Menu
Menu
Menu
Menu
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.
We conducted a qualitative study comprising in-depth interviews with key stakeholders in relation to antenatal depression in rural Ethiopia. The study was conducted in Sodo district, south central Ethiopia, which encompasses 58 sub-districts (54 rural and four urban). There are eight primary healthcare centres (PHCs), each about 25,000 population, and one district level primary hospital. The facility-based PHC workers (nurses, midwives and health officers (BSc degree level healthcare workers trained both in clinical and preventive activities) provide antenatal, delivery and postnatal care. Ethiopian women are expected to attend at least four antenatal care appointments, with at least their first and last antenatal care appointments at the PHC facility. Women without complications can attend the remaining antenatal care visits in health posts. Each PHC facility is associated with five ‘health posts’ which are grassroots level community-based healthcare facilities, each staffed by two health extension workers (HEWs). HEWs are community-based healthcare workers responsible for core preventive and public health promotion activities, including reproductive health, hygiene and maternal health [35]. HEW duties include the identification of pregnant women in the community, linking women to facility-based antenatal care and providing some antenatal care at the community level. Over the past 8 years, the Programme for Improving Mental Health carE (PRIME) team [36] worked with district health office planners and local stakeholders to implement a mental health care plan based on task-shared care delivered in primary and maternal health care settings in Sodo district. In the absence of a contextually adapted psychological therapy, the model of task-shared maternal mental health care implemented in PRIME was limited to psycho-education, basic psychosocial support and antidepressants for women who were more severely unwell. Women who scored five or more on a locally validated version of the Patient Health Questionnaire (PHQ-9) during pregnancy as part of our previous study [37] (conducted between September 2014 to June 2015) [38], were invited by project workers to participate in an interview. Interviews took place during December 2017. Healthcare workers engaged in maternal care, PHC facility-based health workers and health extension workers, were identified and invited to participate through key informants (district health office representatives). We used purposive sampling to identify clinical staff with varying qualifications, levels of experience and who were based in rural and urban health facilities. Recruitment of participants continued until no new perspectives arose, i.e. until theoretical saturation was attained. All interviews were conducted in the most conveniently located health centre for the participant. Research assistants (females for women and PHC workers; and a male for HEWs) with at least a master’s level degree and experience with qualitative research conducted all interviews in Amharic, the official language of Ethiopia. Interview topic guides were informed by Kleinman’s explanatory model interview [32, 39]. Accordingly, the interview topic guide for women explored: their experience, description and explanations of emotional difficulties in pregnancy; impact of emotional difficulties; coping strategies; treatment preferences; their expectations of HCWs, family and traditional healthcare providers; and barriers and facilitators in relation to accessing psychosocial support (supplementary file 1). We used the term ‘emotional difficulties’ to avoid imposing a medical conceptualisation of their experiences and because the term ‘depression’ is not familiar to women in the study site. The interview topic guide for facility-based PHC providers explored: emotional and social problems faced by women in pregnancy, pregnant women’s conceptualisation of depression, types of support provided to women with emotional problems, identifying women with depression, acceptability of psychological interventions and suggestions for how such interventions might be adapted and implemented (supplementary file 2). The interview topic guide for HEWs explored: their role in helping pregnant women seek healthcare, barriers to and motivators of women’s help seeking, responses to women not attending antenatal care, problems women face during pregnancy, ways to help women access antenatal care, presentations of emotional problems and their perception of women’s treatment preferences (supplementary file 3). Participants were reimbursed for their transportation. The interviews lasted between 40 and 82 min. All interviews were audio-recorded, with the permission of the participants. Audio-recorded interviews were transcribed verbatim and translated into English. The first two transcripts were coded independently by two reviewers (TB generated 58 codes and RK 53) using Open Code qualitative analysis software [40]. Discrepancies were discussed to reach consensus on the naming, merging and creation of new codes, yielding a final 55 codes which were then condensed after discussion with the senior author (CH) to 36 (see: Supplementary file 4). One of the reviewers (TB) then coded the remaining transcripts using this final set of agreed upon codes. No further codes emerged from the remaining data. Thematic analysis was employed, where the codes were synthesized into four themes and then into sub-themes through discussion between CH and TB. Each transcript was then summarized in a spreadsheet based on themes and sub-themes (see: Supplementary Table). However, the third and fourth themes overlapped substantially, so were merged.
