literacy (i.e., attained secondary school education and beyond). Employment status was classified into unemployed and employed. Family size was categorised into 1-4 and ≥5 members. Monthly household income was categorised into five groups, namely, do not know, <$115.55, $115.93-$288.88, $290.12 - $464.10, and ≥ $464.16, while child grant was categorised as no and yes. Obstetric history included parity (1-2 or >2), planned pregnancy (no or yes), delivery mode (vaginal or cesarean), birthplace (home, clinic or hospital), baby gender (boy or girl), preferred gender (none, boy or girl), baby age (<6 weeks or ≥6 weeks), baby health (good or not good), and breastfeeding (no or yes).

The EPDS is a 10-item self-report scale designed specifically as a screening instrument for the postnatal period and has been validated in South Africa [31Lawrie TA, Hofmeyr GJ, de Jager M, Berk M. Validation of the edinburgh postnatal depression scale on a cohort of south african women. S Afr Med J 1998; 88(10): 1340-4.
[PMID: 9807193]
]. The screening tool collects data to assess the mood of women during the first 12 months after their baby is born, as well as health problems, relationship with husband/partner, and history of intimate partner violence, social support and life stress. Social support is a voluntary act that one individual (the donor) gives to another individual (the recipient), which elicits a positive response in the recipient [32Hupcey JE. Clarifying the social support theory-research linkage. J Adv Nurs 1998; 27(6): 1231-41.
[http://dx.doi.org/10.1046/j.1365-2648.1998.01231.x] [PMID: 9663875]
]. Social support can be given by a family member, friend, husband/partner, and/or others, and it may be given in different forms, like emotional (e.g., empathy, caring, love), instrumental (e.g., financial), and appraisal (e.g., information promoting self-evaluation) [33Logsdon MC, Koniak-Griffin D. Social support in postpartum adolescents: Guidelines for nursing assessments and interventions. J Obstet Gynecol Neonatal Nurs 2005; 34(6): 761-8.
[http://dx.doi.org/10.1177/0884217505281855] [PMID: 16282235]
]. Life stress was defined by having experienced severe stressful life events in the past six months, such as severe financial crisis, death and/or a serious illness of a close person, been a victim of a life-threatening crime, violence or accident, moved to a new place, changed or lost a job. These experiences were grouped into two categories, which are general problems and pregnancy/ relationship problems.

A score within the range of 0 - 9 may indicate the presence of some symptoms of distress that may be short-lived and are less likely to interfere with the day-to-day ability to function at home or at work. However, if these symptoms persist for more than a week or two, further inquiries are warranted. A score within the range of 10 - 12 indicates the presence of symptoms of distress that may be discomforting. A score of 13+ requires further assessment and appropriate management as the likelihood of depression is high. Referral to a psychiatrist/ psychologist may be necessary [34Al-Hejji Z, Al-Khudhair M, Al-Musaileem M, Al-Eithan M. Prevalence and associated risk factors of antenatal depression among women attending antenatal clinics in primary health care centers in the Ministry of Health in Al-Ahsa City, Saudi Arabia. J Family Med Prim Care 2019; 8(12): 3900-7.
[http://dx.doi.org/10.4103/jfmpc.jfmpc_724_19] [PMID: 31879633]
].

3. DATA ANALYSIS

During data analysis, none of the questionnaires had missing data above 10%, and the final sample of 228 women was considered in this paper. Data was stored in Microsoft Excel and analysed using STATA (Intercooled Stata® Version 14, College Station, TX). Descriptive statistics [i.e., mean, Standard Deviation (SD), frequency (n) and percentage (%)] was computed. The outcome measures were an EDPS of 13+, indicating the probability of PND. A chi-square test (χ2) was performed to compare the EDPS across different categories of exposure (risk) factors among mothers, and the results are presented as n (%), χ2 and p-values. Fisher’s exact was applied to variables with expected values lesser than five (5) in a cell. Univariate logistic regression analysis was performed and the purposeful selection process of each variable to be included in the multivariate model considered a cut-off p-value of less than 0.25. The results are presented as crude (i.e., unadjusted) odds ratio (crude OR) with a 95% Confidence Interval (CI) and p-values. Multivariate logistic regression analysis, using a backward stepwise elimination procedure, was used to determine the association of the probability of PND with independent variables. Results are presented as adjusted odds ratio (adjusted OR) with 95% CI and the significance level was considered p < 0.05.

4. RESULTS

4.1. Descriptive Characteristics of Women

The sociodemographic and obstetric characteristics of women are presented in Table 1. The mean age of women was 28 ± 7 years. Fifty-nine percent (59%) of women in this study were aged less than 30 years and 41% were 30 years and above. Most women in this study were single (61%), while 20% of women were married and 19% were cohabiting. Forty-one percent (41%) of women had a low level of literacy, while 59% had a high level, and 80% were employed. Most women lived in households with five or more family members (77%), and a combined household income of less than $288.88 (63%). Only 36% of women were receiving a child support grant. Sixty-three percent (63%) of women in this study had more than two children, with boys (47%) being slightly lower than girls (53%). Most of the women (61%) had babies aged less than six weeks, while 39% had babies aged six weeks and above. Normal (i.e., vaginal) delivery was reported by 83% of women, with most births (65%) occurring in hospitals. Unplanned pregnancies accounted for 65%, with only 10% of babies reported as not in good health, and 90% were breastfed (Table 1).

Table 1
Descriptive characteristics of the study population.


4.2. Comparisons of EDPS Across Different Categories of Exposure (Risk) Factors

Twenty-two percent (22%) of women had EDPS ≥13, which indicated the likelihood of PND, while 11% indicated discomforting symptoms of stress (EDPS of 10-12). EDPS scores were associated with partner/husband support (χ2=25.00, p ≤ 0.0001), partner/husband having another sexual partner in the past 12 months (χ2=14.26, p=0.001), receiving social support (χ2=11.06, p=0.003), and having a person who offered social support (χ2=17.70, p=0.010). In addition, the EPDS scores were also associated with partner/husband violence (χ2=10.25, p=0.046) and severe stressful events (χ2=21.00, p ≤ 0.0001) (Table 2).

4.3. Factors Associated with the Likelihood of Developing PND

In the univariate logistic regression analyses, marital status, household income, parity, baby age and gender, preferred baby gender and breastfeeding were associated with the probability of PND. Further univariate analyses showed that having a partner/husband, partner/husband support, and partner/husband who had other sexual partners in the past 12 months were associated with the likelihood of developing PND. In addition, the probability of PND was associated with receiving social support, having a person who offers support, partner/husband violence and a stressful life event (p < 0.25).

Table 2
Comparisons of EDPS across different categories of exposure (risk) factors.


Table 3
Association of the probability of PND with variables among mothers.


All of the above-mentioned variables were used to build a multivariate model and a backward stepwise elimination procedure was used. Table 3 reports the factors associated with the probability of developing PND, and crude OR and adjusted OR, 95% CI and p-values are presented. From the multivariate logistic analyses, developing PND was significantly associated with the age of the baby, household income, partner/husband support, social support, partner/husband violence and a stressful life event. The odds of developing PND were three times more likely in women with babies aged six weeks and above (AOR=3.17 CI; 1.39 - 7.23) and 4.50 times more likely in women living in households with an income of less than $115.55 (AOR=4.50, CI; 1.03 - 19.74). Partner/husband violence increased the odds of developing PND (AOR = 6.89, CI; 1.49 - 31.93), as well as stressful life events (AOR= 3.73, CI: 1.52 - 9.17). Having a partner/husband support (AOR=0.1, CI: 0.03 - 0.4) and receiving social support (AOR=0.3, CI: 0.1 - 0.9) reduced the probability of PND.

5. DISCUSSION

This study screened for PND and determined the associated risk factors among postpartum women in selected community health centres situated in the Nkangala District of the Mpumalanga Province, South Africa. Consistent with other studies in South Africa and sub-Saharan Africa (SSA), the findings highlight that the likelihood of developing PND among postpartum women was high. The findings further showed that the likelihood of developing PND was associated with several factors such as baby age, household income, partner/husband support, partner/husband having another sexual partner, social support, having a person who offers social support, partner/husband violence, and stressful life events [9Tomlinson M, Cooper PJ, Stein A, Swartz L, Molteno C. Post-partum depression and infant growth in a South African peri-urban settlement. Child Care Health Dev 2006; 32(1): 81-6.
[http://dx.doi.org/10.1111/j.1365-2214.2006.00598.x] [PMID: 16398794]
, 16Ramchandani PG, Richter LM, Stein A, Norris SA. Predictors of postnatal depression in an urban South African cohort. J Affect Disord 2009; 113(3): 279-84.
[http://dx.doi.org/10.1016/j.jad.2008.05.007] [PMID: 18571734]
, 17Stellenberg EL, Abrahams JM. Prevalence of and factors influencing postnatal depression in a rural community in South Africa. Afr J Prim Health Care Fam Med 2015; 7(1): 874.
[http://dx.doi.org/10.4102/phcfm.v7i1.874] [PMID: 26842515]
, 21Mokwena K, Shiba D. Prevalence of postnatal depression symptoms in a primary health care clinic in Pretoria, South Africa: management of health care services. Afr J Physic Health Edu Recreat Dance 2014; 20(Suppl. 1): 116-27., 24Fisher J, Mello MCd, Patel V, Rahman A. Prevalence and determinants of common perinatal mental disorders in women in low-and lower-middle-income countries: a systematic review. Bulletin of the World Health Organization 2012; 90: 139-49.].

The likelihood of PND (22%) among the postpartum women recorded in this study was higher than the estimates reported in some urban settings [16Ramchandani PG, Richter LM, Stein A, Norris SA. Predictors of postnatal depression in an urban South African cohort. J Affect Disord 2009; 113(3): 279-84.
[http://dx.doi.org/10.1016/j.jad.2008.05.007] [PMID: 18571734]
], yet lower than other urban settings [21Mokwena K, Shiba D. Prevalence of postnatal depression symptoms in a primary health care clinic in Pretoria, South Africa: management of health care services. Afr J Physic Health Edu Recreat Dance 2014; 20(Suppl. 1): 116-27.] and peri-urban settlements [10Cooper PJ, Tomlinson M, Swartz L, Woolgar M, Murray L, Molteno C. Post-partum depression and the mother-infant relationship in a South African peri-urban settlement. Br J Psychiatry 1999; 175(6): 554-8.
[http://dx.doi.org/10.1192/bjp.175.6.554] [PMID: 10789353]
, 11Hartley M, Tomlinson M, Greco E, et al. Depressed mood in pregnancy: Prevalence and correlates in two Cape Town peri-urban settlements. Reprod Health 2011; 8(1): 9.
[http://dx.doi.org/10.1186/1742-4755-8-9] [PMID: 21535876]
] in South Africa. However, similar estimates of developing PND have been reported in SSA, such as in Ethiopia and Zimbabwe [35Adamu AF, Adinew YM. Domestic violence as a risk factor for postpartum depression among Ethiopian women: Facility based study. Clin Pract Epidemiol Ment Health 2018; 14: 109-19.
[http://dx.doi.org/10.2174/1745017901814010109] [PMID: 29997678]
, 36Shamu S, Zarowsky C, Roelens K, Temmerman M, Abrahams N. High-frequency intimate partner violence during pregnancy, postnatal depression and suicidal tendencies in Harare, Zimbabwe. Gen Hosp Psychiatry 2016; 38: 109-14.
[http://dx.doi.org/10.1016/j.genhosppsych.2015.10.005] [PMID: 26607330]
] and other LMICs, such as India and China [37Upadhyay RP, Chowdhury R, Aslyeh Salehi , et al. Postpartum depression in India: A systematic review and meta-analysis. Bull World Health Organ 2017; 95(10): 706-717C.
[http://dx.doi.org/10.2471/BLT.17.192237] [PMID: 29147043]
-39Agarwala A, Rao PA, Narayanan P. Prevalence and predictors of postpartum depression among mothers in the rural areas of Udupi Taluk, Karnataka, India: A cross-sectional study. Clin Epidemiol Glob Health 2019; 7(3): 342-5.
[http://dx.doi.org/10.1016/j.cegh.2018.08.009]
]. The prevalence of PND has been reported to be higher in other studies in Africa, mainly Nigeria [15Odinka JI, Nwoke M, Chukwuorji JC, et al. Post-partum depression, anxiety and marital satisfaction: A perspective from Southeastern Nigeria. S Afr J Psychiatr 2018; 24(1): 1109.
[http://dx.doi.org/10.4102/sajpsychiatry.v24i0.1109] [PMID: 30263209]
, 40Chinawa JM, Odetunde OI, Ndu IK, Ezugwu EC, Aniwada EC, Chinawa AT, et al. Postpartum depression among mothers as seen in hospitals in Enugu, South-East Nigeria: An undocumented issue. Pan Afr Med J 2016; 23(1)
[http://dx.doi.org/10.11604/pamj.2016.23.180.8244]
, 41Ukaegbe C, Iteke O, Bakare M, Agbata A. Postpartum depression among Igbo women in an Urban Mission Hospital South East Nigeria. EMJ 2012; 11(1&2): 29-36.] and lower in Ghana, Malawi, Tanzania and Zambia [42Anokye R, Acheampong E, Budu-Ainooson A, Obeng EI, Akwasi AG. Prevalence of postpartum depression and interventions utilized for its management. Ann Gen Psychiatry 2018; 17(1): 18.
[http://dx.doi.org/10.1186/s12991-018-0188-0] [PMID: 29760762]
-45Stewart RC, Bunn J, Vokhiwa M, et al. Common mental disorder and associated factors amongst women with young infants in rural Malawi. Soc Psychiatry Psychiatr Epidemiol 2010; 45(5): 551-9.
[http://dx.doi.org/10.1007/s00127-009-0094-5] [PMID: 19609476]
], as compared to the findings of the current study. In high income and western countries, previous research on PND has recorded a prevalence of between 10% and 20% [46Gavin NI, Gaynes BN, Lohr KN, Meltzer-Brody S, Gartlehner G, Swinson T. Perinatal depression: A systematic review of prevalence and incidence. Obstet Gynecol 2005; 106(5 Pt 1): 1071-83.
[http://dx.doi.org/10.1097/01.AOG.0000183597.31630.db] [PMID: 16260528]
, 47O’Hara MW, McCabe JE. Postpartum depression: Current status and future directions. Annu Rev Clin Psychol 2013; 9: 379-407.
[http://dx.doi.org/10.1146/annurev-clinpsy-050212-185612] [PMID: 23394227]
]. Literature documents that the differences in the prevalence among studies might be because of the effect of social, cultural, lifestyle and racial factors on depression [48Bakhshayesh A. The relationship between sexual satisfaction, general health and marital satisfaction in couples 2010.]. Furthermore, the effect of sample size, study design and diverse regions on the variation in the prevalence of PND has been implicated [12Dadi AFA, Akalu TY, Baraki AG, Wolde HF. Epidemiology of postnatal depression and its associated factors in Africa: A systematic review and meta-analysis. PLoS One 2020; 15(4)e0231940
[http://dx.doi.org/10.1371/journal.pone.0231940] [PMID: 32343736]
, 49Kestenbaum B. Cross-Sectional studies epidemiology and biostatistics: An introduction to clinical research 2019.].

In the current study, the likelihood of PND was significantly associated with baby age, low household income, and lack of partner/husband support, lack of social support, partner/husband violence and stressful life events. The odds of developing PND were 3.17 times more likely in women with babies aged six weeks and above. Researchers have reported that developing PND is directly proportional to the time after delivery. Furthermore, the likelihood of PND in the first two to 12 weeks after delivery increases due to hormonal fluctuation and the new environment of maternity [50Affonso DD, De AK, Horowitz JA, Mayberry LJ. An international study exploring levels of postpartum depressive symptomatology. J Psychosom Res 2000; 49(3): 207-16.
[http://dx.doi.org/10.1016/S0022-3999(00)00176-8] [PMID: 11110992]
, 51Beck CT. State of the Science on postpartum depression: What nurse researchers have contributed--part 1. MCN Am J Matern Child Nurs 2008; 33(2): 121-6.
[http://dx.doi.org/10.1097/01.NMC.0000313421.97236.cf] [PMID: 18327112]
].

Women living in households with an income of less than $115.55 were more likely to develop PND in this study. Socio-economic factors are also of great importance in establishing the risk of developing PND. Having a low income can put immense pressure on an individual and increase stress levels during pregnancy [52O’hara MW, Swain AM. Rates and risk of postpartum depression: A meta-analysis. Int Rev Psychiatry 1996; 8(1): 37-54.
[http://dx.doi.org/10.3109/09540269609037816]
]. However, evidence on the relationship between socio-economic status and mental health is conflicting in developing countries, especially with regards to employment and income [53Ardington C, Case A. Interactions between mental health and socioeconomic status in the South African national income dynamics study. Tydskrif vir studies in ekonomie en ekonometrie= Journal for studies in economics and econometrics 2010; 34(3): 69.]. Living in a lower economic environment has been reported to increase the risk of PND [12Dadi AFA, Akalu TY, Baraki AG, Wolde HF. Epidemiology of postnatal depression and its associated factors in Africa: A systematic review and meta-analysis. PLoS One 2020; 15(4)e0231940
[http://dx.doi.org/10.1371/journal.pone.0231940] [PMID: 32343736]
]. Previous studies have similarly demonstrated associations between common mental disorders and low income [54Patel V, Araya R, de Lima M, Ludermir A, Todd C. Women, poverty and common mental disorders in four restructuring societies. Soc Sci Med 1999; 49(11): 1461-71.
[http://dx.doi.org/10.1016/S0277-9536(99)00208-7] [PMID: 10515629]
, 55Patel V, Kleinman A. Poverty and common mental disorders in developing countries. Bull World Health Organ 2003; 81(8): 609-15.
[PMID: 14576893]
]. Literature documents that women with a low socio-economic status could become underprivileged due to scarcity of financial resources and insufficient health insurance, which leads to stress in LMICs [56Gelaye B, Rondon MB, Araya R, Williams MA. Epidemiology of maternal depression, risk factors, and child outcomes in low-income and middle-income countries. Lancet Psychiatry 2016; 3(10): 973-82.
[http://dx.doi.org/10.1016/S2215-0366(16)30284-X] [PMID: 27650773]
, 57Abdollahi F, Zarghami M, Azhar MZ, Sazlina SG, Lye MS. Predictors and incidence of post-partum depression: A longitudinal cohort study. J Obstet Gynaecol Res 2014; 40(12): 2191-200.
[http://dx.doi.org/10.1111/jog.12471] [PMID: 25132641]
].

In the current study, stressful life events increased the odds of developing PND. Previous studies have reported that the more stressful life events that occur in the perinatal period, the more likely mothers are to develop PND [58Liu CH, Tronick E. Re-conceptualising prenatal life stressors in predicting post-partum depression: Cumulative, specific, and domain specific approaches to calculating risk. Paediatr Perinat Epidemiol 2013; 27(5): 481-90.
[http://dx.doi.org/10.1111/ppe.12072] [PMID: 23930784]
, 59Stone SL, Diop H, Declercq E, Cabral HJ, Fox MP, Wise LA. Stressful events during pregnancy and postpartum depressive symptoms. J Womens Health (Larchmt) 2015; 24(5): 384-93.
[http://dx.doi.org/10.1089/jwh.2014.4857] [PMID: 25751609]
]. Literature documents that during the postpartum period, there is a fall in cortisol and corticotrophin-releasing hormones in the days and weeks after birth and the decrease may be linked to the onset of PND [60Dickens MJ, Pawluski JL. The HPA axis during the perinatal period: Implications for perinatal depression. Endocrinology 2018; 159(11): 3737-46.
[http://dx.doi.org/10.1210/en.2018-00677] [PMID: 30256957]
]. Studies have also shown that the relationship between changes in the hypothalamic-pituitary-adrenal axis and PND is due to lower cortisol levels that are evident in women with PND up to one year postpartum [61Parry BL, Sorenson DL, Meliska CJ, et al. Hormonal basis of mood and postpartum disorders. Curr Womens Health Rep 2003; 3(3): 230-5.
[PMID: 12734034]
-63Szpunar MJ, Parry BL. A systematic review of cortisol, thyroid-stimulating hormone, and prolactin in peripartum women with major depression. Arch Women Ment Health 2018; 21(2): 149-61.
[PMID: 29022126]
].

Experiencing partner/husband violence doubled the odds of developing PND. It has previously been reported that exposure to different forms of partner violence/abuse increases the odds of developing PND among postpartum women in several countries, including LMICs [56Gelaye B, Rondon MB, Araya R, Williams MA. Epidemiology of maternal depression, risk factors, and child outcomes in low-income and middle-income countries. Lancet Psychiatry 2016; 3(10): 973-82.
[http://dx.doi.org/10.1016/S2215-0366(16)30284-X] [PMID: 27650773]
, 64Ross LE, Dennis C-L. The prevalence of postpartum depression among women with substance use, an abuse history, or chronic illness: A systematic review. J Womens Health (Larchmt) 2009; 18(4): 475-86.
[http://dx.doi.org/10.1089/jwh.2008.0953] [PMID: 19361314]
]. Domestic violence before and/or during pregnancy has been reported as a risk factor for PND in South Africa [65Schneider M, Baron E, Davies T, Munodawafa M, Lund C. Patterns of intimate partner violence among perinatal women with depression symptoms in Khayelitsha, South Africa: A longitudinal analysis. Glob Ment Health (Camb) 2018; 5: e13.
[http://dx.doi.org/10.1017/gmh.2018.1] [PMID: 29868233]
], Nigeria [66Okafor CN, Barnett W, Zar HJ, et al. Associations of emotional, physical, or sexual intimate partner violence and depression symptoms among South African women in a prospective cohort study. J Interpers Violence 2018.886260518796522
[http://dx.doi.org/10.1177/0886260518796522] [PMID: 30160637]
], and Ethiopia [35Adamu AF, Adinew YM. Domestic violence as a risk factor for postpartum depression among Ethiopian women: Facility based study. Clin Pract Epidemiol Ment Health 2018; 14: 109-19.
[http://dx.doi.org/10.2174/1745017901814010109] [PMID: 29997678]
], as well as in developed countries such as Canada [67Desmarais SL, Pritchard A, Lowder EM, Janssen PA. Intimate partner abuse before and during pregnancy as risk factors for postpartum mental health problems. BMC Pregnancy Childbirth 2014; 14(1): 132.
[http://dx.doi.org/10.1186/1471-2393-14-132] [PMID: 24708777]
] and Chile [68Quelopana AM. Violence against women and postpartum depression: the experience of Chilean women. Women Health 2012; 52(5): 437-53.
[http://dx.doi.org/10.1080/03630242.2012.687443] [PMID: 22747182]
]. The possible mechanism behind partner violence promoting the development of PND has been explained through the link between traumatic and psychological distress. The enduring stress, low self-esteem, isolation, hopelessness and physical pain that usually accompany partner violence can lead to mental health problems, PND in particular [56Gelaye B, Rondon MB, Araya R, Williams MA. Epidemiology of maternal depression, risk factors, and child outcomes in low-income and middle-income countries. Lancet Psychiatry 2016; 3(10): 973-82.
[http://dx.doi.org/10.1016/S2215-0366(16)30284-X] [PMID: 27650773]
, 69Kabir ZN, Nasreen H-E, Edhborg M. Intimate partner violence and its association with maternal depressive symptoms 6-8 months after childbirth in rural Bangladesh. Glob Health Action 2014; 7(1): 24725.
[http://dx.doi.org/10.3402/gha.v7.24725] [PMID: 25226416]
-71Dillon G, Hussain R, Loxton D, Rahman S. Mental and Physical Health and Intimate Partner Violence against Women: A Review of the Literature. Int J Family Med 2013; 2013313909
[http://dx.doi.org/10.1155/2013/313909] [PMID: 23431441]
].

Psychological factors are also of great importance in the risk of developing PND. An individual’s social context can be protective (i.e., social support), as is observed in this study, with partner/husband support and social support being associated with a decreased likelihood of developing PND. Having support from spouses and other family members was protective against the likelihood of developing PND in the current study, which means that lack of support could predispose women to PND. Several studies in South Africa [18Peltzer K, Shikwane M. Prevalence of postnatal depression and associated factors among HIV-positive women in primary care in Nkangala District, South Africa. South Afr J HIV Med 2011; 12(4): 24-8.
[http://dx.doi.org/10.4102/sajhivmed.v12i4.168]
, 29Kathree T, Selohilwe OM, Bhana A, Petersen I. Perceptions of postnatal depression and health care needs in a South African sample: the “mental” in maternal health care. BMC Womens Health 2014; 14(1): 140.
[http://dx.doi.org/10.1186/s12905-014-0140-7] [PMID: 25389015]
] and other LMICs including other African countries [12Dadi AFA, Akalu TY, Baraki AG, Wolde HF. Epidemiology of postnatal depression and its associated factors in Africa: A systematic review and meta-analysis. PLoS One 2020; 15(4)e0231940
[http://dx.doi.org/10.1371/journal.pone.0231940] [PMID: 32343736]
, 14Dlamini LP, Mahanya S, Dlamini SD, Shongwe MC. Prevalence and factors associated with postpartum depression at a primary healthcare facility in Eswatini. S Afr J Psychiatr 2019; 25(0): 1404.
[http://dx.doi.org/10.4102/sajpsychiatry.v25i0.1404] [PMID: 31745444]
, 72Shrivastava SR, Shrivastava PS, Ramasamy J. Antenatal and postnatal depression: A public health perspective. J Neurosci Rural Pract 2015; 6(1): 116-9.
[http://dx.doi.org/10.4103/0976-3147.143218] [PMID: 25552868]
, 73Mohamad Yusuff AS, Tang L, Binns CW, Lee AH. Prevalence and risk factors for postnatal depression in Sabah, Malaysia: A cohort study. Women Birth 2015; 28(1): 25-9.
[http://dx.doi.org/10.1016/j.wombi.2014.11.002] [PMID: 25466643]
] have confirmed that women who lack support from their partners and close family members at delivery or during care of the newborn had higher odds of developing PND because they were less satisfied and more stressed [74Al Dallal F, Grant I. Postnatal depression among Bahraini women: prevalence of symptoms and psychosocial risk factors. EMHJ-Eastern Mediterran Health J 2012; 18(5): 439-45.
[http://dx.doi.org/10.26719/2012.18.5.432]
].

6. LIMITATIONS

This study was undertaken at a single point in time and thus provides a snapshot screening, which can only estimate emotional status and the likelihood of developing PND. Although sampling in this study required a deliberate choice of women in the postpartum period, we acknowledge the use of non-probability sampling (i.e., purposive), which has a tendency of introducing bias and impedes the ability to draw inferences about a population [75Etikan I, Musa SA, Alkassim RS. Comparison of convenience sampling and purposive sampling. Am J Theor Appl Stat 2016; 5(1): 1-4.
[http://dx.doi.org/10.11648/j.ajtas.20160501.11]
]. In addition, the effectiveness and approach of snapshot screening for PND in detecting maternal mental health problems have been raised as a concern. The study is applicable only to peri-urban settings and cannot be extrapolated to populations with different settings and characteristics. Nonetheless, this study used a validated EDPS tool to estimate the probability of PND among postpartum women who attended the three randomly selected community health centres in the Thembisile Hani local municipality in the Nkangala District of the Mpumalanga Province, South Africa, at one point in time.

CONCLUSION

The probability of PND was high among the postpartum women attending community health centres in the Nkangala District. The key determinants for the probability of PND among women were the age of a baby, household monthly income, partner/husband violence, partner/husband support and receiving social support. This study supports the need to improve maternal and child health and to integrate routine screening into the postnatal care setting to identify women who are at risk of developing PND and for immediate interventions to save the mother and her baby from different forms of morbidity. However, concerns such as medicalisation of childbirth and motherhood and stigma being attached to screening for PND exist and should be considered in future studies.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

All procedures involving human subjects were approved by the Sefako Makgatho Health Sciences University Research and Ethics Committee, South Africa [SMUREC/H/101/2016: IR]. Permission to conduct the study was obtained from the Department of Health, Mpumalanga Province in South Africa.

HUMAN AND ANIMAL RIGHTS

Not applicable.

CONSENT FOR PUBLICATION

Written informed consent was obtained from each participant prior to the study.

AVAILABILITY OF DATA AND MATERIALS

The dataset analysed during the current study is available from the corresponding author [P.M] and can be made available upon a reasonable request.

FUNDING

The South African Medical Research (SAMRC), through the Research Capacity Development programme, supported the research reported in this publication.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

The authors would like to thank the Department of Health, Mpumalanga Province (South Africa) for permission to conduct the study in community health centres. We also appreciate the participants from these selected community health centres. We acknowledge the research assistants for collecting data.

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