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Background: Maternal mental health care is a neglected area in low and middle income countries (LAMIC) such as South Africa, where maternal and child health care priorities are focused on reducing maternal and infant mortality and promoting infant physical health. In the context of a paucity of mental health specialists, the aim of this study was to understand the explanatory models of illness held by women with maternal depression with the view to informing the development of an appropriate counselling intervention using a task sharing approach. Methods: Twenty semi-structured qualitative interviews were conducted with mothers from a poor socio-economic area who were diagnosed with depression at the time of attending a primary health care facility. Follow-up interviews were conducted with 10 participants in their homes. Results: Dimensions of poverty, particularly food and financial insecurity and insecure accommodation; unwanted pregnancy; and interpersonal conflict, particularly partner rejection, infidelity and general lack of support were reported as the causes of depression. Exacerbating factors included negative thoughts and social isolation. Respondents embraced the notion of task sharing, indicating that counselling provided by general health care providers either individually or in groups could be helpful. Conclusion: Counselling interventions drawing on techniques from cognitive behavioural therapy and problem solving therapy within a task sharing approach are recommended to build self-efficacy to address their material conditions and relationship problems in poorly resourced primary health care facilities in South Africa.
The study was conducted in a community health centre (CHC) in the Dr Kenneth Kaunda district in the North West Province. Economic activities in the district are predominantly mining and agricultural. The unemployment rate in the North West Province was 26.6% in the period the interviews were conducted, relative to 29.1% for South Africa as a whole [24]. Known as the “Platinum Province” with reference to its mineral wealth, mining is the mainstay of the North West Province, and typically attracts male employees. Some men have multiple families or partners, often both at a family home, and at the mining district. This is partly a historical product of the lack of facilities at mines to cater for families who are consequently left behind at home, sometimes in another province for lengthy periods [25]. The CHC is located in an urban township with a mixture of formal and informal dwellings. The facility provides both antenatal and postnatal services as well as a childbirth delivery service. HIV testing is routinely offered antenatally, and most women in the district give birth at health facilities and are attended by midwives. Home observations situate the context in which participants lived. Homes could be categorised as formal brick dwellings, basic Reconstruction and Development Programme (RDP) houses (low cost state subsidised two roomed homes with a kitchen and toilet), and informal shacks constructed with aluminium, cardboard and other materials. Access to electricity or inside ablutions is variable. A focused ethnographic qualitative research approach using in-depth face-to-face interviews, follow-up interviews and observations of participants in the home environment was adopted. A qualitative study was deemed appropriate given the exploratory nature of the research [26]. Kleinman’s concept of explanatory models of illness [23] was used to guide the interviews. This framework typically seeks to understand the way people understand an illness in relation to the cause, course and treatment options for their symptoms. Focused ethnography is used to collect focussed information and assist with interpretations of cultures and systems. Fieldworkers explained the study to women attending services at the CHC postnatal waiting room. Women were randomly approached by a fieldworker in the waiting room and requested to participate. The criteria for participation in the study was women over the age of 18 not previously diagnosed with depression, who had given birth to a live infant who was at the time of the study aged between six weeks and twelve months old. Fifty-three women were screened over two months of which twenty women screened positive and were recruited. There were no refusals. A first stage screening instrument, the Edinburgh Postnatal Depression Scale (EPDS) was administered to participants as it is commonly used worldwide and has been validated for use in South Africa [27]. A cut-off score of 12 was used in this study as suitably predictive of PND [28,29]. A second diagnostic screen, the Structured Clinical Interview for DSM-IV (SCID-II).was used by two clinical psychologists to confirm diagnoses for major depressive disorder. Twenty participants, who met the criteria for a major depressive episode were recruited into the study over a period of 2 months and recruitment ceased once saturation of data was reached. Participants with a history of depression were excluded to ensure the focus on postnatal rather than general or chronic depression. Participants were compensated for their time with $5 (R50) supermarket vouchers. Participants’ demographic characteristics are detailed in Table 1. Sample descriptives of women screened positive on EPDS and meeting criteria for major depressive episode With the participants’ consent, semi-structured, audio-recorded interviews were conducted in Setswana by two clinical psychologists to explore participants’ experiences and explanatory models of postnatal depression, their symptoms and coping strategies. Ten follow-up interviews were conducted with available participants from the first wave of interviewees two months later in their homes. The objective of the follow-up interviews was for participants to confirm earlier findings, to gain a better understanding of participants’ home environments and social contexts, and observe their interactions with family members and infants. The analysis of the first and second set of interviews was combined. The interviews were translated and transcribed into English with back-translation checks being applied by an independent English/Setswana speaker. Thematic analysis was both theory and data driven. Interviews were guided by specific research questions but the participants were encouraged to respond to the questions and to add any related information that they wanted to share. This approach was used to ensure that the essential data that was required to assist with developing the intervention would be collected and that any other data that was collected not specifically related to the research questions but related to the interview would add richness and depth to the data and would be useful to guide the intervention. The data was thus coded using apriori themes based on the interview questions as well as emergent themes with the help of Nvivo qualitative software for data analysis. The first and second authors independently generated themes and coded the data. The generated themes and coded data were compared and consensus reached on the final coded data. Ethical approval was obtained from the Humanities and Social Sciences Research Ethics Committee at the University of KwaZulu-Natal (ethical clearance number HSS/0880/011), and the Policy, Planning, Research, Monitoring and Evaluation division based at the Department of Health in the North West Province. The information and consent sheets were verbally explained to potential participants who were then given the opportunity to read the information sheets and ask questions confidentially. Participants were recruited following informed consent in their preferred language i.e. either Setswana or English. Participants who met the criteria for a major depressive episode and/or suicidal ideation were referred for further assessment and treatment using existing referral pathways. The methodological guideline for qualitative research reporting (RATS) [30] was adhered to in the reporting of the qualitative study in this paper.
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