Prevalence and predictors of depressive symptoms among postpartum women by HIV status and timing of HIV diagnosis in Gauteng, South Africa. Dorina Onoya1, Idah Mokhele1, Cornelius Nattey1, Constance Mongwenyana1, Nelly Jinga1, Given Mohomi1, Matthew P. Fox1,2,3 Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa. Departments of Global Health, and Epidemiology, Boston University School of Public Health, Boston, Massachusetts. Department of Epidemiology, Boston University School of Public Health

Background Postpartum depression (PPD) is one of the leading non-obstetric causes of maternal postpartum morbidity globally. Prevalence rates of PPD in high income countries are between 10- 15%. Recent studies (2015-2016) in South Africa have demonstrated prevalence of 30-50%. Globally almost 50% of PPD cases are undiagnosed, with only 30% of diagnosed cases receiving treatment. Untreated PPD can lead to chronic depression, disruptions of family and marital relationships, and can cause long-term health and developmental problems for children born to affected mothers.

Background PPD has been found to be elevated in the context of HIV (40%). South Africa and other LMIC have the world largest burden of HIV. Globally, young women and girls make up more than half (52%)of the of all adults living with HIV, and HIV positive women also have double the risk of depression than their male counterparts. PPD in the context of high HIV burden is a barrier in achieving maternal and child health; and HIV care and treatment program goals There needs to be a better understanding of how prevalence and predictors of depressive symptoms compares by HIV status and timing of HIV diagnosis among postpartum women.

Study aims To determine the prevalence and predictors of postpartum depression by HIV status and timing of HIV diagnosis among postpartum women.

Study design and population A cross-sectional study among adult women attending their first post- natal visit (3-6 days after delivery) at four Midwife Obstetrics Units (MOUs) in the Gauteng province of South Africa. Inclusion criteria: Adult women (>=18 years) Having been seen for 3-6 days postnatal visit at the selected MOU Well (physically/psychologically) enough to complete a questionnaire Willing to provide informed consent Participants were recruited via referrals from the health care providers (nurses) and interviewed on the day of enrolment.

Data collection Statistical analysis Postpartum depression was measured using the CES-D 10 scale (Cronbach α = 0.8), a 10 questions scale measuring general depressive symptoms experienced up to 7 days prior to the interview A mean score (score range 1 to 3) was calculated and categorised as low depression (0-1) or medium (1-2) & high depression (2-3). Variables assessed included socio-demographic factors Source of most income, employment status, type of accommodation, and perceived social support (high or medium). Number of children dependants (own and others’), and support during pregnancy and expected child care support postpartum. HIV status and timing of HIV diagnosis (current or prior in-pregnancy, pre-pregnancy) Statistical analysis Modified Poisson with robust standard errors was used to determine predictors of PPD. Adjusted relative risk (aRR) and 95% confidence intervals (CIs) are reported

Baseline socio-demographic data Factor HIV negative Diagnosed during latest pregnancy In-pregnancy diagnosis with prior HIV care/ART Pre-pregnancy diagnosis with prior HIV care/ART Total n (col %) Age   18-25 182.0 (39.6) 63.0 (28.8) 11.0 (12.9) 7.0 (6.8) 263.0 (30.3) 26-30 145.0 (31.5) 75.0 (34.2) 29.0 (34.1) 25.0 (24.3) 274.0 (31.6) 31-35 93.0 (20.2) 51.0 (23.3) 32.0 (37.6) 40.0 (38.8) 216.0 (24.9) >35 40.0 (8.7) 30.0 (13.7) 13.0 (15.3) 31.0 (30.1) 114.0 (13.1) Gender (baby) Male 225.0 (48.8) 114.0 (51.6) 43.0 (50.6) 46.0 (44.7) 428.0 (49.2) Female 236.0 (51.2) 107.0 (48.4) 42.0 (49.4) 57.0 (55.3) 442.0 (50.8) Highest level of schooling completed Tertiary level 61.0 (13.2) 34.0 (15.4) 7.0 (8.2) 11.0 (10.7) 113.0 (13.0) Matric 146.0 (31.7) 53.0 (24.0) 19.0 (22.4) 20.0 (19.4) 238.0 (27.4) Highschool 234.0 (50.8) 126.0 (57.0) 55.0 (64.7) 63.0 (61.2) 478.0 (54.9) Primary school or less 20.0 (4.3) 8.0 (3.6) 4.0 (4.7) 9.0 (8.7) 41.0 (4.7) Current marital status Married 124.0 (27.0) 37.0 (16.8) 18.0 (21.2) 23.0 (22.5) 202.0 (23.3) In a relationship (living together) 178.0 (38.7) 103.0 (46.8) 41.0 (48.2) 45.0 (44.1) 367.0 (42.3) In a relationship (not living together) 139.0 (30.2) 67.0 (30.5) 21.0 (24.7) 30.0 (29.4) 257.0 (29.6) Not in a relationship 19.0 (4.1) 13.0 (5.9) 5.0 (5.9) 4.0 (3.9) What is your current employment status? Employed-work all day 113.0 (24.5) 70.0 (31.7) 28.0 (32.9) 33.0 (32.0) 244.0 (28.0) Employed-shift work 41.0 (8.9) 18.0 (8.1) 10.0 (9.7) 76.0 (8.7) Unemployed (not job hunting) 127.0 (27.5) 32.0 (14.5) 16.0 (15.5) 186.0 (21.4) Unemployed (job hunting) 180.0 (39.0) 101.0 (45.7) 39.0 (45.9) 44.0 (42.7) 364.0 (41.8) Where do you get MOST of your money from? Paid job, salary or business 108.0 (23.5) 78.0 (35.5) 26.0 (30.6) 29.0 (28.4) 241.0 (27.8) Government grant 5.0 (1.1) 12.0 (11.8) 38.0 (4.4) Spouse/ partner 280.0 (61.0) 108.0 (49.1) 56.0 (54.9) 486.0 (56.1) Parents/ relatives 66.0 (14.4) 26.0 (11.8) 5.0 (4.9) 101.0 (11.7) Perceived social support High 298.0 (64.6) 46.0 (54.1) 56.0 (54.4) 514.0 (59.1) Medium 163.0 (35.4) 47.0 (45.6) 356.0 (40.9) The study consisted of a total of 872 mothers. 61.9% were between the ages of 18-30 years and, over 80% had at least some secondary school level of education. A total of 202 mothers were married, with a higher proportion of HIV negative mother (61.4%) married compared to HIV positive women (38.6%) 36.8% of the mothers were employed, with a slight majority (51.9%) of HIV positive mothers employed 59.2% of the mothers had high perceived social support.

Baseline contextual data Factor HIV negative Diagnosed during latest pregnancy In-pregnancy diagnosis with prior HIV care/ART Pre-pregnancy diagnosis with prior HIV care/ART Total n (col %) Where do you live?   Own home 173.0 (37.6) 90.0 (40.9) 38.0 (44.7) 44.0 (42.7) 345.0 (39.7) Family's home 153.0 (33.3) 74.0 (33.6) 26.0 (30.6) 33.0 (32.0) 286.0 (32.9) Friends or house-share 134.0 (29.1) 56.0 (25.5) 21.0 (24.7) 26.0 (25.2) 237.0 (27.3) Who do you live with? With partner/spouse 293.0 (63.8) 138.0 (63.0) 60.0 (71.4) 65.0 (63.7) 556.0 (64.4) Parents/relatives 147.0 (32.0) 70.0 (32.0) 15.0 (17.9) 28.0 (27.5) 260.0 (30.1) Alone/with children 19.0 (4.1) 11.0 (5.0) 9.0 (10.7) 9.0 (8.8) 48.0 (5.6) Where is your primary house? Current house 168.0 (36.4) 83.0 (37.7) 33.0 (38.8) 46.0 (44.7) 330.0 (38.0) Rural area 12.0 (2.6) 4.0 (1.8) 2.0 (2.4) 3.0 (2.9) 21.0 (2.4) Another province 108.0 (23.4) 59.0 (26.8) 27.0 (26.2) 220.0 (25.3) Another country 147.0 (31.9) 57.0 (25.9) 15.0 (17.6) 23.0 (22.3) 242.0 (27.8) Same province 26.0 (5.6) 17.0 (7.7) 9.0 (10.6) 4.0 (3.9) 56.0 (6.4) How many children do you have (older than this new baby)? 0 children 138.0 (31.1) 41.0 (19.2) 4.0 (4.8) 5.0 (5.0) 188.0 (22.3) ≥1 children 306 (68.9) 173 (80,9) 80 (95.2) 96 (95.2) 655 (77.7) How many children other than your own do you care for and live with? 340.0 (86.1) 181.0 (92.3) 62.0 (81.6) 78.0 (88.6) 661.0 (87.5) 55 (13.9) 15 (7.7) 14 (18.4) 10 (11.3) 94 (12.5) Was this last pregnancy planned? No 209.0 (45.3) 119.0 (53.8) 46.0 (54.1) 64.0 (62.1) 438.0 (50.3) Yes 252.0 (54.7) 102.0 (46.2) 39.0 (45.9) 39.0 (37.9) 432.0 (49.7) Baby's father involvement in the pregnancy? Very involved 404.0 (87.6) 190.0 (86.0) 70.0 (82.4) 86.0 (83.5) 750.0 (86.2) Somewhat involved 35.0 (7.6) 14.0 (6.3) 7.0 (8.2) 10.0 (9.7) 66.0 (7.6) Not at all involved 22.0 (4.8) 8.0 (9.4) 7.0 (6.8) 54.0 (6.2) Who was your greatest support base during this pregnancy? Partner 247.0 (53.9) 127.0 (57.7) 53.0 (63.1) 60.0 (58.3) 487.0 (56.3) Baby father(if not partner) 99.0 (21.6) 47.0 (21.4) 12.0 (14.3) 21.0 (20.4) 179.0 (20.7) Family members 101.0 (22.1) 41.0 (18.6) 18.0 (21.4) 18.0 (17.5) 178.0 (20.6) Other 11.0 (2.4) 5.0 (2.3) 1.0 (1.2) Who will help the most in the care of your baby? 187.0 (40.7) 96.0 (43.4) 42.0 (49.4) 49.0 (47.6) 374.0 (43.1) 88.0 (19.2) 43.0 (19.5) 13.0 (15.3) 19.0 (18.4) 163.0 (18.8) 173.0 (37.7) 78.0 (35.3) 29.0 (34.1) 32.0 (31.1) 312.0 (35.9) 19.0 (2.2) Over 50% of the mothers were originally from outside Gauteng 27.7% came from other provinces and 27.8% were from other countries Among the international migrants, 39.3% were HIV positive. Over 50% of the mothers did not plan their latest pregnancy Over 80% of the mothers reported that the baby’s father was very involved in the pregnancy

Prevalence of depressive symptoms Characteristic Low Depression Medium to high Depression Total n (col %) HIV status and timing of diagnosis   HIV negative 148 (42.8) 313 (59.7) 461 (53.0) Diagnosed during latest pregnancy 98 (28.3) 123 (23.5) 221 (25.4) In-pregnancy diagnosis with prior HIV care/ART 41 (11.9) 44 (8.4) 85 (9.8) Pre-pregnancy diagnosis with prior HIV care/ART 59 (17.0) 103 (11.8) The study consisted of 411 (47.0%) HIV positive and 461 (53.0%) HIV negative mothers The majority (54.0%) of HIV positive mothers were diagnosed during the latest pregnancy Among those who already knew their HIV positive status before the latest pregnancy, (45.2%) had an in-pregnancy diagnosis and (54.8%) were diagnosed at a non-pregnant state Overall two third of women (60.2%) experienced medium to high level of depressive symptoms after delivery Of these, the majority (59.7%) were HIV negative, and 213 (40.3%) were HIV positives

Predictors of post-partum depression Factor All women (HIV negative & positive) HIV positive women only Crude Adjusted RR (95% CI) aRR (95% CI) Marital status Married 1 In a relationship (living together) 0.93 (0.80 - 1.07) 0.93 (0.78 - 1.10) 0.80 (0.62 - 1.01) 0.66 (0.49 - 0.89)* In a relationship (not living together) 1.08 (0.94 - 1.25) 0.88 (0.65 - 1.20) 0.96 (0.75 -1.23) 0.66 (0.39 - 1.09) Not in a relationship 1.09 (0.85 - 1.40) 0.86 (0.56 - 1.31) 1.10 (0.76 - 1.60) 0.94 (0.44 - 2.00) Perceived social support High Medium 1.13 (1.01 - 1.25) 1.14 (1.00 - 1.29)* 1.18 (0.98 - 1.43) 1.28 (1.01 - 1.62)* Number of children other than your own you care of and live with 0 children >=1 children 1.3 (1.14 - 1.49) 1.21 (1.04 - 1.41)* 1.32 (0.94 - 1.87) Baby's father involvement in the pregnancy? Very involved Somewhat involved 1.40 (1.23 - 1.60) 1.32 (1.12 - 1.55)* 1.58 (1.27 - 1.97) 1.70 (1.20 - 2.41)* Not at all involved 1.05 (0.84 - 1.31) 1.04 (0.75 - 1.44) 1.14 (0.83 - 1.59) 1.01 (0.57 - 1.82) Who was your greatest support base during this pregnancy? Partner Baby father(if not partner) 1.05 (0.91 - 1.21) 1.02 (0.77 - 1.35) 1.24 (0.98 - 1.57) 1.66 (1.04 - 2.66)* Family members 1.21 (1.07 - 1.37) 0.99 (0.80 - 1.22) 1.36 (1.09 - 1.69) 1.07 (0.67 - 1.70) Other 1.17 (0.86 - 1.60) 1.05 (0.61 - 1.81) 1.08 (0.57 - 2.04) 0.58 (0.22 - 1.52) All women Significant predictors of PPD: Perceived social support (high vs. low) Number of children women take care of other than their own (0 children vs. ≥1 children) Baby’s father involvement in the pregnancy (very involved vs. somewhat involved) HIV positive women only HIV specific Significant predictors of PPD: Marital status (married vs. in a relationship-living together) Who was your greatest support base during pregnancy (Partner vs. baby’s father (if not partner))

Predictors of post-partum depression Factor All women (HIIV negative & positive) HIV positive women only Crude Adjusted RR (95% CI) aRR (95% CI) HIV status and timing of diagnosis HIV negative 1   Diagnosed during latest pregnancy 0.82 (0.72 - 0.94) 0.84 (0.72 -0.98)* In-pregnancy diagnosis with prior HIV care/ART 0.76 (0.62 - 0.95) 0.78 (0.62 - 0.99)* 0.93 (0.73 - 1.18) 0.96 (0.73 - 1.27) Pre-pregnancy diagnosis with prior HIV care/ART 0.63 (0.50 - 0.80) 0.70 (0.54 - 0.90)* 0.77 (0.60 - 0.99) 0.83 (0.62 - 1.11) HIV positive women were less likely to have depressive symptoms compared to HIV negative women However, the significance was lost when HIV negative mothers were removed from the analysis.

Discussions/Conclusions Considerably high prevalence of depressions was found in our study population Many women learn about their HIV positive during a pregnancy which can have a negative impact on their mental health Results from our study supports the call for integrating routine mental health screening in maternal care, and increasing the availability of appropriate interventions. Our results highlight the need for increased attention for women who test HIV negative during ANC and after delivery, who may otherwise be neglected. There needs to be greater investment by LMIC in contextually appropriate and cost effective prevention and treatment intervention for maternal depression 

Acknowledgements STUDY PARTICIPANTS!