Dr Liane Manikkam graduated with a Masters Degree in Psychiatry after concluding a study that investigated the urban prevalence of antenatal depression and its risk factors in KwaZulu-Natal.

Manikkam was struck by the fact that antenatal depression – depression that occurs during pregnancy – is often overlooked and underdiagnosed. She said there had been a recent increase in interest in its association with adverse obstetric, neonatal and maternal outcomes, but local data on the prevalence and risk factors were lacking.

Her study, supervised by Head of Psychiatry Professor Jonathan Burns, was conducted using the Edinburgh Postnatal Depression Scale and a socio-demographic questionnaire in English and isiZulu. The study population was made up of 387 antenatal outpatients at King Edward VIII Hospital.

According to Manikkam, pregnancy is usually viewed by the public and the medical profession as a period of emotional well-being that is protected against mental disorder.

‘Antenatal care traditionally focuses on physical health rather than on emotional health,’ she said. ‘Consequently, antenatal depression is regularly overlooked and underdiagnosed, locally and globally. In contrast, there has long been a focus on depression in the postpartum period, with considerable literature and public awareness. Only during the past decade have studies of antenatal psychiatric morbidity become more common.’

She said studies show that the prevalence of antenatal depression is higher than that of postnatal depression and is associated with adverse fetal, obstetric and neonatal outcomes, including intra-uterine growth retardation (IUGR), low birth weight, preterm delivery and infant behavioural problems.

‘Nutritional deprivation and poor maternal weight gain during pregnancy are risk factors for IUGR, and when depression is associated with weight loss, fetal growth may be negatively affected. Physiological mechanisms underlying the negative impact of antenatal depression on fetal growth and neonatal development include hyperactivity of the hypothalamo-pituitary axis and increased cortisol secretion,’ she explained.

Manikkam also said that apart from physiological effects on the fetus, depression in pregnancy can affect a mother’s functional status and cause cognitive distortions that affect her decision-making capacities. ‘This may be associated with poor attendance at antenatal clinics and lack of motivation to follow physician care regimens, and lead to other problems such as maternal substance abuse. These factors invariably increase the risk of adverse pregnancy outcomes.’

In line with recent studies conducted in developing countries that indicate that more than a third of women have significant depressive symptoms during pregnancy, Manikkam’s study confirmed that the high prevalence of antenatal depressive symptoms and thoughts of deliberate self-harm support a policy of routine screening for antenatal depression in South Africa, especially in HIV-seropositive women.

Burns said the most striking findings in this study are those that show that over a third of pregnant women attending an antenatal clinic were depressed and had recent thoughts of harming themselves. ‘This is really serious and reveals a hidden epidemic which impacts not only on the lives of these women, but also on the healthy development of their unborn children. The other important finding in our context is that HIV seropositivity increases risk for depression by a factor of 1.6, thus women with HIV are 60 percent more likely to develop depression during pregnancy than those who are negative.

The study also provided evidence that HIV infection may place mothers at additional risk of depression during pregnancy. ‘Such an association, if confirmed by subsequent studies, has major implications for managing peripartum risk in HIV-positive women.’

Manikkam said that in order to realise the national and international objectives of improving maternal and child health, a policy of routine screening for depression in antenatal women should be developed and implemented without delay in South Africa.

The study was published in the South African Medical Journal in December 2012.

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