Knowledge of Midwives Regarding Antenatal Depression,Screening,and Referral in South Africa: A Qualitative Study Protocol

Abstract

Women are twice at risk of developing depression compared to men. This risk is even higher during pregnancy where many physiological, hormonal, social, and psychological changes occur. Prevalence studies show perinatal mental disorders are at least as prevalent in sub-Saharan Africa as they are in high-income and other low- and middle-income sub-regions. The mean weighted prevalence of both antenatal and postpartum depression are 11.3% and 18.3%, respectively, and the mean prevalence of both prenatal and postpartum anxiety is 14.8% and 14%, respectively in both high and low- and middle-income countries. Although maternal mental disorders, including antenatal depression, are widespread and have serious consequences, there remains a lack of understanding and inadequate care provided to pregnant women, by midwives who are their main healthcare providers. Therefore, this study aims to explore the midwives’ knowledge of antenatal depression before and after a training session on antenatal depression. The study will follow a qualitative research methodology and will be conducted in a Community Healthcare Center, in South Africa. In-depth individual interviews will be conducted with the midwives who attend to pregnant women at the study site before and after a training session on antenatal depression. Elo and Knygas’ content analysis will be used to analyse data. It is hoped that the results of the study may provide support for advocating the integration of mental health services into maternal care programmes.

Keywords

antenatal depression knowledge midwives South Africa pregnamt women

Background and Study Justification

One of the main causes of pregnancy-related morbidity and death is maternal depression, a non-psychotic depressive episode that is linked to behavioral, emotional, and cognitive issues (Sutherland et al., 2022). According to prevalence studies, perinatal mental disorders are at least as prevalent in sub-Saharan Africa as they are in high-income (HIC) and other low-to middle-income sub-regions (LMIC) (Ng’oma et al., 2019; Nweke et al., 2024). A systematic review found that the mean weighted prevalence of both antenatal and postpartum depression was 11.3% and 18.3%, respectively, and the mean prevalence of both prenatal and postpartum anxiety was 14.8% and 14%, respectively in both HICs and LMICs (Ng’oma et al., 2019; Nweke et al., 2024). This presents a global public health concern according to the World Health Organization (WHO, 2021) who reported that depression during pregnancy ranks third internationally in terms of disease burden among women between the ages of 14 and 44. By 2030, according to WHO projections, it may surpass heart disease and traffic accidents (WHO, 2021).

In sub-Saharan Africa, studies report rates of prenatal depression of 8.3%–26.6% (Adeoye et al., 2022) in Nigeria, 12%–18.7% in Tanzania and Kenya (Ngocho et al., 2022; Nweke et al., 2024; Tele et al., 2022). On the other hand, in three South African provinces i.e. Limpopo, KwaZulu Natal, and Cape Town prenatal depression ranged between 31.7% to 44% (Govender et al., 2020; Ramohlola et al., 2022). This is despite, the South African government, through its National Development Plan (NDP) National Mental Health Policy Framework and Strategic Plan (2013–2020), committing itself to providing support for the mental health of its citizens, including pregnant women (South African Department of Health, 2011). Regardless of its commitment the integration of perinatal mental health care and routine screening for antenatal depression has been overlooked (Brown & Sprague, 2021). This neglect not only increases the risk of inadequate care, mismanagement, and non-compliance with prenatal visits but also raises the likelihood of adverse delivery outcomes for both mother and child (Mokwena & Modjadji, 2022; Simonovich et al., 2021). These children may also require longer hospital stays due to various health conditions that can persist into childhood, adolescence, and adulthood (Frayne et al., 2019; Howard & Khalifeh, 2020). Moreover, maternal depression can have intergenerational effects, as Dadi et al. (2020) found that offspring of depressed mothers are more likely to experience depression in their teenage years and as mothers themselves. It is reiterated that the primary risk factor for postpartum depression is depression during pregnancy (Khan et al., 2020). Thus, the pregnant woman’s mental state not only negatively affects the pregnancy outcome but also impacts the health of her unborn child (Pereira et al., 2012).

Although maternal mental disorders, including antenatal depression, are widespread and have serious consequences, there remains a lack of understanding and inadequate care provided to pregnant women, particularly by midwives who are their main healthcare providers (Howard & Khalifeh, 2020). Midwives have different levels of knowledge regarding the occurrence and signs of antenatal depression (Howard & Khalifeh, 2020; Martin et al., 2020). This can be partially attributed to the lack of clear guidelines for detecting and addressing mental health problems during pregnancy (Chorwe-Sungani, 2022). Moreover, midwives showcased diverse viewpoints regarding the potential causes of depressive symptoms during pregnancy. It could be argued that midwives in LMICs have inadequate knowledge about antenatal mental health not because they are uninterested, but mainly due to a scarcity of training resources. Despite this, midwives in LMICs, South Africa included, remain highly confident in the mental health treatment plan they adhere to and play a crucial role in connecting pregnant women with social workers, clinical psychologists, and psychiatrists to ensure high-quality mental health care. Throughout this process, midwives are confronted with challenges such as frustration from their heavy workload and lack of communication with other healthcare workers, as well as resistance from mothers due to stigma and poor healthcare facilities conditions (Chorwe-Sungani, 2022). We can therefore hypothesize that the training and education provided to midwives may not sufficiently equip them to effectively screen and refer women who exhibit antenatal depression regularly. The level of knowledge that midwives have about antenatal depression screening and referral should therefore be explored.

Research Questions

1. What is the level of knowledge of midwives regarding antenatal depression screening and referral before exposure to an education training module?

2. What is the level of knowledge of midwives regarding antenatal depression screening and referral after exposure to an education training module?

Study Approach and Design

The study will employ a qualitative approach that is exploratory and descriptive, situated within the paradigm of social constructivism (Gillet, 1998). The researchers consider this methodology to be suitable since they hold the belief that knowledge is constructed through social interactions. The aim is to actively involve the study participants in meaningful conversations (Hammarberg et al., 2016). Furthermore, the focus of this study is on the experiences of interviewees and how they perceive the world (DeJonckheere & Vaughn, 2019) and antenatal depression. Finally, the semi-structured interviews will allow the analysis and comparison of the participants’ responses (McIntosh & Morse, 2015) before and after the training session on antenatal depression

Study Setting

The healthcare system in South Africa is split between public and private sectors, catering to different demographics. The private sector mainly serves affluent, educated individuals who are members of medical aid schemes, while the public sector caters to the less educated population who rely on state-funded healthcare services (Malakoane et al., 2020). To address these disparities, the post-apartheid South African government has committed to promoting Universal Health Coverage (UHC). Therefore, the selected community healthcare center (CHC) antenatal care clinic situated in Durban is the focus of this study as it primarily serves those reliant on state-funded healthcare services. Durban, is a popular coastal city in South Africa’s KwaZulu-Natal province, with a young population of 61% under the age of 35. The selected community is an informal settlement with women often working as domestic workers with low earnings due to limited education and skills, impacting their health and living standards. Men in the area typically work as taxi conductors or laborers, earning modest incomes that affect their access to basic necessities and adequate housing. Around 400 pregnant women receive routine antenatal care every month at the CHC. Out of these 400 visits, approximately 140 are first visits. From February 2023 to January 2024, 1592 women received antenatal care services at the clinic. All services provided at this specific CHC are completely free of charge. Additionally, the CHC has an outpatient mental healthcare division, which is managed by a trained mental healthcare nurse. There is also a weekly visiting clinical psychologist and psychiatrist available. If any antenatal women are screened positive for depression, they will be referred to the outpatient department (OPD) by the treating midwife at the antenatal clinic. At the OPD, a registered psychiatric nurse, who is trained and capable of providing immediate mental healthcare, will attend to the patient. The mental health nurse will then schedule an appointment for the patient with the clinical psychologist and psychiatrist. The visiting psychiatrist is authorized to initiate treatment for the patient. However, in cases of acute psychosis, the patient is referred to a tertiary hospital located 4.2 km away from the CHC for further mental healthcare. While receiving mental healthcare at the tertiary hospital, the patient will also continue to receive maternity healthcare at the CHC.

Study Participants

This study will target all consenting midwives employed at the CHC of interest who actively provide antenatal care services during the data collection period. Any unconsenting midwives, those not on duty during the data collection period due to leave of absence will be excluded from the study.

Sampling

The researchers plan to select participants who possess expertise in the topic being discussed. Therefore, they will employ the non-probability purposive sampling method. The expected sample size will range from six (6) to 16 individuals, as suggested by Braun and Clarke (2019).

Interview Guide

The interview guide could not be developed on a pre-used and validated guide. Therefore, the research team attempted to develop a guide based on the objective of the training session on antenatal depression (see Supplemental File 1). However, because the aim is to provide the midwives with a module that is tailored to their specific needs, they will include what will transpire from the interviews in the module. As of May 2024, OBB and EMK have already interviewed five midwives. The preliminary analysis indicated the significance of incorporating a section on promoting women to disclose their HIV status with their partners and family members. This is because participants have cited it as a contributing factor to depression among young pregnant women. Further significant findings resulting from the interview with the midwives will be reviewed with the research team for potential incorporation in the training session on antenatal depression upon consensus. The addition to the guide will be reported accordingly in the subsequent reports.

Data Collection

The main goal of the project is to provide the midwives with a training session on antenatal depression screening. Therefore, two researchers (OBB and EMK) will first interview the midwives before the training session. The findings from these interviews will be added to the training session on antenatal depression as the goal is to provide a module that is specific to the needs of the midwives in the selected clinic. Data will be gathered through individual in-depth interviews until data saturation and redundancy are attained, following an interview guide. The interviews will be conducted in either English or IsiZulu, based on the midwives’ preference, and will be audio-recorded and then transcribed verbatim. Each interview is expected to last between 30 to 45 minutes. Field notes will be recorded while conducting interviews. To date, five interviews have been conducted with the midwives. After the first two interviews, the transcripts were sent to a member of the team to ensure that OBB and EMK did not ask leading questions. All the comments and suggestions were included in the subsequent interviews.

The training session on antenatal depression will be introduced in June for three days to allow all to the midwives to attend the session according to their schedules. It will be a 3-h, in-person training that focuses on antenatal depression and its symptomatology, utilisation, scoring, and interpretation of the 10-item Edinburgh Postnatal Depression Scale (EPDS) and referral processes to a mental healthcare division within the community centre. It has been arranged that the first 3 hours of each day will be allocated to the training. The reason behind this is that the clinic follows a three-step procedure for patient flow, with the meeting with the midwife being the final step. This allows for a limited time of 2–3 hours for their training. These steps involve registering the patient into the electronic system, measuring vital signs such as pulse, blood pressure, and temperature, and conducting urine dipstick tests. Additionally, routine laboratory tests including haemoglobin, tuberculosis, HIV, and Covid tests are also performed. The duration of this process can vary depending on the number of patients present at the clinic on that particular day. Consequently, the midwives are granted a two-hour break before they commence attending to the women. In the absence of an antenatal screening tool, the midwives will be introduced to the EDPS tool. They will be required to systematically screen every woman from July 2024 over six months by ensuring that the antenatal woman completes the EPDS, followed by him/her (midwife) scoring and interpreting the screening results.

Six months after the training session on antenatal depression, OBB and EMK will interview the same midwives about their knowledge of antenatal depression. A question about their experiences with a focus on barriers to the utilisation of the depression screening tool and implementation of the referral process will be added to the guide. identify. Only midwives who work in the antenatal clinic, have attended the training session, and have voluntarily administered the EPDS tool to antenatal women will be recruited for the post-module interviews. Their knowledge before and after the training will be presented to see if there is a change or improvement.

Data Analysis

The research will employ the Inductive Approach of Content Analysis, as described by Elo and Kyngäs (2008). This systematic method involves condensing extensive text into fewer content categories through the application of explicit coding rules. The content analysis is structured into three primary phases: Preparation, Organization, and Reporting.

Organising and Preparation of Data

One researcher (EMK) will transcribe all interviews verbatim and the other two (OBB, LL) will validate the transcriptions. Participants will be requested to select pseudonyms to maintain confidentiality and improve direct quotations. The researchers will read through all the interviews, gaining a comprehensive understanding of the whole, which will allow them to reflect on its significance. Any underlying meanings will be noted in the margins.

Coding of the Data

In accordance with the study’s objective, participants’ understanding of antenatal depression screening and referral will be emphasized in all interviews. Common ideas expressed in the individual interviews will be highlighted and marked, creating text segments. A suitable phrase will be assigned to accurately describe each text segment, resulting in codes. The researchers will utilize the most descriptive language to provide a topic for all related codes, forming categories. The corresponding codes will be grouped, and sub-categories will be identified within each theme as applicable. These categories will then be analyzed for each interview and across all interviews.

Representing the Findings

The results, groupings, and sub-groupings will be displayed in a tabular format. A detailed description of the findings, including direct quotes from the participants, will also be provided. The categories will be expanded and elucidated by integrating the literature review with the findings, enhancing the depth of the results. The data will be analysed individually by the researchers (OBB, LL & EMK), who will then convene at regular intervals to discuss the identified categories and sub-categories. NVIVO version 12 will be utilized to facilitate the manual data analysis process. The results will be reported following the Standards for Reporting Qualitative Research (O’Brien et al., 2014).

Techniques to Enhance Trustworthiness

The authors will take measures to ensure the quality of the data by following established methods of trustworthiness (Johnson et al., 2020; Lincoln & Guba, 1985). To guarantee credibility, a detailed description of the research process will be provided. Additionally, the data analysis process will involve double-checking the emerging findings with the participants to ensure objectivity in data representation. Finally, the other members of the research team made up of academics from two local universities and a non-government organisation in South Africa and one LMIC university in Ghana will validate the emerging findings. Regular discussions between the research team will also take place to address emerging sub-categories and categories. Confirmability will be achieved by validating transcripts against live audio-recordings, study objectives, and emerging sub-categories and categories. Dependability will be ensured through the provision of a comprehensive description of the study methodology and data. To ensure transferability to other contexts, a detailed account of the research will be provided. Additionally, the quality of the research report will be based on COREQ (Consolidated Criteria for Reporting Qualitative Research) guidelines. (Tong et al., 2007).

Ethics and Dissemination

This study will adhere to the guidelines outlined in the Declaration of Helsinki (64th WMA General Assembly, Fortaleza, Brazil, October 2013). Since this research is qualitative and relies on interviews, it is considered to have minimal risks associated with it. However, if a research participant expresses any discomfort during the interview related to their experiences of dealing with antenatal depression, the interview will be temporarily paused. Furthermore, if a participant wishes to withdraw from the research, the research will be immediately discontinued. Vulnerable participants will not be included in the study to ensure their protection. All research-related documents, including case report forms, will be recorded and labeled with the research subject identification code instead of the participant’s name. No personally identifiable information, such as name, resident registration number, address, or phone number, will be recorded. The utmost effort will be made to safeguard personal information. Any records that could potentially identify the research subject will be kept confidential. Research data will be securely stored in locked cabinets, with access limited to authorized researchers only. Additionally, all documents containing research data will be stored on computer storage devices in locked research rooms, protected by security settings that require separate passwords for access. This ensures that the records are protected from unauthorized access. The findings of the study will be disseminated through publication in reputable journals and magazines, as well as presentations at credible conferences. Both the participants and the research setting will be anonymized to maintain confidentiality. The research protocol has also been submitted to the University of KwaZulu-Natal Biomedical Research Ethics Committee and received approval in January 2024 (BREC/00005625/2023). The research has also received approval from the KwaZulu-Natal Department of Health (KZ_222308_024).

Discussion

Women are twice at risk of developing depression compared to men (Guo et al., 2021). This is independent of their age, nationality, and some biological processes like genetically determined vulnerability and hormonal fluctuations (Luciano et al., 2022). Furthermore, the risk of developing depression is higher in certain periods such as pregnancy (Howard & Khalifeh, 2020) where many physiological, hormonal, social, and psychological changes occur (Insan et al., 2022), leading to depressive and comorbid anxiety symptoms (Chandra & Nanjundaswamy, 2020; Rajkumar, 2022). Recent literature highlights that depressive symptoms during pregnancy include depressed mood, low self-esteem, loss of appetite, feelings of fatigue, and poor concentration (Bedaso et al., 2021). In a minority of cases, pregnant depressed women show suicidal ideation (Koire et al., 2022). In LMICs, the incidence of antenatal depression is higher (Wisner et al., 2020), probably due to the lack of integration between psychiatric and gynecological units, poor understanding and acceptance of mental health conditions, and higher socio-economic deprivation (Shidhaye et al., 2016). The majority of studies carried out so far have mainly focused primarily on risk factors, effects, treatment, and prevention of perinatal and/or postnatal depression depressive symptoms with the onset during the post-partum period (Luciano et al., 2022).

Research on antenatal depression in low- and middle-income countries (LMICs) is limited, particularly in terms of midwives’ knowledge of the subject. Where there is a controversial debate on whether antenatal depression is linked to postnatal depression (Luciano et al., 2022), one could assume that midwives’ knowledge of postnatal depression is similar to their knowledge of antenatal depression. However, unless this is explicitly investigated, the extent to which knowledge of postnatal depression can be assumed to translate to antenatal depression may be limited. Therefore, this qualitative study aims to address this gap by examining midwives’ literacy on antenatal depression before and after a training session on antenatal depression. Specifically, the study will provide insights into midwives' understanding of antenatal depression screening and referral. The findings of this study will not only contribute to the existing knowledge on antenatal depression but will also serve as a foundation for the development of a context-specific and socio-economically relevant antenatal depression screening tool for Sub-Saharan African countries. Additionally, this project will generate data to support the integration of mental healthcare services into primary healthcare settings for maternal health. The project’s findings will be disseminated through various channels, including reports, datasets, policy briefings, fact sheets tailored to different audiences, and peer-reviewed publications.

Supplemental Material

Supplemental Material - Knowledge of Midwives Regarding Antenatal Depression, Screening, and Referral in South Africa: A Qualitative Study Protocol

Supplemental Material for Knowledge of Midwives Regarding Antenatal Depression, Screening, and Referral in South Africa: A Qualitative Study Protocol by Olivia B. Baloyi, Luke Laari, Cedric X. Mbobnda Kapche, and Esther L. Mbobnda Kapche in International Journal of Qualitative Methods.

Footnotes

Author’s Note

The study protocol will be conducted in partial fulfilment of the first author’s research project on antenatal depression screening and referral in South Africa. The overall aim of the project is to adopt and integrate an effective strategy aimed at implementing a routine antenatal depression screening and referral protocol for women receiving antenatal care at a selected community healthcare center in South Africa. The quantitative and longitudinal parts of the project will be described in other reports.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Research Foundation Thutuka grant (TTK23041994789, South Africa) and the lead author of the paper (OBB), was funded by Office of Global and Community Health Initiatives (OGACHI) through DUKE University, School of Nursing, North Carolina, USA. This research is supported by the College of Health Sciences of the University of KwaZulu-Natal, South Africa.

Ethical Statement

ORCID iD

Esther L. Mbobnda Kapche

Supplemental Material

Supplemental material for this article is available online.

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