Thesis (PhD)--University of Stellenbosch, 2011. / ENGLISH ABSTRACT: Pregnancy is a vulnerable time in settings such as sub-Saharan Africa, and is associated
with exposure to a multitude of physiological, social and psychological risks. High HIV
prevalence, and the fact that many women will test for HIV for the first time during their
pregnancy, has raised concern about women‘s psychological health during pregnancy.
Depression during the antenatal period is of public health concern as it has been shown to be
associated with poorer foetal and delivery outcomes, risky behaviours, and poorer uptake of
antenatal care. Antenatal depression is a predictor of postnatal depression, and postnatal
depression has been associated with poor maternal sensitivity and attachment in mothers which
is known to result in increased behavioural and developmental difficulties in children.
The aim of this research was to provide a clear, in depth and culturally sensitive
understanding of the manifestation of depression in pregnant women in a rural area with high
HIV prevalence in South Africa. The research method included a diagnostic assessment of
depression in 109 women in their third trimester of pregnancy, and an in-depth qualitative
examination of the contextual framework within which HIV testing and depression are
experienced with a sub-sample of 56 women.
The quantitative results demonstrated that the prevalence of antenatal depression was
high (46.7%), with close to half of the women being diagnosed with depression. Presentations of
depression most frequently included disturbances in mood, loss of interest and suicide ideation.
Symptoms which overlap with common side effects of pregnancy such as loss of energy and
weight change did not result in an overestimation of depression. Likewise, very little evidence of
the somatisation of depression, or particular cultural barriers to the diagnosis of depression based
on DSM-IV criteria was found. Rates of suicide ideation were high and equally common among
HIV positive as HIV negative women.
Factors significantly associated with depression included living within a family
homestead, access to a regular source of income and practical support from a partner. Both
income and partner support had a negative association with depression. Living away from a
family or parental home had a positive association with depression. The results showed that the Edinburgh Postnatal Depression Scale (EPDS) was effective
in identifying depression and that a shorter three item version was as effective as longer versions.
A positive score for depressed mood on the EPDS was significantly associated with HIV,
suggesting that the EPDS is a good screening tool for elevated psychological risks among HIV
positive women post HIV testing.
Qualitative results showed that having an unsupportive partner and the occurrence of
relationship or familial conflict played an important role in the development of emotional
distress during pregnancy and resulted in a high number of unwanted pregnancies. Partner and
familial conflict was intertwined with cultural practices which govern the acceptability of
childbearing among unmarried women and the social recognition of partnerships and paternal
responsibilities. Testing for HIV was considered a stressful life event for all women regardless of
their HIV status and was a particularly negative life event for women who tested HIV positive or
for women who had concerns over partner infidelity. Disclosure among HIV positive women
frequently lead to increased partnership conflict. Qualitative findings suggested that depression
and emotional distress after HIV testing did interfere with women‘s ability to engage with
prevention messages. Women who were coping well with learning their HIV positive status had
high levels of family disclosure and subsequent family support in common.
The implication of this research is that it is important that public health programmes
screen for depression among childbearing women. These data suggests that a shorter three item
version of the EPDS along with screening for partner and family support or conflict would
effectively detect most women at high risk for depression. Likewise, public health interventions
for women with depression which are implemented in primary health care facilities and in
isolation of the partnership and familial context within which depression occurs are not likely to
be effective. Further research is needed to establish the precise prevalence of antenatal and
postnatal depression in women at high risk for HIV; to validate the effectiveness of a shorter
screening tool in resource limited settings; and to establish risk and protective factors, and
trimester specific risks which could inform the design of cost effective interventions in poorly
resourced settings. / AFRIKAANSE OPSOMMING: Swangerskap in Afrika, suid van die Sahara, is ʼn kwesbare tydperk met blootstelling aan
ʼn menigte fisiologiese, sosiale en sielkundige risiko‘s. Die hoë voorkoms van HIV en die feit
dat baie vrouens gedurende swangerskap vir die eerste keer vir HIV wil toets, het ‗n besorgdheid
oor vrouens se sielkundige gesondheid gedurende swangerskap laat ontstaan.
Depressie gedurende die voorgeboortelike periode is van belang vir publieke gesondheid,
want daar is bewyse wat dui op ‗n verband tussen depressie en swakker fetale en geboorte
resultate, riskante gedrag en verminderde gebruik van voorgeboortelike sorg . Voorgeboortelike
depressie is ʼn indikasie van moontlike nageboortelike depressie en nageboortelike depressie
word geassosieer met swak moederlike sensitiwiteit en die gebrekkige vorming van ‗n band
tussen moeder en kind; wat reeds bewys is om te lei tot verhoogde gedrags- en
ontwikkelingsprobleme in kinders.
Die doel van hierdie navorsing was om ʼn duidelike, indiepte en kulturele-sensitiewe
begrip van die manifestasie van depressie in swanger vroue in ʼn landelike omgewing met hoë
HIV voorkoms in Suid Afrika te verkry. Die navorsingsmetode sluit in ʼn simptomatiese
beraming van depressie by 109 vroue in hul derde trimester van swangerskap en ʼn indiepte
kwalitatiewe ondersoek na die kontekstuele raamwerk waarbinne HIV toetse en depressie
ondervind word met ʼn sub-steekproef van 56 vrouens.
Die bevinding was dat die voorkoms van voorgeboortelike depressie hoog was, 46.7 %,
met feitlik die helfte van die vrouens wat met depressie gediagnoseer is. In die meeste gevalle
het die voorkoms van depressie gepaard gegaan met ʼn verandering in gemoedstoestand, ʼn verlies
aan belangstelling en selfmoordgedagtes. Simptome wat ooreenstem met algemene newe-effekte
van swangerskap, soos verlies aan energie en verandering in gewig, het nie bygedra tot ʼn
oorberekening van depressie nie. Soortgelyk is baie min bewyse gevind dat somatosasie van
depressie, of spesifieke kulturele grense, tot die diagnose van depressie gebaseer op DSM-IVkriteria bydra. Die oorweging van selfmoord was hoog en algemeen tussen beide HIV-positiewe
en HIV-negatiewe vouens. Faktore wat aansienlik met depressie geassosieer word, sluit in om in ʼn familiegroep te bly, toegang tot ʼn vaste bron van inkomste en die praktiese ondersteuning van
ʼn lewensmaat. Beide inkomste en die ondersteuning van ʼn lewensmaat het ʼn negatiewe
verbintenis met depressive. Om nie by familie of in ʼn ouerhuis te bly nie het ʼn positiewe
assosiasie met depressive. Alhoewel HIV-status verband hou met depressie, was dit nie uitermate
die geval nie, alhoewel daar ʼn gebrek aan statistiese kragdoeltreffendheid was om die effek van
HIV vas te stel, gegee die beperkte grootte van die steekproef.
Die resultate het getoon dat die EPDS graderingsinstrument effektief was om depressie te
identifiseer en dat ʼn korter driepunt weergawe daarvan net so effektief was soos die langer
weergawe. ʼn Positiewe telling vir ʼn depressiewe gemoedstoestand op die EPDS het ʼn
betekenisvolle assosiasie met HIV en dui daarop dat die EPDS ʼn goeie graderingsinstrument is
vir verhoogde sielkundige risiko by HIV-positiewe vrouens, selfs al is HIV-positiewe vrouens in
dié steekproef statistieksgewys nie meer geneig tot depressie as HIV-negatiewe vrouens nie.
Kwalitatiewe resultate toon dat ʼn lewensmaat wat nie ondersteunend is nie en die
voorkoms van verhoudings- of familiekonflik ʼn belangrike rol speel in die ontwikkeling van
emosionele angs gedurende swangerskap en dit het gelei tot ʼn groot aantal ongewenste
swangerskappe. Konflik met ʼn lewensmaat en met familie was verweefd met kulturele gebruike
wat die aanvaarbaarheid van geboortes onder ongetroude vrouens beheer en die sosiale
erkenning van verhoudings en die vader se verantwoordelikhede. ʼn HIV-toets is as ʼn stresvolle
lewensgebeurtenis beskou deur alle vroue, ongeag van hulle HIV-status en was ʼn besondere
negatiewe lewensgebeurtenis vir vroue wat HIV-positief getoets het of vir vroue wat bekommerd
was oor hulle lewensmaats se getrouheid. Onthulling van die HIV-status van positiewe vrouens
het gereeld tot verhoogde konflik in verhoudings gelei. Kwalitatiewe bevindings dui daarop dat
depressie en emosionele angs na ʼn HIV-toets inmeng met ʼn vrou se vermoë om ag te slaan op
voorkomingsboodskappe. Vroue wat die kennis van hulle HIV-positiewe status goed hanteer
het, het hoë vlakke van bekendmaking van hulle status en die ondersteuning van hulle familie in
gemeen.
Die implikasie van die navorsing is dat dit belangrik is vir publieke
gesondheidsorgprogramme om te toets vir depressie onder swanger vroue. Die resultate dui
daarop dat ʼn korter driepunt weergawe van die EPDS, saam met ʼn ondersoek na die ondersteuning van of konflik met ʼn lewensmaat en familie, effektief kan wees om vroue met ʼn
hoë risiko vir depressie te identifiseer. Soortgelyk, publieke gesondheidsingryping in primêre
gesondheidsorg fasiliteite vir vroue met depressie wat in isolasie van die lewensmaat en familie
konteks, waar depressie voorkom geadministreer word, is onwaarskynlik om te slaag.
Bevindings onderskryf die belangrikheid van ondersteuning vir die familie om effektief te kan
reageer en herstel van stresvolle faktore soos onbeplande swangerskappe en HIV-diagnose, in ʼn
konteks wat swaar deur HIV geaffekteer word, aangesien dit ʼn voorkomende effek op depressie
kan hê.
Verdere navorsing is nodig om die presiese voorkoms van voorgeboortelike en
nageboortelike depressie in vrouens met ʼn hoë blootstelling aan HIV vas te stel; om die sukses
van ʼn korter graderingsinstrument in arm omgewings te staaf; en om die risiko en beskermende
faktore vas te stel en trimester spesifieke risiko‘s wat die ontwerp van ʼn koste-effektiewe
ingryping in gebiede met ontoereikende hulpbronne kan beïnvloed.
| Identifer | oai:union.ndltd.org:netd.ac.za/oai:union.ndltd.org:sun/oai:scholar.sun.ac.za:10019.1/6843 |
| Date | 03 1900 |
| Creators | Rochat, Tamsen Jean |
| Contributors | Tomlinson, Mark, University of Stellenbosch. Faculty of Arts and Social Sciences. Dept. of Psychology. |
| Publisher | Stellenbosch : University of Stellenbosch |
| Source Sets | South African National ETD Portal |
| Language | en_ZA |
| Detected Language | Unknown |
| Type | Thesis |
| Format | 289 p. : ill. |
| Rights | University of Stellenbosch |
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