Untreated depression in pregnancy may result in adverse health outcomes to both the mother and her unborn child. Pharmacotherapy with antidepressants is the most common treatment option for depression; however, the decision to treat with medication becomes complicated by pregnancy. Risk benefit assessments are critical tools to guide the treatment decision. Factors that should be included in these analyses include the pharmacokinetics and pharmacodynamics of antidepressants in pregnancy and their maternal and fetal safety. The economic cost of untreated maternal depression is also important to keep in mind. When the pharmacokinetics of the antidepressants venlafaxine and bupropion were studied in pregnancy it was found that the apparent oral clearance rate of bupropion was increased in late pregnancy when compared to early pregnancy (p = 0.03). There was a trend for lower area under the curve for these medications when the third trimester was compared to the first trimester. When the metabolism of antidepressants was investigated using hair analysis it was found that there was increased metabolism in pregnancy when compared to the postpartum period for citalopram (p = 0.02) but not venlafaxine (p = 0.77). Follow up of depressive symptoms throughout pregnancy identified that depression scores were highest in the first trimester of pregnancy, which may be due to concurrent nausea and vomiting of pregnancy. A meta-analysis of paroxetine use in early pregnancy demonstrated that there was no increased risk for cardiac malformations; case-control studies had an odds ratio of 1.18 (CI95: 0.88 – 1.59) while a weighted average difference of 0.3% was found in case-control studies (CI95: -0.1 – 0.7%, p = 0.19) The direct medical costs incurred by the Ontario government due to discontinuation of antidepressant medications in pregnancy was estimated to exceed $20,000,000 CAD. The management of depression in pregnancy with pharmacotherapy is an important and complex issue. My study documents the advantages of conducting risk benefit assessments for vulnerable populations such as pregnant women with depression.

Dissertation submitted in fulfillment of the requirements for the Degree in Masters of Technology: Nursing, Durban University of Technology, 2011. / Background South Africa is burdened by consistently high maternal and perinatal mortality rates. In a move to alleviate this burden the South African National Department of Health (DoH) instructed the adoption of the Basic Antenatal Care (BANC) approach in all antenatal care (ANC) facilities. Whereas many facilities have begun the implementation of the BANC approach, in the eThekwini district, not all of the facilities have been successful in doing so. The study was conducted in those eThekwini Municipality Primary Health Care (PHC) facilities that have been successful in order to identify the factors influencing their success in implementing BANC. Methods The facilities that had been successful in implementing BANC were identified, followed by a review of the past records of the patients who had completed their ANC and had given birth. This was done in order to establish whether the facilities that were said to be implementing BANC, were in fact, following BANC guidelines. The factors that influenced successful implementation of BANC were identified based on information obtained from the midwives who were working in the ANC facilities that were successfully implementing BANC. The sample size was comprised of 18 PHC facilities that were successfully implementing BANC from which a total of 59 midwives were used as the study participants. Results Several positive factors that influenced successful implementation of BANC were identified. These factors included; availability and accessibility of BANC services: Policies, Guidelines and Protocol; various means of communication; a comprehensive iii package of services and the integration of services; training and in-service education; human and material resources and the support and supervision offered to the midwives by the PHC supervisors. Other factors included BANC programme supervisors’ understanding of the programme and the levels of experience of midwives involved in implementation of BANC. There were, however, certain challenges and negative factors that were identified and these included: shortage of staff; lack of cooperation from referral hospitals; lack of in-service training; problems in transporting specimens to the laboratory; lack of material resources; lack of management support and the unavailability of BANC guidelines.

Master of Public Health - MPH / Globally, the maternal mortality rate (MMR) dropped by 44%, from 342 deaths per 100 000 to 211 maternal deaths per 100,000 live births in 2017. Developing countries have reached two-thirds coverage (69 %) of the recommended focused visits and first ANC. In sub-Saharan Africa alone, approximately 66% (201,000) of deaths occur during birth. MMR can be reduced if pregnant women initiate ANC early enough and receive quality care. In Swaziland, only 14% of pregnant women make their first ANC visit during the first trimester, 64% during the 2nd trimester and 22% during the 3rd trimester. The study aimed to explore pregnant women's perceptions of the factors contributing to late ANC booking in the Shiselweni Region.

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Depression occurs in approximately 20% of pregnant women, and up to 25% of them experience anxiety. Several pregnancy complications and labour and delivery outcomes have been associated with antenatal depression and anxiety, such as higher rates of nausea and vomiting, bleeding, psychosomatic complaints, preterm labour and delivery complications. Neonatal outcomes include lower Apgar scores, shorter gestation, smaller head circumference, and increased admissions to the neonatal intensive care unit. Research Questions: 1. To examine the prevalence of pregnancy complications and neonatal outcomes in this study sample. 2. To examine whether there is a difference in the association between observed pregnancy complications and neonatal outcomes and major depression, when depression is episodic compared to when the depression is continuous. 3. To examine whether there is a difference in the association between observed pregnancy complications and neonatal outcomes and mild depression, when the mild depression is episodic compared to when it is continuous. 4. To examine whether there is a difference in the association between observed pregnancy complications and neonatal outcomes and anxiety, when anxiety is episodic compared to when it is continuous. Methods: The data for this study was collected for the Feelings in Pregnancy and Motherhood Study (FIP). This population-based study interviewed 649 participants three times: in the second trimester, the third trimester, and in the early postpartum. Participants were screened for depression and anxiety with the Edinburgh Postnatal Depression Scale (EPDS), using the validated cut-off scores of >12 and >4 respectively. Sociodemographic data as well as detailed risk behaviours, and sources of stress and coping, were explored. Finally, pregnancy, labour and delivery and neonatal complications were collected. Descriptive and multivariate logistic regression analyses were completed. Results: Major depression in the second trimester was significantly associated with gestational diabetes (OR: 3.518; 95% CI 1.56, 7.93) and swelling/edema (OR: 2.099; 95% CI 1.13, 3.89). Major depression that occurred continuously throughout pregnancy was significantly associated with induced labour (2.417; 95% CI 0.99, 5.92) and antenatal bleeding/abruption (OR: 2.099; 95% CI 1.13, 3.89). Anxiety in the second trimester was significantly associated with caesarean birth (OR: 0.522; 95% CI 0.29, 0.95). Anxiety occurring continuously throughout pregnancy was significantly associated with swelling/edema (OR: 1.816; 95% CI 1.19, 2.77) and there was a significant interaction between age and anxiety that predicted epidural use during pregnancy: while age decreased in the participants who had anxiety in both trimesters, the likelihood of using an epidural increased. Finally, mild depression in the second trimester was significantly associated with antenatal bleeding/abruption (OR: 2.124; 95% CI 1.09, 4.14) and PROM (OR: 2.504; 95% CI 1.04, 6.05). Mild depression in the third trimester was associated with caesarean birth (OR: 0.298; 95% CI 0.10, 0.86). Mild depression that occurred continuously throughout pregnancy was significantly associated with the use of vacuum/forceps in delivery or an operative delivery (OR: 4.820; 95% CI 1.10, 21.16). Conclusions: These results show that episodic depression and anxiety can have a more profound impact on pregnancy complications and labour and delivery outcomes than continuous depression and anxiety. Furthermore, the results demonstrate that even mild depression can have a significant negative impact on pregnancy complications and labour and delivery outcomes. These results further highlight the imperative need for women to be screened and treated for depression and anxiety during pregnancy.

MSc (Med) Epidemiology and Biostatistics, Faculty of Health Sciences, University of the Witwatersrand / Research Project Title: HIV Prevalence and Factors Associated with HIV Infection in South Africa: Analysis of the Antenatal Clinic Survey Data. Background: In sub-Saharan Africa, the HIV epidemic is commonly monitored through the sentinel surveillance of pregnant women attending antenatal clinics (ANC), which provides important indications for planning and evaluating public-health interventions. Many of such surveillance systems in South Africa reported limited information on factors associated with HIV infection, even though the survey collected information related to a woman’s participation. This is likely to compromise the development of effective preventive programmes that are more focussed. To address this, the 2005 HIV (ANC) surveillance data was used with the objective of increasing the available information on the HIV epidemic in the country and identifying the socio-demographic factors associated with HIV infection in each province. Methodology: The data from the 2005 ANC survey was analysed in depth. The chi-square test was used to test bivariate associations for categorical associations of HIV infection and other associated factors. In addition a logistic regression model was used to explore the association of sociodemographic and other variables with HIV infection in each province. Results: The HIV prevalence reported in this study was similar to earlier reports released by the Department of Health in 2005. That is the overall HIV prevalence is 30.1% (29.5-30.8%) with KwaZulu Natal having the highest (39.1%, 37.5-40.1%) and Western Cape recorded the lowest HIV prevalence of 15.9% (14.1-17.4%).