Risk factors and experiences of prepartum depression in urban- low-income settlement 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 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 15 to 49 years who visited ANCs for antenatal check-up in Kawangware or Kangemi composed the study population. Women who gave a written informed consent and women who are not mentally disturbed to the extent of not giving correct information.

This cross-sectional study was part of the baseline assessment of a longitudinal cohort study that targeted depressed pregnant women for intervention for depression care among pregnant women in urban low-income settlement in Nairobi Kenya. Sample size was calculated using sample size estimation for longitudinal designs with attrition (Diggle et al., 2002). We needed approximately 100 subjects. To obtain the above sample size at baseline, consecutive sampling was used where every pregnant woman who came for checkup during the study period was asked to be 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 prepartum depression. The EPDS is a 10-item questionnaire in which women report on how they have been feeling in the past seven days; according to EPDS, a Score of 10 or greater indicates possible depression and women who score above 13 are likely to have depressive illness of varying severity¹⁷. EPDS 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 depression¹⁷.

Qualitative data. Focus Group Discussions (FDGs) were conducted with women who were identified as depressed, in order to get a deeper understanding of women's experiences during the present pregnancy. The non-depressed women were not included in this study because the study interest was to offer an intervention for the depression so there was a need to understand the experiences of depression pregnant women to provide way forward for an intervention study. After the identification of women with depression using EPDS), we asked the pregnant women who were willing to participate in the FDG’s. Convenience sampling was used to select and invited the depressed pregnant women for FGD’s.

The aim of FGD’s 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’s. The FGD’s lasted for 60–90 minutes, and it was conducted in Kiswahili language and was audio-recorded. 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 depression. Independent variables were categorized and analyzed; the association between independent predictor and outcome variable, using a univariable analysis odds ratio (OR) with 95% confidence interval (CI) was calculated. Those variables that were associated with p<0.001 in the univariable analysis were entered into multivariable logistic regression analysis. Variables with p<0.05 in the multivariable 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, the data was coded until all the information required for the study was exhausted, and finally, four major themes emerged from the discussion. COREQ (Consolidated criteria for Reporting Qualitative research) checklist was followed. 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

All approached pregnant women who attended prenatal clinic during the study period at Kawangware and Kangemi Health center, were screened for depression as part of service delivery. A total of 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 with age range of 18–42 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

Edinburgh Postnatal Depression Scale (EPDS), guided the scoring system¹⁷. EPDS has 10 questions which generates scores of 0 to 30 maximum. According to this tool, a score of 10 out of 30 or greater indicates possible depression. Women who score above 13 out of 30 are likely to be suffering from clinical depression of varying severity. The depression scores in this study were categorized into two levels (depressed and not depressed). A score greater than 13 indicated the existence of clinical prepartum depression of various severities

Out of the 262 women, about a third (33.6%; 95% CI 27.9-40.7) had prepartum 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 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). All women who appeared to have suicidal ideation and those who were experiencing violence were referred to the mental health counselling services provided at the health facility for treatments; further the second part of the study was an intervention study so they were enrolled to proceed with the intervention.

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

Prevalence of prepartum depression among pregnant women in urban low-income settlements in Nairobi, Kenya

Qualitative results

Focus Group Discussions included pregnant women with age range of 18 to 33, and EPDS score range 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- which 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 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 is discussed in detail below and experiences in quotes.

Poverty: Poverty is the root cause of stress and depression that 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. The experiences are explained in quotes below:-

Financial struggles

Pregnant women reported having financial struggles because they have no income, or their partner not having any employment, 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 is a big problem; if I have money in my pocket, I would be just fine." Participant 15

    "Because I have no job, I’m only a stay home mom, when I lack something and I ask my husband, and he doesn’t have money he 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.

    “ Sometimes we don’t have food, and there is nothing to eat this causes me to be sad." Participant 12

    "My husband will leave me and there is nothing to eat at home I'm pregnant, and I have no job so that one usually bores me so much." Participant 17

    “Sometimes the food may be available but my husband stresses me, how will I be able to eat? You cannot." Participant 10

    "Sometimes the basic food is available, but the food that I crave/want to eat I can't get because I don’t have money, I love and admire eating pizza, but there is not enough money to buy it." Participant 11

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

Social support: Most of the pregnant women felt that they lack emotional and financial support from the partners responsible for their pregnancy. In addition, some of the partners rejected the pregnancy, and don’t want to take any responsibilities.

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

    "Before I became pregnant, my boyfriend wanted me to be pregnant and have a baby and that he will marry me. But when I became pregnant he doesn’t want to marry me, he doesn’t do what he said, that makes very sad.." Participant 4

    "I was admitted in the hospital and I was alone, the doctors called my boyfriend because there was a need for me to get blood transfusion; they called him to come to replace the blood. He doesn’t know me.’ He just talks rubbish." Participant 12

    "As for me, my boyfriend doesn’t want to support me, so I’m prepared to give birth and raise the baby myself because he doesn’t want to know about me and baby" Participant 19

    "My husband doesn’t care when he sees me cry or sad, he will ask me, 'what are you crying for? Just cry when you are tired you keep quiet". Participant 5

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

    “I’m all alone; I don't have anybody around that I can trust to the level that I can share my story." Participant 7

    “I have some people around me, but I have never trusted somebody so much, because some of them cannot be true." Participant 5

    "I cannot trust someone just like that; some people, you can tell them your problems thinking that it’s only between you two, but after that you will hear it with everybody, and that is very embarrassing." Participant 15

    “There are some people whom you can tell and maybe you 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. The experiences that women go through have been narrated below:-

Physical abuse

    "One day, my husband came and started quarreling with me, and then he later slapped me, and 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 he doesn’t say anything, when I ask him where he was then at that point we start a big fight, and he will leave without leaving you food or any money, 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, they can’t go anywhere because they can’t sustain themselves.

    "If I go tell my parents they say you cannot live a life with a husband without being beaten" Participant 3

    “Now if you leave your partner, where will you go?" Participant 9

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

Psychological abuse

Women reported being psychologically abused, by their partners who refuses to offer emotional support to their wives.

    "My husband is keeping quiet, if I don't talk, he cannot talk to me and this hurts me so much." Participant 19

    "Mine says that he will beat me, and that he is not the one responsible for the pregnancy, then he says that I should abort, so I abandoned him." Participant 13

    "Mine also doesn't want to talk, when I’m tired and tell him that today I am not feeling well’, he tells me ‘it's up to you’. Participant 9

Separation/Divorce

Some women experienced separation or divorce.

    "I don't stay with him because he is so contemptuous; he cannot even offer me any 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 to it." Participant 8

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

    "Fear of how it will be the day I go for delivery I don't know if my baby will be alive or die, so I have so much thought and think a lot" Participant 3

    "I fear how that situation will be during childbirth, so my mind is being tormented thinkingthe day that I will go to deliver." Participant 7

    "I fear delivery, and that is my stress, since I have never had a baby before, people tell me it is fine 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 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 it-self sometimes is a source of stress.

    "They pressed my belly so hard and painful, and they tell me go you are done, and another one is called; they don’t explain anything well, I don’t know how my 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 experiences of prepartum depression and has complemented the quantitative part of the study providing a full story. Also prepartum depression has not been studied much in low and middle-income countries, and is 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 high 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. Moreover, although EPDS is an established and widely used screening tool for maternal depression with high specificity and sensitivity, it is not as a definitive diagnosis, hence the inherent limitation of using this tool. Also other possible confounding factors such as child sex preference, history of previous mental disorder, spousal alcohol intake as a risk factor for depression were not assessed hence limitation of this study. Additionally this was a cross sectional study and as a limitation cross sectional studies does not establish the causal relationship hence the limitation for this study

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).