Risk factors and experiences of prepartum depression among pregnant women in urban- low income in Nairobi Kenya: a mixed-method study

Study setting and participants

This was a mixed-method cross-sectional study that involved pregnant women who attended antenatal care clinics, during the study period March 2019 to June 2019. Ethical approval was obtained from The Kenyatta National Hospital/University of Nairobi Ethical and Research Committee (KNH/UoN-ERC Ref: P56/02/2018). The study took place in two public health facilities in two urban low-income settlements, namely Kangemi and Kawangware. The two sites are both growing informal settlements, located on the outskirts of the Nairobi city center. They were chosen purposively because the antenatal clinics (ANC) at these health facilities receive a high volume of pregnant women. Eligibility criteria included all pregnant women aged 18 to 44 years who visited ANCs for antenatal check-up in Kawangware or Kangemi composed the study population.

This cross-sectional study was part of the baseline assessment of a longitudinal cohort study of pregnant women that targeted 100 depressed pregnant women, which examined the efficacy of dietary intervention for depression care among pregnant women in urban low-income Nairobi Kenya. To obtain the above sample size at baseline, consecutive sampling was used where every pregnant woman who came for checkup was assessed for depression; hence 262 pregnant women were recruited in this study.

Data collection

Quantitative data. Data were obtained from pregnant women by means of an interview administered questionnaire. All women who came to the ANCs and were queuing in the waiting room were approached to participate. The study purpose was explained to them that participation was voluntary, and refusal to participate will involve no penalty of benefits to which one is entitled at the clinic. The participants were assured about their privacy and confidentiality. After obtaining a written informed consent signed by the respondent based on willingness to participate, the interview commenced.

Socio-demographic characteristics questionnaire: Using a questionnaire, pregnant women provided data on socio-demographic characteristics, age, marital status, maternal education level, employment status, partner's occupation, monetary decision-making, and family monthly income.

Maternal depression questionnaire: Edinburgh Postnatal Depression Scale (EPDS), was used to assess maternal depression. The EPDS is a 10-item questionnaire in which women report on how they have been feeling in the past seven days¹⁷. EPDS, which has a Kiswahili translation version, has been validated for detecting depression in both prepartum and postpartum mothers in many countries, including Kenya¹⁸. EPDS is one of the most well-known and evaluated instruments for maternal depression and has demonstrated acceptable clinical utility as a screening tool. It has a sensitivity of 86%, specificity of 78% and a positive predictive value of 73%^19,20. The depression scores were categorized into two levels; EPDS score higher than 13 indicated existence of clinical maternal depression¹⁷.

Qualitative data. A focus group discussion (FDG) was conducted with women who were identified as depressed, in order to get a deeper understanding of women's experiences during the present pregnancy. After identifying women as depressive in the questionnaire (above), we asked the pregnant women if they would be willing to participate in the FDG. Convenience sampling was used to select and invited the depressed pregnant women for FGD.

The aim of FGDs was to identify the causes of depression among pregnant women and the experiences around them. In this qualitative inquiry, 20 pregnant women with depressive symptoms (EPDS score cut-off score >13) were invited to participate. Two FGDs with a group of 10 participants were conducted from each site of Kangemi and Kawangware, respectively. Face to face discussion was conducted away from the health center by two female field researchers (BM and a research assistant) in a hired hall convenient for the women to discuss. BM has Master in Public Health, and the research assistant has MSc in Clinical Psychology. They were both trained on mental health quantitative and qualitative research methods. The relationship between researcher and pregnant women was established prior to the FDG. The FGD lasted for 60–90 minutes, and it was conducted in the Kiswahili language and was audio-recorded. The data was coded until when the ability to obtain additional new information was exhausted for the study purpose. The interview guide can be found in Extended data²¹.

Data analysis

Quantitative analysis. The filled questionnaires were checked for completeness, errors, and discrepancies; this was followed by data entry, cleaning, and analysis using SPSS version 22. Descriptive statistics such as percentage means and standard deviation were used to summarize the socio-demographic data. An EPDS score of >13 pointed the likelihood of the presence of clinical depressive illness. Independent variables were categorized to analyzed, the association between independent and outcome variable, using a bivariate analysis odds ratio (OR) with 95% confidence interval (CI). Those variables that were associated with p<0.001 in the bivariate analysis were entered into multivariate analysis. Variables with p<0.05 in the multivariate analysis were considered to be significant.

Qualitative analysis. The FDGs in Kiswahili was transcribed and translated into English at the same time. Thematic analysis was employed to process the data. Two coders (BM and a research assistant) were involved in the coding process. The study primarily followed the inductive approach and identified the emerging codes, and to some extent, the deductive approach was also used to determine the codes²². Coding was manually done, and finally, four major themes emerged from the discussion. Informed consent was obtained from participants in this research for future uses of data, such as publication, preservation, and long-term use of research data. Confidentiality was assured. The information collected was kept confidential. Serial numbers were used instead of a name.

Socio-demographic characteristics of pregnant women in the urban low-income settlement

In total 262 women responded to the questionnaire, 134 from Kangemi and 128 from Kawangware. The mean (SD) age of the 262 women was 25.3±5.0 years (range, 18–44 years). The majority of the women (82%) were married, with 29.8% having less than high school education and 14% had tertiary level education. About 79.4% of the women had no employment but depended on their partners or parents, only 20.6% were employed. Slightly less than half of the women (43%) were first-time mothers, while 70% of them were in their second trimester during baseline assessment. Almost all the women (98%) owned a basic personal phone, and slightly less than three quarters owned a television (73%). The mean (SD) income level was 10845.8 Kenyan shillings (KES) per month, and almost half of the women (49.6%) lived on an income less than KES 15,000, equivalent of 150 USD per month, while two-fifths of the women (38.9%) had their husbands make decisions on household finances (Table 1).

Levels of prepartum depression among pregnant women in urban low-income

Guided by the EPDS scoring system, the 10 items generated a depression score ranging from 0 to 30. The depression scores were categorized into two levels (depressed and not depressed). A score greater than 13 indicated the existence of prepartum depression of various severities

Out of the 262 women, about a third (33.6%; 95% CI 27.9-40.7) had depression as indicated by EPDS >13 (Figure 1). Suicidal Ideation (EPDS item 10) revealed that 24% of pregnant women had some suicidal ideation. The mean (SD) EPDS score was 11.1, interquartile range of 10 with a minimum score of 0 and a maximum score of 26. When the socio-demographic characteristics were compared between depressed women and those not depressed, results showed that women's gestation age in the second trimester (87.5%) was statistically significantly associated with maternal depression (OR 3.37; 95% CI 1.60-7.10; p<0.001). Income levels was also statistically significantly associated with maternal depression where women (58%) with income level <10,000 KES were depressed (OR 0.39; 95% CI 0.23-0.66; p<0.001; Table 2).

Figure 1. Prepartum depression among pregnant women in urban low income Nairobi -Kenya.

Qualitative results

Participants were aged from 18 to 44 years, and these women all had an EPDS score of 13–25 and were in their second trimesters. Table 3 provides participant's characteristics in the FGDs.

The qualitative results from the FDGs were categorized into four major themes: poverty – manifested through a financial struggle, unemployment and food insecurity; social support – women reported inadequate support from their partners/husbands, the lack of a trustworthy person/friend who they could share their worries, loneliness, living far from family members, and feeling neglected; marital disharmony – issues of domestic violence (physical abuse and psychological/emotional abuse), and separation/divorce were reported; trauma experiences – women reported fear and worries about childbirth and birth outcome, considering that most of them were first-time mothers, and some women reported a previous loss of a child, previous birth difficulties, and fear of facing health care providers. Each of these themes are discussed in detail below.

Poverty. Poverty is the root cause of stress and prepartum depression and contributes to other risk factors of depression. Women reported having not enough making and everything seeming difficult because of this. The three subthemes identified were financial struggles, food insecurity, and lack of employment.

Financial struggles

Pregnant women reported having financial struggles because they have no income, or their partner not being employed, so it becomes so difficult for them to do things.

    "I don't have a job, and I'm pregnant, and my husband doesn't have a job, and we live that way looking here and there; we are supposed to pay rent, food, and different kinds of needs. So you live with questions and start questioning yourself." Participant 20

    "Lack of money; If I have money in my pocket, I would be just fine." Participant 15

    "By the way, you stay in the house; maybe you lack something, and when you ask for it, and the husband doesn't have money, so he begins to become harsh, then it results in quarreling, just that." Participant 5

Food insecurity

Some pregnant women reported a lack of enough food, or sometimes basic food may be available, but the food that they crave during their pregnancy they cannot get.

    “There is sometimes we don’t have food, and there is nothing to eat." Participant 12

    "My husband will leave without leaving me food to eat, and I'm pregnant, whereby I don't understand whatever is happening so that one usually bores me so much." Participant 17

    "The problem is even if it is available yet my husband stresses me, how will I eat? You cannot." Participant 10

    "Sometimes the basic food is available, but the food I feel like eating I can't get, I love and admire eating pizza, but there is not enough money to buy it." Participant 11

    "When I ask him about house needs, he becomes harsh and doesn't understand me." Participant 6

Social support. Most of the pregnant women felt that they lacked emotional and financial support from the partners responsible for the pregnancy. In addition, some of the partners denied their pregnancy, and do not want to take any responsibilities.

    "I stay with a family from my husband's side, and there is no support of any kind that they offer me, and the husband himself doesn't support me, so the people who support me are neighbors when I have a problem I tell them." Participant 2

    "So before I got pregnant, he is the one who used to insist that I should give birth, and then he will marry me and such things, so when I got pregnant up to the moment, he still doesn't do what he said to me." Participant 4

    "Was in the hospital they rang him saying, ‘we want blood transfusion on her can you come and replace the blood?’ He said ‘I don't know EV.’ He just talks rubbish." Participant 12

    "So for me, it is just to give birth and raise the baby by myself because he is not supporting" Participant 19

    "My husband tells me, 'what are you crying for? Just cry when you are tired you keep quiet". Participant 5

Some women reported that they do not have a trusting person around them to share their worries and talk heart to heart. Living conditions in slums where people live in one plot, some neighbors are stubborn and like making fun to others, further contributing to stress, anger and depression. Some stay away from their family members, and so they feel they lack support.

    "I don't have anybody to tell my story." Participant 7

    "They are available, but I have never trusted somebody so much." Participant 5

    "You cannot trust someone; maybe you can tell them your problems and think that it has ended there, but you will hear it with everybody." Participant 15

    "Then there is another person whom you can tell and maybe feel that she is a friend, you sit with her and tell her; she also supports you as if she has pity over you, but maybe after you leave she is a type that laughs at you." Participant 16

Marital disharmony. In the FDGs, women reported hopelessness and helplessness around the experience of domestic abuse, which manifested as both physical and emotional abuse.

Physical abuse

    "One day, my husband came and quarreled at me, and then he later slapped me, then pushed me. I fell on the table and hit my stomach. I started feeling pain on the stomach and thought my baby in my belly was hurt." Participant 6

    "My husband has a lot of disrespect whereby he sometimes spends a night out when he comes back and ask him where he was then at that point we start a big fight, and he will leave without leaving you food usually that bores me so much." Participant 17

Some women defend themselves.

    "Yes; whenever he starts, we just hit each other, there is no sparing him; so he also fears me, I have a lot of energy, and he cannot quarrel with me so much." Participant 14

Sometimes women are forced to stay with abusive partners even if they are beaten as they cannot sustain themselves.

    "If you go tell parents you're told that "you cannot live a life with a husband without being beaten" Participant 3

    "When you leave, where will you go?" Participant 9

    "I don't have a job; don't have money; if I have had a job and money would get myself out. Where will I stay?" Participant 11

Psychological abuse

    Women reported being psychologically abused, with many partners not wanting to offer emotional support to their wives.

    "He is keeping quiet, if I don't talk, he cannot talk, and it hurts me so much." Participant 19

    "He said that he will beat me and that he is not the one responsible for the pregnancy, then he said that I abort, but I abandoned him." Participant 13

    "That one he doesn't want to talk when you are tired and tell him ‘Today I am not feeling well’, he tells you ‘it's up to you’. Participant 9

Separation/Divorce

Some women experienced separation or divorce.

    "I don't stay with him too, but he is so contemptuous; he cannot even offer you support, he has even blacklisted my number." Participant 12

    "I don't know how to put it, but we parted ways those days when I was the first month, so all along I have been surviving, and I have become used." Participant 8

Trauma experiences. Some women had previous trauma experiences, such as loss of a child and difficult birth.

    "Fear of how it will be when I go for delivery you don't know if your child will be alive." Participant 3

    "I fear how that situation will be, so my mind is tormented by the day that I will go to deliver." Participant 7

    "I fear delivery that is the stress I have, since I have never had a baby, people tell me but it frightens me" Participant 1

Some women feel that health care is unfriendly. When they go to the clinic, nothing is explained to them, even during a physical examination. For example, pregnant women are not given any feedback about how they are doing, or if their babies are growing well. They reported that they are dismissed without any information given to them, only the date to come back for checkup is provided. Therefore, the women reported that health care itself is a source of stress.

    "They press my belly so hard and painful, and they tell me go you are done, and another one is called; you are not told how your baby is doing, so I don't understand." Participant 6

Strengths and limitations

This study used mixed methods, both quantitative and qualitative. The qualitative part was useful in gaining a better understanding of the causes of prepartum depression and has complemented the quantitative part of the study to provide a fuller story. Prepartum depression has not been studied much in low and middle-income countries, contributing to a high disease burden. Therefore, our study focus on prepartum depression contributes to filling a knowledge gap and awareness to health-care providers, researchers, policymakers, and the public about the rates and risk factors of prepartum depression. However, due to reasons that the recruitment occurred at the ANC where the attendance rate is not 100% for all residents in the settlements, many women with depressive symptoms may not been reached, and even those who came to the ANC, not all of them were screened leading to underreporting of the cases hence the result cannot be generalized.

Underlying data

Figshare: Socio-demography and Depression Questionnaire, https://doi.org/10.6084/m9.figshare.13265297.v1²⁸.

Figshare: Maternal Depression experiences FDG transcription, https://doi.org/10.6084/m9.figshare.13265549.v1²⁹.

Extended data

Figshare: Maternal Depression Experiences FDGs Interview guide, https://doi.org/10.6084/m9.figshare.13265420.v2²¹.

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).