Advertisement

Antenatal depression and associated factors among HIV-positive pregnant women in South Gondar zone public health facilities, northwest Ethiopia, a cross-sectional study

Open AccessPublished:May 31, 2022DOI:https://doi.org/10.1016/j.cegh.2022.101072

      Abstract

      Introduction

      Depression and HIV/AIDS are estimated to be the world's two leading causes of burden of disease by 2030. Depression during pregnancy is a significant public health problem because it has negative effects on the health of the mother and her fetus. However, evidence on antenatal depression and associated factors among HIV-positive women is scarce in the study area.

      Objective

      This study was aimed to assess antenatal depression and associated factors among HIV-positive pregnant women attending prevention of mother to child transmission service in South Gondar zone public health facilities, northwest Ethiopia.

      Methods

      Institutional-based cross-sectional study was conducted on 606 HIV-positive pregnant women. The data were collected by face-to-face interviews and chart review. Edinburgh Perinatal Depression Scale was used to assess antenatal depression. Data were entered into Epi-Data version 4.6 and analyzed by SPSS version 23. Multivariable logistic regression model was fitted and AOR with 95% CI was computed to determine the level of significance.

      Results

      The prevalence of antenatal depression was 36.4% (95% CI: 32.7, 40.2). Being unmarried (AOR = 2.77, 95% CI: 1.26, 6.07), experienced intimate partner violence during this pregnancy (AOR = 1.50, 95% CI: 1.05, 2.15), ART non -adherence (AOR = 2.18, 95% CI: 1.50, 3.18), and experienced internalized AIDS stigma (AOR = 1.46, 95% CI: 1.02, 2.09) were significantly associated with antenatal depression.

      Conclusion and recommendation

      In this study, more than one-thirds of HIV-positive pregnant women had antenatal depression. Screening HIV-positive pregnant women for depression and provision of intervention is recommended.

      Keywords

      1. Introduction

      Depression is characterized by feelings of low self-worth, loss of interest, feelings of regret, restlessness, loss of appetite, feelings of fatigue, and poor concentration.
      • Marcus M.
      • Yasamy M.T.
      • Ommeren M.
      • Chisholm D.
      • Saxena S.
      Depression: A Global Public Health Concern.
      According to the World Health Organization (WHO), depression is one of the leading causes of disability for both males and females. However, the burden of depression is 50% higher in females than males. At its worst, depression can lead to suicide, and globally, around 1 million lives have been lost every year due to suicide.
      • Marina Marcus MTY MvO
      • Chisholm Dan
      • Saxena Shekhar
      In addition, depression is the most common psychiatric manifestation among people living with the human immunodeficiency virus.
      • Arseniou S.
      • Arvaniti A.
      • Samakouri M.
      HIV infection and depression.
      Depression and human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) are estimated to be the world's two leading causes of burden of disease by 2030.
      • Loncar D.
      • Mathers C.D.
      Loncar D Projections of global mortality and burden of disease from 2002 to 2030.
      To promote mental health, international mental health action plans were developed and one of the key objectives of these action plans was to implement strategies for the prevention of mental illness.
      • Saxena S.
      • Funk M.
      • Chisholm D.
      World health assembly adopts comprehensive mental health action plan 2013 ;2020.
      Ethiopia also sets national mental health strategies to increase mental health care among those special vulnerable groups that include pregnant women, women in the postpartum period, and people living with HIV/AIDS.
      • Health FDRoEMo
      National Mental Health Strategy 2012/13–2015/16. Public Policy Document, Federal Democratic Republic of Ethiopia.
      Antenatal depression is a syndrome of depression, in which women experience during a period of pregnancy.
      • Austin M.-P.
      Highest N and the Expert Working Group.
      Globally, the prevalence of antenatal depression is ranged from 15% to 65% and the prevalence is high in low-income and middle-income countries (LAMICs).
      • Dadi A.F.
      • Miller E.R.
      • Bisetegn T.A.
      • Mwanri L.
      Global burden of antenatal depression and its association with adverse birth outcomes: an umbrella review.
      ,
      • Halim N.B.J.
      • Mesic A.
      • Patel A.
      • Henderson D.
      • Hibberd P.
      Intimate partner violence during pregnancy and perinatal mental disorders in low and lower middle income countries: a systematic review of literature, 1990-2017.
      Specifically, HIV-infected pregnant women might be one of the most vulnerable groups, with high rates of depression and psychiatric morbidity.
      • Kapetanovic S.
      • Dass-Brailsford P.
      • Nora D.
      • Talisman N.
      Mental health of HIV-seropositive women during pregnancy and postpartum period: a comprehensive literature review.
      The serious forms of depression characterized by the idea of suicide or self-harming, are also relatively common in pregnancy.
      • Arachchi N.S.M.
      • Ganegama R.
      • Husna A.W.F.
      • et al.
      Suicidal ideation and intentional self-harm in pregnancy as a neglected agenda in maternal health; an experience from rural Sri Lanka.
      Antenatal depression increases the risk of complications during birth, including prolonged labor and causing long-lasting, even permanent effects on child development and well-being.
      • Wagner G.J.
      • McBain R.K.
      • Akena D.
      • et al.
      Maternal depression treatment in HIV (M-DEPTH): study protocol for a cluster randomized controlled trial.
      In addition, low birth weight, preterm births, small for gestational age, delayed cognitive and language, delayed development, behavioral problems, poor academic performance, and emotional problems are some of its complications to the baby. Moreover, it affects maternal health-seeking behavior and increases risky behaviors such as substance use. Antenatal depression among HIV-infected women might also accelerate the progression of HIV infection and increases maternal morbidity and mortality. Furthermore, untreated depression during pregnancy is a risk factor for postpartum depression, and a lower likelihood of exclusive breastfeeding after delivery might increase.
      • Fekadu Dadi A.M.E.
      • Mwanri L.
      Antenatal depression and its association with adverse birth outecomes in low and middle-income countries: a systematic review and meta- analysis.
      • EastwoodJ O.
      • HendryA NobleJ.
      • Page A.
      for the Early Years Research Group (EYRG)
      The impact of antenatal depression on perinatal outcomes in Australian women.
      • Antelman G.
      • Kaaya S.
      • Wei R.
      • et al.
      Depressive symptoms increase risk of HIV disease progression and mortality among women in Tanzania.
      • Gelaye B.
      • Rondon M.B.
      • Araya R.
      • Williams M.A.
      Epidemiology of maternal depression, risk factors, and child outcomes in low-income and middle-income countries.
      • Smith M.V.
      • Shao L.
      • Howell H.
      • Lin H.
      • Yonkers K.A.
      Perinatal depression and birth outcomes in a Healthy Start project.
      • Tuthill E.L.
      • Pellowski J.A.
      • Young S.L.
      • Butler L.M.
      Perinatal depression among HIV-infected women in KwaZulu-natal South Africa: prenatal depression predicts lower rates of exclusive breastfeeding.
      • Shen H.M.C.
      • Rai D.
      • Lundberg M.
      • Le-Scherban F.
      • Dalman C.
      • et al.
      Associations of parental depression with child school performance at age 16 years in Sweden.
      Though antenatal depression has a devastating effect on the health of the women and the fetus, it has not received much attention in the health care community compared to postnatal depression.
      • Shidhaye P.
      • Giri P.
      Maternal depression: a hidden burden in developing countries.
      Several studies done in different countries suggest different factors associated with antenatal depression, include; single marital status, being unemployed, unplanned pregnancy, ART non-adherence, length of time on ART, intimate partner violence, poor social support, and history of depression.
      • Peltzer K.
      • Rodriguez V.J.
      • Jones D.
      Prevalence of prenatal depression and associated factors among HIV-positive women in primary care in Mpumalanga province, South Africa.
      • Ngocho J.S.
      • Watt M.H.
      • Minja L.
      • et al.
      Depression and anxiety among pregnant women living with HIV in Kilimanjaro region, Tanzania.
      • Harrington B.J.
      • Pence B.W.
      • John M.
      • et al.
      Prevalence and factors associated with antenatal depressive symptoms among women enrolled in Option B+ antenatal HIV care in Malawi: a cross-sectional analysis.
      • Kaida A.
      • Matthews L.T.
      • Ashaba S.
      • et al.
      Depression during pregnancy and the postpartum among HIV-infected women on antiretroviral therapy in Uganda.
      • Nyamukoho E.
      • Mangezi W.
      • Marimbe B.
      • Verhey R.
      • Chibanda D.
      Depression among HIV positive pregnant women in Zimbabwe: a primary health care based cross-sectional study.
      • Bonacquisti A.
      • Geller P.A.
      • Aaron E.
      Rates and predictors of prenatal depression in women living with and without HIV.
      Reduction of premature mortality from non-communicable diseases through prevention, treatment, and promotion of mental health and well-being is a global agenda as specified in the third component of Sustainable Development Goals (SDGs). One way to achieve this goal may be routine antenatal screening and timely intervention of antenatal depression.
      Even though antenatal depression is a serious mental health issue among HIV-positive women, as the author's deep review, there is no study conducted on antenatal depression and its associated factors among HIV-positive pregnant women in Ethiopia. Therefore, the aim of this study was to assess antenatal depression and associated factors among HIV-positive pregnant women attending PMTCT service in South Gondar zone public health facilities, northwest Ethiopia.

      2. Methods and materials

      2.1 Study settings, design, period and population

      An institutional-based cross-sectional study was conducted from November 1st/2020 to April 30th/2021. The study was conducted in public health facilities in South Gondar zone, Amhara national regional state, northwest Ethiopia. Debre Tabor is the capital city of the South Gondar administrative zone, which is found 103 km away from Bahir Dar; the capital city of Amhara regional state, and about 666 km away from Addis Ababa (the capital city of Ethiopia). A total of 2,484,929 populations are living in the South Gondar zone of which, 1,227,606 are females. It consists of 18 Woredas.
      • Addis A.
      Federal Democratic Republic of Ethiopia central statistical agency population projection of Ethiopia for all regions at Wereda level from 2014–2017.
      There are eight governmental hospitals and 96 public health centers, 140 private clinics, and 403 health posts (unpublished zonal health office report). The source population were all HIV-positive pregnant women who came for PMTCT service in South Gondar zone public health facilities and HIV-positive pregnant women who came for PMTCT service at the selected public health facilities in South Gondar zone during the study period were the study population.

      2.2 Inclusion and exclusion criteria

      HIV-positive pregnant women who attended PMTCT service at public health facilities in South Gondar zone were eligible for the study. Women who were critically ill and unable to give a response throughout the data collection period and women under age of 18 were excluded.

      2.3 Sample size determination and sampling technique

      The sample size for this study was determined by using a single population proportion formula based on the following assumptions: 95% level of confidence, and 5% margin of error, 39.4% of antenatal depression among HIV positive pregnant women.
      • Nyamukoho E.
      • Mangezi W.
      • Marimbe B.
      • Verhey R.
      • Chibanda D.
      Depression among HIV positive pregnant women in Zimbabwe: a primary health care based cross-sectional study.
      n=(Zα/2)2p(1p)(d)2=(1.96)2*0.394(10.394)(0.05)2=367. After considering a design effect of 1.5 and a non-response rate of 10%, we obtained a total sample size of 606.
      The calculated sample sizes for the second objective (associated factors) were less than that was computed for the first objective, so we have used the sample size calculated for the first objective as mentioned above.
      In the South Gondar zone, there is one comprehensive referral hospital, seven primary governmental hospitals, and 96 public health centers. Thirty-one public health facilities (30%) were selected randomly using a lottery method. Then, the calculated sample size was proportionally allocated to each health facility based on their six months report of cases. Thereafter, the skipping interval (Kth) was calculated by dividing the total number of cases by the calculated sample size (1216/606), resulting in 2. The first case in each facility was selected randomly using a lottery method. Finally, a systematic random sampling technique was used to select all eligible pregnant women by using the PMTCT registration book (Fig. 1).
      Fig. 1
      Fig. 1Schematic presentation of sampling procedure on antenatal depression and associated factors among HIV positive pregnant women attending PMTCT service in South Gondar zone public health facilities, northwest Ethiopia 2020/21.DTRH = Debre Tabor Referral Hospital, NMPH= Nefa Mewcha Primary Hospital AZPH = Adis Zemen Primary Hospital, MEPH = Mekane Eyesus Primary Hospital.

      2.4 Variables of the study

      Antenatal depression was the outcome variable, whereas maternal age, religion, residence, current marital status, educational status of women, maternal occupation, educational status of the husband, occupational status of the husband, and family's monthly income, parity, gestational age, planned pregnancy, mode of delivery in the past, history of abortion, history of stillbirth, number of alive children, chronic medical illness, months on ART, ART adherence, WHO HIV clinical-stage, Having HIV positive child, diagnosed with HIV in this pregnancy, partner's HIV serostatus, opportunistic infections, viral load, social support, internalized AIDS stigma, intimate partner violence, disclosure of HIV status to anyone, disclosure of HIV status to partner, and previous history of depression were independent variables.

      2.5 Operational definitions and measurements

      Antenatal Depression: The Edinburgh Postnatal/Perinatal Depression Scale (EPDS) has been used to detect depression. The EPDS is a 10 item questionnaire, scored from 0 up to 3 (higher score indicating more depressive symptoms), that has been validated for detecting depression in antepartum and postpartum period in many countries including Ethiopia. We used EPDS cutoff point 13 to identify pregnant women with depression.
      • Cox J.L.
      • Holden J.M.
      • Sagovsky R.
      Detection of postnatal depression. Development of the 10-item Edinburgh postnatal depression scale.
      Those HIV-positive pregnant women who had a score of 13 and above were categorized as depressed, while pregnant women who had a score below 13 were considered as not depressed.
      • Peltzer K.
      • Rodriguez V.J.
      • Jones D.
      Prevalence of prenatal depression and associated factors among HIV-positive women in primary care in Mpumalanga province, South Africa.
      Social support: Was measured using Oslo's three-item social support scale.
      • Abiola T.
      • Udofia O.
      • Zakari M.
      Psychometric properties of the 3-item oslo social support scale among clinical students of Bayero University Kano, Nigeria.
      The respondents who had a score of 3–8 on the Oslo's three-item social support scale were categorized as having a poor social support, 9–11 were categorized as having moderate social support, and 12–14 were categorized as having a strong social support.
      • Duko B.
      • Geja E.
      • Zewude M.
      • Mekonen S.
      Prevalence and associated factors of depression among patients with HIV/AIDS in Hawassa, Ethiopia, cross-sectional study.
      ,
      • Bitew T.
      • Hanlon C.
      • Kebede E.
      • Medhin G.
      • Fekadu A.
      Antenatal depressive symptoms and maternal health care utilisation: a population-based study of pregnant women in Ethiopia.
      ART adherence: The four-item Morisky Medication Adherence Rating Scale (MMARS) questionnaire was used to measure ART drug adherence.
      • Knobel JA H.
      • Casado J.L.
      • et al.
      Validation of a simplifed medication adherence questionnaire in a large cohort of HIV-infected patients.
      HIV-positive pregnant women who responded “No” to all the four adherence questions were considered to have ART adherence. Participants who responded “Yes” to one question out of four were considered ART non-adherent.
      • Tesfaye D.J.
      • Hibistu D.T.
      • Abebo T.A.
      • et al.
      Option B plus antiretroviral therapy adherence and associated factors among HIV positive pregnant women in Southern Ethiopia.
      Internalized AIDS Stigma: AIDS-Related Stigma Scale was used to measure internalized AIDS-related stigma. Study participants have been classified as having or not having stigma using the mean of the stigma variables as the cutoff point. Participants who had scored above the value of the mean were considered as having internalized AIDS-related stigma, whereas, those participants who had a score below the value of the mean were considered as not having internalized AIDS-related stigma.
      • Phillips K.D.
      • Moneyham L.
      • Tavakoli A.
      Development of an instrument to measure internalized stigma in those with HIV/AIDS.
      ,
      • Abadiga M.
      Depression and its associated factors among HIV/AIDS patients attending ART clinics at Gimbi General hospital, West Ethiopia, 2018.
      Intimate partner violence: Study participants who respond “Yes” to any one of sexual, psychological, physical, or any combination of the three coercive acts used against HIV-positive pregnant women by their intimate partner. In this study intimate partner was considered as a current spouse, cohabited (live in the same house without formal marriage), Current non-marital partners (boyfriends), former partner or spouse.
      • Azene Z.N.
      • Yeshita H.Y.
      • Mekonnen F.A.
      Intimate partner violence and associated factors among pregnant women attending antenatal care service in Debre Markos town health facilities, Northwest Ethiopia.

      2.6 Data collection tools & procedures

      The data collection tool was developed by reviewing related literature. Data were collected using structured, pretested questionnaires through face-to-face interviews and chart review. The questionnaires contain socio-demographic characteristics, obstetric-related variables, HIV-related, and psychosocial related variables. Edinburgh Postnatal/Perinatal Depression Scale (EPDS) was used to assess antenatal depression. Data collection were done by thirty-one BSc midwives who work at PMTCT clinics in the selected health facilities, and five BSc midwives were supervisors.

      2.7 Data quality control measures

      The data collection tool was prepared in English and then translated into the local language Amharic then translated back to English to check the consistency. Before the actual data collection, the questionnaire was pretested on 5%
      • Nydoo P.
      • Naicker T.
      • Moodley J.
      Depressive scores in newly diagnosed HIV-infected and HIV-uninfected pregnant women.
      of the total sample size at Tach Gyint primary hospital and Alember health center. Training was given to data collectors and supervisors about the aim of the study, contents of the tool, sampling technique, and also how to give clarification and adequate description for the participants. During data collection, data collectors were supervised for any difficulties. The consistency and completeness of the data were checked by the data collectors and supervisors.

      2.8 Data processing & analysis

      The data were checked, coded, cleaned, and entered using Epi data version 4.6 and then exported to SPSS version 23 for analysis. Descriptive statistics like frequencies, percentage mean and standard deviation were computed. The analyzed data were presented using text, tables, and graph. The association of each independent variable with the dependent variable was tested using bivariable logistic regression analysis, and all associated variables with a p-value of ≤0.2 were entered into the final multivariable logistic regression model to identify independent factors associated with antenatal depression. Adjusted odds ratio (AOR) with 95% CI was computed to determine the presence and strength of association. A p-value of ≤0.05 was taken to declare the presence of statistical significance.

      3. Results

      3.1 Socio-demographic characteristics of study participants

      A total of 606 HIV-positive pregnant women were found from the selected health facilities in this study. Of these, 590 participants were interviewed with a response rate of 97.36%. The median age of the participants was 30 years with an interquartile range of (26–35 years) and 57.3% of respondents were between the age group of 25–34 years. Three fourth (75.9%) and more than two-thirds (70.3%) of the women were Orthodox Christians by religion and urban residency, respectively. The majority (84.4%) and more than half (51.9%) of the study participants were currently married and housewives, respectively. Moreover, nearly two-fifths (37.6%) of HIV-positive pregnant women and 26.7% of their husbands were unable to read and write, respectively (Table 1).
      Table 1Socio-demographics characteristics of HIV-positive pregnant women who were attending PMTCT service in South Gondar zone public health facilities, northwest Ethiopia, 2020/21 (n = 590).
      CharacteristicsFrequencyPercentage
      Maternal age in years
      18–249015.2
      25–3433857.3
      ≥3516227.5
      Residence
      Rural17529.7
      Urban41570.3
      Religion
      Orthodox44875.9
      Muslim11519.5
      Protestant274.6
      Educational status of the women
      Unable to read and write22237.6
      Able to read and write10117.1
      Primary(1–8)10016.9
      Secondary (9–12)9616.3
      College and above7112.1
      Maternal occupation
      Employed (governmental/Private)7212.2
      Housewife30651.9
      Merchant8414.2
      Student274.6
      Farmer7813.2
      Daily laborer233.9
      Current marital status
      Married49884.4
      Unmarried
      ----- single, divorced, widowed.
      9215.6
      Husbands' educational status (n = 498)
      Unable to read and write13326.7
      Able to read and write8416.9
      Primary
      • Marcus M.
      • Yasamy M.T.
      • Ommeren M.
      • Chisholm D.
      • Saxena S.
      Depression: A Global Public Health Concern.
      • Marina Marcus MTY MvO
      • Chisholm Dan
      • Saxena Shekhar
      • Arseniou S.
      • Arvaniti A.
      • Samakouri M.
      HIV infection and depression.
      • Loncar D.
      • Mathers C.D.
      Loncar D Projections of global mortality and burden of disease from 2002 to 2030.
      • Saxena S.
      • Funk M.
      • Chisholm D.
      World health assembly adopts comprehensive mental health action plan 2013 ;2020.
      • Health FDRoEMo
      National Mental Health Strategy 2012/13–2015/16. Public Policy Document, Federal Democratic Republic of Ethiopia.
      • Austin M.-P.
      Highest N and the Expert Working Group.
      • Dadi A.F.
      • Miller E.R.
      • Bisetegn T.A.
      • Mwanri L.
      Global burden of antenatal depression and its association with adverse birth outcomes: an umbrella review.
      7815.7
      Secondary
      • Halim N.B.J.
      • Mesic A.
      • Patel A.
      • Henderson D.
      • Hibberd P.
      Intimate partner violence during pregnancy and perinatal mental disorders in low and lower middle income countries: a systematic review of literature, 1990-2017.
      • Kapetanovic S.
      • Dass-Brailsford P.
      • Nora D.
      • Talisman N.
      Mental health of HIV-seropositive women during pregnancy and postpartum period: a comprehensive literature review.
      • Arachchi N.S.M.
      • Ganegama R.
      • Husna A.W.F.
      • et al.
      Suicidal ideation and intentional self-harm in pregnancy as a neglected agenda in maternal health; an experience from rural Sri Lanka.
      • Wagner G.J.
      • McBain R.K.
      • Akena D.
      • et al.
      Maternal depression treatment in HIV (M-DEPTH): study protocol for a cluster randomized controlled trial.
      7615.3
      College and above12725.4
      Husbands' occupational status (n = 498)
      Employed (governmental/Private15230.5
      Merchant12324.7
      Farmer15931.9
      Daily laborer5711.4
      Other
      -----Jobless, driver ETB = Ethiopian birr.
      71.5
      Average monthly income (n = 590)
      ≤1000ETB12721.5
      1001-2000ETB11619.7
      2001-3000ETB9315.8
      >3000ETB25443.0
      b ----- single, divorced, widowed.
      a -----Jobless, driver ETB = Ethiopian birr.

      3.2 Obstetrics related characteristics of study participants

      Among the study participants, more than half (51.4%) of them were para two and above. Two-thirds (75.3%) and 57.6% of the study subjects had planned pregnancy and were in the second trimester, respectively. Nearly one-fifth (18.6%) of women had a history of abortion (Table 2).
      Table 2Obstetrics related characteristics of HIV-positive pregnant women who were attending PMTCT service in South Gondar zone public health facilities, northwest Ethiopia, 2020/21 (n = 590).
      CharacteristicsFrequencyPercentage (%)
      Parity
      None13723.2
      One15025.4
      Two and above30351.4
      Trimester of current pregnancy
      1stTrimester274.6
      2nd Trimester34057.6
      3rd Trimester22337.8
      Pregnancy planned
      Yes44475.3
      No14624.7
      Mode previous delivery (n = 453)
      Vaginal delivery38785.4
      Cesarean delivery439.5
      Instrumental delivery235.1
      History of abortion
      Yes11018.6
      No48081.4
      History of stillbirth
      Yes193.2
      No57196.8
      Number of alive children
      None14123.9
      One15826.8
      Two and above29149.3
      Chronic medical illness
      Yes427.1
      No54892.9

      3.3 HIV related characteristics of the study participants

      Among HIV-positive pregnant women, 85.3% had been diagnosed with HIV positive before the current pregnancy and of these, 42.5% were on ART for longer than 25 months. In this study, 70.5%, 82%, and 94.1% of the study participants had undetected viral loads, stage I HIV/AIDS, and had no opportunistic infections respectively. Nearly half (47.8%) of the women were ART adherent (Table 3).
      Table 3HIV related characteristics of HIV-positive pregnant women who were attending PMTCT service in South Gondar zone public health facilities, northwest Ethiopia,2020/21 (n = 590).
      CharacteristicsFrequencyPercentage
      When Diagnosed with HIV
      In this pregnancy8714.7
      Before this pregnancy50385.3
      For how long on ART(in months)
      ≤6 months13623.1
      7–24 months20334.4
      ≥25 months25142.5
      ART Adherence
      Yes28247.8
      No30852.2
      Viral load
      Not detected41670.5
      <10007612.9
      ≥10007713.1
      Unknown213.5
      WHO HIV clinical stage
      Stage I48482
      Stage II and above10618
      Opportunistic infections
      Yes355.9
      No55594.1
      Partners' HIV sero-status
      HIV positive48281.7
      HIV negative or Unknown10818.3
      Do you have HIV positive children (n = 449)
      Yes4610.2
      No or unknown status40389.8

      3.4 Psychosocial characteristics of the study participants

      Among the study participants, 42.7% reported that they had experienced intimate partner violence during their current pregnancy. About 44.8% and 48.1% of the study participants had moderate social support and had experienced internalized AIDS-related stigma, respectively (Table 4).
      Table 4Psychosocial related characteristics of HIV-positive pregnant women who were attending PMTCT service in South Gondar zone public health facilities, northwest Ethiopia, 2020/21 (n = 590).
      CharacteristicsFrequencyPercentage
      Intimate partner violence
      Yes25242.7
      No33857.3
      Social support
      Poor support16327.6
      Moderate support26444.8
      Strong support16327.6
      Internalized AIDS Stigma
      Yes28448.1
      No30651.9
      Disclosure of HIV status to anyone
      Yes49383.6
      No9716.4
      Disclosure of HIV status to partner
      Yes47580.5
      No11519.5
      History of depression
      Yes50.8
      No58599.2

      3.5 Prevalence of antenatal depression among HIV-positive pregnant women

      The prevalence of antenatal depression among HIV-positive pregnant women was found to be 36.4% (95% CI: 32.7, 40.2).

      3.6 Factors associated with antenatal depression among HIV-positive pregnant women

      In the bi-variable analysis, the factors had found to be significantly associated with antenatal depression were: unmarried current marital status, parity, unplanned pregnancy, having a chronic medical illness, ART non-adherence, had experienced intimate partner violence in the current pregnancy, poor social support, and had experienced internalized AIDS stigma. Of the variables found to be significant in bi-variable analysis, being unmarried, ART non-adherence, had experienced intimate partner violence in the current pregnancy and had experienced internalized AIDS stigma were factors independently associated with antenatal depression in multivariable logistic regression.
      The current study found that developing antenatal depression among currently unmarried HIV-positive pregnant women was 2.77 times higher as compared to currently married women [AOR = 2.77; 95% CI: (1.26, 6.07)].
      This study also suggested that participants who were ART non-adherent had 2.18 times higher odds of developing antenatal depression than those participants who were ART adherent [AOR = 2.18, 95% CI: (1.50, 3.18)].
      In addition, the odds of antenatal depression were 1.50 times higher among HIV-positive pregnant women who had experienced intimate partner violence in the current pregnancy than their counterparts [AOR = 1.50, 95% CI: (1.05, 2.15)].
      Lastly, HIV-positive pregnant women who had experienced internalized AIDS stigma had 1.46 times higher odds of developing antenatal depression as compared to those women who had not experienced internalized AIDS stigma [AOR = 1.46, 95% CI: (1.02, 2.09)] (Table 5).
      Table 5Bivariate and multivariable logistic regression analysis of factors associated with antenatal depression among HIV-positive pregnant women who were attending PMTCT service in South Gondar zone public health facilities, northwest Ethiopia,2020/21 (n = 590).
      VariableDepressionCOR(95%CI)AOR(95%CI)
      YesNo
      Current marital status
      Married17432411
      Unmarried41511.49 (0.95,2.35)2.77 (1.26, 6.07)*
      Parity
      None54831.32 (0.87, 2.00)0.65 (0.33, 1.31)
      One61891.39 (0.93, 2.08)1.52 (1.00,2.32)
      Two and above10020311
      Planned pregnancy
      Yes15129311
      No64821.51 (1.03, 2.22)1.19 (0.76, 1.85)
      Chronic medical illness
      Yes22202.02 (1.08, 3.80)1.62 (0.83, 3.18)
      No19335511
      ART Adherence
      Yes7520711
      No1401682.30 (1.62, 3.25)2.18 (1.5, 3.18) **
      Intimate partner violence
      Yes1121401.82 (1.30,2.56)1.50 (1.05, 2.15)*
      No10323511
      Social support
      Poor support73901.55 (0.99,2.42)1.19 (0.74,1.92)
      Moderate support861780.92 (0.61,1.39)0.75 (0.49,1.17)
      Strong support5610711
      Internalized AIDS Stigma
      Yes1221621.72 (1.23,2.42)1.46 (1.02, 2.09)*
      No9321311
      COR= Crude odds ratio, AOR = Adjusted odds ratio, CI=Confidence interval.
      * P-value ≤0.05, ** P-value ≤0.001.

      4. Discussion

      Antenatal depression among HIV-positive pregnant women is a devastating problem that directly affects both the health outcome of the mother and the fetus. Hence, this study assessed antenatal depression and associated factors among HIV-positive pregnant women in south Gondar zone, northwest Ethiopia. The study result showed that the prevalence of antenatal depression was 36.4% (95% CI: 32.7, 40.2).
      The current study is higher than the studies done in Malawi 9.5%,
      • Harrington B.J.
      • Pence B.W.
      • John M.
      • et al.
      Prevalence and factors associated with antenatal depressive symptoms among women enrolled in Option B+ antenatal HIV care in Malawi: a cross-sectional analysis.
      Tanzania 25%,
      • Ngocho J.S.
      • Watt M.H.
      • Minja L.
      • et al.
      Depression and anxiety among pregnant women living with HIV in Kilimanjaro region, Tanzania.
      and Ukraine 27%.
      • Bailey H.
      • Malyuta R.
      • Semenenko I.
      • et al.
      Prevalence of depressive symptoms in pregnant and postnatal HIV-positive women in Ukraine: a cross-sectional survey.
      The discrepancy of this study with study in Malawi might be due to different socio-demographic statuses. The majority of the study participants for the study in Malawi were currently married women compared to the current study participants (90% vs 84.4%). So, married women might have psychological and financial support from their husbands, this has a role in decreasing antenatal depression.
      • Ngocho J.S.
      • Watt M.H.
      • Minja L.
      • et al.
      Depression and anxiety among pregnant women living with HIV in Kilimanjaro region, Tanzania.
      The possible explanation for the discrepancy from a study in Tanzania might be due to the difference in the educational status of the study participants. Most of the study participants in Tanzania were in primary education and above compared to this study (98% vs 45.3). This is evidenced by depression is more prevalent among less educated people.
      • Josje ten Kate J.
      • de Koster W.
      • van der Waal J.
      Why are depressive symptoms more prevalent among the less educated? The relevance of low cultural capital and cultural entitlement.
      This may be due to lower educational status associated with lower socioeconomic status, financial dependency, and unemployment. In addition, they may have misconceptions about HIV and prone to perceive AIDS-related stigma and social withdrawal results in depression.
      The discrepancy from a study in Ukraine might be due to most of the study participants in Ukraine had disclosed their HIV-positive status compared to the study participants in the current study (91% vs 83.6%). So, disclosed HIV-positive status is associated with decreased depression by increasing social support from their friends, families, children, and partner.
      • Seid S.
      • Abdu O.
      • Mitiku M.
      • Tamirat K.S.
      Prevalence of depression and associated factors among HIV/AIDS patients attending antiretroviral therapy clinic at Dessie referral hospital, South Wollo, Ethiopia.
      The current study is in line with studies conducted in Zimbabwe 39.4%
      • Nyamukoho E.
      • Mangezi W.
      • Marimbe B.
      • Verhey R.
      • Chibanda D.
      Depression among HIV positive pregnant women in Zimbabwe: a primary health care based cross-sectional study.
      and America 36%.
      • Bonacquisti A.
      • Geller P.A.
      • Aaron E.
      Rates and predictors of prenatal depression in women living with and without HIV.
      On the other hand, the finding of this study is lower than the study reported from South Africa 48%.
      • Peltzer K.
      • Rodriguez V.J.
      • Jones D.
      Prevalence of prenatal depression and associated factors among HIV-positive women in primary care in Mpumalanga province, South Africa.
      The variation of this study from the study in South Africa could be due to differences in the inclusion criteria. The current study used HIV-positive pregnant women in all trimesters while, the study in South Africa used women at a gestational age of 20 weeks and above. The possible explanation might be as gestational age increases and close to the date of delivery the women would be more worried about the coming delivery and the health of the fetus. Thus, antenatal depression increases during mid and late trimesters.
      • Fatoye F.O.
      • Adeyemi A.B.
      • BY Oladimeji
      Emotional distress and its correlates among Nigerian women in late pregnancy.
      The current study found that current marital status was a significant predicting factor for antenatal depression. Thus, developing antenatal depression among currently unmarried HIV-positive pregnant women was 2.77 times higher as compared to currently married women. Similar findings were reported by a study conducted in Tanzania
      • Ngocho J.S.
      • Watt M.H.
      • Minja L.
      • et al.
      Depression and anxiety among pregnant women living with HIV in Kilimanjaro region, Tanzania.
      in which the likelihood of antenatal depression is higher among currently unmarried women. This could be because psychological, social, financial, and emotional support by the partner has a major role in decreasing depression during pregnancy.
      • Baranowska-Rataj A.
      • Matysiak A.
      • Mynarska M.
      Does lone motherhood decrease women's happiness? Evidence from qualitative and quantitative research.
      Evidence supports that unmarried women are highly prone to social, economic, and psychological challenges that may increase the occurrence of depression.
      • Stack R.J.
      • Meredith A.
      The impact of financial hardship on single parents: an exploration of the journey from social distress to seeking help.
      Moreover, societal norms and culture may contribute to this variation in which being a single mother is unacceptable in the community.
      The current study also suggested that participants who were ART non-adherent had 2.18 times higher odds of developing antenatal depression than those participants who were ART adherent. This finding is supported by a similar study conducted in South Africa.
      • Peltzer K.
      • Rodriguez V.J.
      • Jones D.
      Prevalence of prenatal depression and associated factors among HIV-positive women in primary care in Mpumalanga province, South Africa.
      This might be due to the fact that if patients did not adhere to ART medications may have poor viral suppression and more immune compromisation. Besides, ART non-adherence could associate with the progression of HIV disease to advanced stages and increase the risk of MTCT.
      • Antelman G.
      • Kaaya S.
      • Wei R.
      • et al.
      Depressive symptoms increase risk of HIV disease progression and mortality among women in Tanzania.
      ,
      • Schnack A.
      • Rempis E.
      • Decker S.
      • et al.
      Prevention of mother-to-child transmission of HIV in option B+ era: uptake and adherence during pregnancy in Western Uganda.
      These, in turn, will lead to an increased risk of depression due to poor quality of life and the inability to cope with daily activities.
      The odds of antenatal depression were 1.50 times higher among HIV-positive pregnant women who had experienced intimate partner violence in the current pregnancy than their counterparts. This finding is consistent with studies done in South Africa,
      • Peltzer K.
      • Rodriguez V.J.
      • Jones D.
      Prevalence of prenatal depression and associated factors among HIV-positive women in primary care in Mpumalanga province, South Africa.
      Malawi,
      • Harrington B.J.
      • Pence B.W.
      • John M.
      • et al.
      Prevalence and factors associated with antenatal depressive symptoms among women enrolled in Option B+ antenatal HIV care in Malawi: a cross-sectional analysis.
      and Zimbabwe.
      • Nyamukoho E.
      • Mangezi W.
      • Marimbe B.
      • Verhey R.
      • Chibanda D.
      Depression among HIV positive pregnant women in Zimbabwe: a primary health care based cross-sectional study.
      This could reveal that psychological, physical, and sexual abuse by the intimate partner particularly during pregnancy could lead to depression.
      Lastly, this study showed that those HIV-positive pregnant women who had experienced internalized AIDS stigma had 1.46 times higher odds of developing antenatal depression as compared to those who had not experienced internalized AIDS stigma. This finding is supported by a study done in South Africa.
      • Brittain K.
      • Mellins C.A.
      • Phillips T.
      • et al.
      Social support, stigma and antenatal depression among HIV-infected pregnant women in South Africa.
      Having HIV, which is one of the chronic life-long disease and is prone to high levels of stigma. So patients may prefer withdrawal from society to avoid stigma so that, feelings of exclusion or loneliness may lead to depression.

      5. Conclusion

      More than one in three HIV-positive pregnant women had antenatal depression. Being unmarried, had experienced intimate partner violence during the current pregnancy, had experienced internalized AIDS stigma and ART non-adherence were factors independently associated with antenatal depression among HIV-positive pregnant women. Therefore, there is a need to integrate routine screening for antenatal depression and intervention in antenatal care service especially in the PMTCT care settings.

      Ethical approval and consent to participate

      Ethical clearance for the study was obtained from Institutional Review Board (IRB) of the University of Gondar. Support letters were submitted to the selected health facilities and permission of facilities was obtained from the demonstratives. After a detailed explanation of the purpose and benefits of the study to the study participants, informed written consent was taken. Personal identifying details were not recorded. The interview was conducted in a separate room in the PMTCT clinic. The questionnaires and all data taken from the participants were kept locked in safe places and used only for the study purpose. The study participants who had the idea of suicide were counseled by the health care providers and were advised to visit the psychiatric clinic for better evaluation and treatment.

      Consent for publication

      Not applicable.

      Availability of data and materials

      The authors declare that the data regarding this manuscript can be accessed as per the request of any interested body.

      Funding

      The authors received no specific funding for this work.

      Authors contribution

      SYD: wrote the proposal, participated in data collection, SYD, MBB, MMA and WZT analyzed the data, drafted the paper and prepared the manuscript, approved the proposal with few revisions, participated in data analysis and revised subsequent drafts of the paper. All the authors read and approved the final manuscript.

      Declaration of competing interest

      The authors declare no conflict of interest exists.

      Acknowledgments

      Our appreciation goes to University of Gondar for providing ethical clearance to carry out this study. We also would like to acknowledge the data collectors and study participants.

      List of abbreviations

      AIDS
      Acquired Immune Deficiency Syndrome
      AOR
      Adjusted Odds Ratio
      ART
      Antiretroviral Therapy
      CI
      Confidence Interval
      COR
      Crude Odds Ratio
      EPDS
      Edinburgh Postnatal Depression Scale
      HIV
      Human Immunodeficiency Virus
      MTCT
      Mother to Child Transmission
      PMTCT
      Prevention of Mother to Child Transmission

      References

        • Marcus M.
        • Yasamy M.T.
        • Ommeren M.
        • Chisholm D.
        • Saxena S.
        Depression: A Global Public Health Concern.
        World Health Organization Paper on Depression, 2012: 6-8
        • Marina Marcus MTY MvO
        • Chisholm Dan
        • Saxena Shekhar
        A Global Public Health. vol. 32. WHO Department of Mental Health and Substance Abuse, 2012
        • Arseniou S.
        • Arvaniti A.
        • Samakouri M.
        HIV infection and depression.
        Psychiatr Clin Neurosci. 2014; 68: 96-109
        • Loncar D.
        • Mathers C.D.
        Loncar D Projections of global mortality and burden of disease from 2002 to 2030.
        PLoS Med. 2006; 3: e442
        • Saxena S.
        • Funk M.
        • Chisholm D.
        World health assembly adopts comprehensive mental health action plan 2013 ;2020.
        Lancet. 2013; 381: 1970-1971
        • Health FDRoEMo
        National Mental Health Strategy 2012/13–2015/16. Public Policy Document, Federal Democratic Republic of Ethiopia.
        2012
        • Austin M.-P.
        Highest N and the Expert Working Group.
        2017 (Mental health care in the perinatal period: Australian clinical practice guideline. Centre of perinatal excellence depression during pregnancy)
        • Dadi A.F.
        • Miller E.R.
        • Bisetegn T.A.
        • Mwanri L.
        Global burden of antenatal depression and its association with adverse birth outcomes: an umbrella review.
        BMC Publ Health. 2020; 20: 173
        • Halim N.B.J.
        • Mesic A.
        • Patel A.
        • Henderson D.
        • Hibberd P.
        Intimate partner violence during pregnancy and perinatal mental disorders in low and lower middle income countries: a systematic review of literature, 1990-2017.
        Clin Psychol Rev. 2017;
        • Kapetanovic S.
        • Dass-Brailsford P.
        • Nora D.
        • Talisman N.
        Mental health of HIV-seropositive women during pregnancy and postpartum period: a comprehensive literature review.
        AIDS Behav. 2014; 18: 1152-1173
        • Arachchi N.S.M.
        • Ganegama R.
        • Husna A.W.F.
        • et al.
        Suicidal ideation and intentional self-harm in pregnancy as a neglected agenda in maternal health; an experience from rural Sri Lanka.
        Reprod Health. 2019; 16: 166
        • Wagner G.J.
        • McBain R.K.
        • Akena D.
        • et al.
        Maternal depression treatment in HIV (M-DEPTH): study protocol for a cluster randomized controlled trial.
        Medicine. 2019; 98
        • Fekadu Dadi A.M.E.
        • Mwanri L.
        Antenatal depression and its association with adverse birth outecomes in low and middle-income countries: a systematic review and meta- analysis.
        PLoS One. 2020; 15e0227323
        • EastwoodJ O.
        • HendryA NobleJ.
        • Page A.
        • for the Early Years Research Group (EYRG)
        The impact of antenatal depression on perinatal outcomes in Australian women.
        PLoS One. 2017; 12 (10.1371/journal. pone.0169907)e0169907
        • Antelman G.
        • Kaaya S.
        • Wei R.
        • et al.
        Depressive symptoms increase risk of HIV disease progression and mortality among women in Tanzania.
        J Acquir Immune Defic Syndr. 2007; 44: 470-477
        • Gelaye B.
        • Rondon M.B.
        • Araya R.
        • Williams M.A.
        Epidemiology of maternal depression, risk factors, and child outcomes in low-income and middle-income countries.
        Lancet Psychiatr. 2016; 3: 973-982
        • Smith M.V.
        • Shao L.
        • Howell H.
        • Lin H.
        • Yonkers K.A.
        Perinatal depression and birth outcomes in a Healthy Start project.
        Matern Child Health J. 2011; 15: 401-409
        • Tuthill E.L.
        • Pellowski J.A.
        • Young S.L.
        • Butler L.M.
        Perinatal depression among HIV-infected women in KwaZulu-natal South Africa: prenatal depression predicts lower rates of exclusive breastfeeding.
        AIDS Behav. 2017; 21: 1691-1698
        • Shen H.M.C.
        • Rai D.
        • Lundberg M.
        • Le-Scherban F.
        • Dalman C.
        • et al.
        Associations of parental depression with child school performance at age 16 years in Sweden.
        JAMA Psychiatr. 2016; 73: 239-246
        • Shidhaye P.
        • Giri P.
        Maternal depression: a hidden burden in developing countries.
        Ann Med Health Sci Res. 2014; 4: 463-465
        • Peltzer K.
        • Rodriguez V.J.
        • Jones D.
        Prevalence of prenatal depression and associated factors among HIV-positive women in primary care in Mpumalanga province, South Africa.
        SAHARA-J (J Soc Aspects HIV/AIDS Res Alliance): Journal of Social Aspects of HIV/AIDS. 2016; 13: 60-67
        • Ngocho J.S.
        • Watt M.H.
        • Minja L.
        • et al.
        Depression and anxiety among pregnant women living with HIV in Kilimanjaro region, Tanzania.
        PLoS One. 2019; 14e0224515
        • Harrington B.J.
        • Pence B.W.
        • John M.
        • et al.
        Prevalence and factors associated with antenatal depressive symptoms among women enrolled in Option B+ antenatal HIV care in Malawi: a cross-sectional analysis.
        J Ment Health. 2019; 28: 198-205
        • Kaida A.
        • Matthews L.T.
        • Ashaba S.
        • et al.
        Depression during pregnancy and the postpartum among HIV-infected women on antiretroviral therapy in Uganda.
        J Acquir Immune Defic Syndr. 2014; 67: S179-S187
        • Nyamukoho E.
        • Mangezi W.
        • Marimbe B.
        • Verhey R.
        • Chibanda D.
        Depression among HIV positive pregnant women in Zimbabwe: a primary health care based cross-sectional study.
        BMC Pregnancy Childbirth. 2019; 19: 53
        • Bonacquisti A.
        • Geller P.A.
        • Aaron E.
        Rates and predictors of prenatal depression in women living with and without HIV.
        AIDS Care. 2014; 26: 100-106
        • Addis A.
        Federal Democratic Republic of Ethiopia central statistical agency population projection of Ethiopia for all regions at Wereda level from 2014–2017.
        Addis Ababa: Central Statistical Agency. 2014;
        • Cox J.L.
        • Holden J.M.
        • Sagovsky R.
        Detection of postnatal depression. Development of the 10-item Edinburgh postnatal depression scale.
        Br J Psychiatry. 1987; 150: 782-786
        • Abiola T.
        • Udofia O.
        • Zakari M.
        Psychometric properties of the 3-item oslo social support scale among clinical students of Bayero University Kano, Nigeria.
        Malaysian Journal of Psychiatry. 2013; 22: 32-41
        • Duko B.
        • Geja E.
        • Zewude M.
        • Mekonen S.
        Prevalence and associated factors of depression among patients with HIV/AIDS in Hawassa, Ethiopia, cross-sectional study.
        Ann Gen Psychiatr. 2018; 17: 45
        • Bitew T.
        • Hanlon C.
        • Kebede E.
        • Medhin G.
        • Fekadu A.
        Antenatal depressive symptoms and maternal health care utilisation: a population-based study of pregnant women in Ethiopia.
        BMC Pregnancy Childbirth. 2016; 16: 301
        • Knobel JA H.
        • Casado J.L.
        • et al.
        Validation of a simplifed medication adherence questionnaire in a large cohort of HIV-infected patients.
        The GEEMA study,”AIDS. 2002; 16: 605-613
        • Tesfaye D.J.
        • Hibistu D.T.
        • Abebo T.A.
        • et al.
        Option B plus antiretroviral therapy adherence and associated factors among HIV positive pregnant women in Southern Ethiopia.
        BMC Pregnancy Childbirth. 2019; 19: 82
        • Phillips K.D.
        • Moneyham L.
        • Tavakoli A.
        Development of an instrument to measure internalized stigma in those with HIV/AIDS.
        Issues Ment Health Nurs. 2011; 32: 359-366
        • Abadiga M.
        Depression and its associated factors among HIV/AIDS patients attending ART clinics at Gimbi General hospital, West Ethiopia, 2018.
        BMC Res Notes. 2019; 12: 527
        • Azene Z.N.
        • Yeshita H.Y.
        • Mekonnen F.A.
        Intimate partner violence and associated factors among pregnant women attending antenatal care service in Debre Markos town health facilities, Northwest Ethiopia.
        PLoS One. 2019; 14e0218722
        • Nydoo P.
        • Naicker T.
        • Moodley J.
        Depressive scores in newly diagnosed HIV-infected and HIV-uninfected pregnant women.
        S Afr J Psychiatr. 2017; 23
        • Bailey H.
        • Malyuta R.
        • Semenenko I.
        • et al.
        Prevalence of depressive symptoms in pregnant and postnatal HIV-positive women in Ukraine: a cross-sectional survey.
        Reprod Health. 2016; 13: 27
        • Josje ten Kate J.
        • de Koster W.
        • van der Waal J.
        Why are depressive symptoms more prevalent among the less educated? The relevance of low cultural capital and cultural entitlement.
        Socio Spectr. 2017; 37: 63-76
        • Seid S.
        • Abdu O.
        • Mitiku M.
        • Tamirat K.S.
        Prevalence of depression and associated factors among HIV/AIDS patients attending antiretroviral therapy clinic at Dessie referral hospital, South Wollo, Ethiopia.
        Int J Ment Health Syst. 2020; 14: 55
        • Fatoye F.O.
        • Adeyemi A.B.
        • BY Oladimeji
        Emotional distress and its correlates among Nigerian women in late pregnancy.
        J Obstet Gynaecol. 2004; 24: 504-509
        • Baranowska-Rataj A.
        • Matysiak A.
        • Mynarska M.
        Does lone motherhood decrease women's happiness? Evidence from qualitative and quantitative research.
        J Happiness Stud. 2014; 15: 1457-1477
        • Stack R.J.
        • Meredith A.
        The impact of financial hardship on single parents: an exploration of the journey from social distress to seeking help.
        J Fam Econ Issues. 2018; 39: 233-242
        • Schnack A.
        • Rempis E.
        • Decker S.
        • et al.
        Prevention of mother-to-child transmission of HIV in option B+ era: uptake and adherence during pregnancy in Western Uganda.
        AIDS patient care and STDs. 2016; 30: 110-118
        • Brittain K.
        • Mellins C.A.
        • Phillips T.
        • et al.
        Social support, stigma and antenatal depression among HIV-infected pregnant women in South Africa.
        AIDS Behav. 2017; 21: 274-282