1. 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

2. 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 %.
Recent studies ( ) 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.

3. 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.

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

5. 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.

6. 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

7. 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
(27.0)
(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
(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 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.

8. 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

9. 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

10. 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 ( )
0.93 ( )
0.80 ( )
0.66 ( )*
In a relationship (not living together)
1.08 ( )
0.88 ( )
0.96 ( )
0.66 ( )
Not in a relationship
1.09 ( )
0.86 ( )
1.10 ( )
0.94 ( )
Perceived social support
High
Medium
1.13 ( )
1.14 ( )*
1.18 ( )
1.28 ( )*
Number of children other than your own you care of and live with
0 children
>=1 children
1.3 ( )
1.21 ( )*
1.32 ( )
Baby's father involvement in the pregnancy?
Very involved
Somewhat involved
1.40 ( )
1.32 ( )*
1.58 ( )
1.70 ( )*
Not at all involved
1.05 ( )
1.04 ( )
1.14 ( )
1.01 ( )
Who was your greatest support base during this pregnancy?
Partner
Baby father(if not partner)
1.05 ( )
1.02 ( )
1.24 ( )
1.66 ( )*
Family members
1.21 ( )
0.99 ( )
1.36 ( )
1.07 ( )
Other
1.17 ( )
1.05 ( )
1.08 ( )
0.58 ( )
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))

11. 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 ( )
0.84 ( )*
In-pregnancy diagnosis with prior HIV care/ART
0.76 ( )
0.78 ( )*
0.93 ( )
0.96 ( )
Pre-pregnancy diagnosis with prior HIV care/ART
0.63 ( )
0.70 ( )*
0.77 ( )
0.83 ( )
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.

12. 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 

13. Acknowledgements
STUDY PARTICIPANTS!