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This study aimed to assess the association between suicidal ideation among mothers living with HIV in Zimbabwe and the cognitive development of their children. Participants were mother–child dyads recruited from two rural districts in Zimbabwe. Data were collected at baseline and 12 months follow-up. Suicidal ideation was assessed using item-10 from the Edinburgh postnatal depression scale. Mixed-effects linear regression was used to assess the association of child cognitive outcomes at follow-up (using the Mullen scales of early learning) with maternal suicidal ideation. Mothers with suicidal ideation at baseline (n = 171) tended to be younger, unmarried, experienced moderate to severe hunger, had elevated parental stress and depression symptoms compared with non-suicidal mothers (n = 391). At follow-up, emerging maternal suicidal ideation was associated with poorer child cognitive outcomes (adjusted mean difference − 6.1; 95% CI − 10.3 to − 1.8; p = 0.03). Suicidal ideation affects child cognitive development and should be addressed, particularly in HIV positive mothers.
Data were collected for the cluster-randomized controlled trial (The Child Health Initiative for Developmental Outcomes-CHIDO [PACTR201701001387209]) [28]. Details of the trial methods have been published previously [28]. In brief, the aim was to determine the effectiveness of a combined parenting and income-generating programme delivered to caregivers living with HIV and their children aged 0–24 months at recruitment, on global child development in Zimbabwe. Mother–child dyads were recruited from catchment areas surrounding 30 clinics in 2 rural districts in Mashonaland East Province. Trial clinics were randomized to the CHIDO intervention or Zimbabwe Ministry of Health and Child Care standard of care, and participants were enrolled in the arm to which their clinic was randomized. Participants in the standard care arm received the recommended standard of care for HIV positive mothers and their HIV exposed or infected children. Participants enrolled in the trial were assessed at baseline and followed up for 12 months for re-assessment. This analysis was confined to biological mothers only and their children who completed both assessments. All participants were provided with full information and gave consent to participate in the study as well as consent for child participation. Socio-demographic information was collected on participant characteristics (age, marital status), and socio-economic factors (educational level, employment status, asset index score, and number of adults living in the household), using interviewer-administered questionnaires. All children had an HIV test at follow-up. A subset of questions from the household food insecurity access scale [29] were used to categorize participants as living: (i) food secure (rarely worried about food access or quality), (ii) moderately food insecure (sometimes i.e. 3–10 times in the last month, worried about food access or quality), or (iii) severely food insecure (≥ 1 household member going to bed hungry or often worrying about food access or quality). The Edinburgh postnatal depression scale (EPDS), a postpartum depression-screening questionnaire that has been validated for use in Zimbabwe [30, 31], was administered to participating mothers. The EPDS comprises 10 questions that generate scores ranging from 0 to 30. A cut-off point of (12) which indicates concern for referral was used at baseline [30, 32]. The EPDS score was further categorized into none or minimal (EPDS scores 0–6), mild (EPDS scores 7–13), moderate (EPDS scores 14–19) and severe depression (EPDS scores 20–30) [33]; assessing the severity of maternal depressive symptoms for this population. The suicidal ideation item (item-10) was excluded from the total score. Suicidal ideation was measured as thoughts of self-harm during screening using a self-reported questionnaire based on the EPDS [30, 31]. The EPDS scale contains a specific target item (item-10 “The thought of harming myself has occurred to me”) which assesses suicidal ideation [34–36] with good sensitivity (77%) and specificity (92%) according to previous studies in South Africa [2, 37]. Those responding “Yes, quite often”, “Sometimes” and “Hardly ever” in the past week were coded as experiencing suicidal ideation, whereas those to respond “Never” were coded as not experiencing suicidal ideation. Longitudinal data was utilised to categorise suicidal ideation over time into four groups. Women who did not report suicidal ideation at both baseline and 12 months follow-up were grouped as non-suicidal. Women reporting suicidal ideation at baseline but not at 12 months follow-up were grouped as improving and women who did not experience suicidal ideation at baseline but did at 12 months were referred to as the emerging suicidal ideation group. Whereas women who experienced suicidal ideation at both baseline and 12 months follow-up were marked as the chronic suicidal ideation group. Parental stress index-short form (PSI-SF), a self-completed screening tool used for identifying different types of stress associated with parenting, was administered to participants [38]. Common mental disorders (CMDs) were assessed using the locally developed and validated Shona symptom questionnaire (SSQ)-8 [39]. The short form is derived from the longer SSQ-14 version. Scores range from 0 to 8, and scores ≥ 6 were used as a cut-off point for CMD symptoms. Child cognitive development was assessed using the Mullen scales of early learning [40, 41]. The Mullen scale is a comprehensive measure that assesses a child’s abilities in five developmental domains from birth through 68 months: gross motor skills, visual reception, fine motor skills, receptive language, and expressive language [40]. The Mullen scales were administered to all children by trained assessors in a standardized format at enrolment and 12 months later [28]. The number of assessors was kept to a minimum to maximize the reliability of measurement. Test scores were transformed into an age-standardized T-score, using a US reference population as there was no local Zimbabwean reference population on this index. Four components—the fine motor, expressive language, receptive language, and visual perception scales—were combined to produce the age-standardized early learning composite (ELC) score of general cognitive functioning. The gross motor scale was not included in the ELC score and was used separately [40, 42]. To compare the characteristics of participants by suicidal ideation, descriptive analyses were used to summarise the baseline characteristics. Logistic regression was used to identify risk factors associated with suicidal ideation at baseline and was reported using odds ratio (OR) and 95% confidence intervals (95% CIs). Data were pooled for this analysis as there was no evidence of a difference in child cognitive outcomes by trial arm. Mixed-effects linear regression was used to compare child cognitive outcomes by maternal suicidal ideation over 12 months. Mean children’s cognitive scores at follow-up by mother’s suicidal ideation categories were presented as adjusted mean differences (aMDs). Confounding variables associated with both exposure (maternal suicidal ideations) and outcome (child cognitive scores) in bivariate analyses (at p < 0.2) were included in the multivariable model. Clustering by study sites was accounted for by incorporating a random effect for clinic in all models. A priori adjustments included baseline child Mullen scores, mother’s age and the code for the person conducting Mullen assessments. All analyses were conducted using STATA v.15.1 (StataCorp LP, College Station, Texas, USA). The trial has been approved by the Medical Research Council of Zimbabwe (MRCZ/A/1943), University College London (6789/002) and the London School of Hygiene and Tropical Medicine (9912).
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