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. Author manuscript; available in PMC: 2022 Oct 1.
Published in final edited form as: Arch Womens Ment Health. 2021 Apr 1;24(5):737–748. doi: 10.1007/s00737-021-01121-8

Perinatal Suicidality: Prevalence and Correlates in a South African Birth Cohort

Karen T Maré 1, Jennifer Pellowski 2, Sheri Koopowitz 1, Nadia Hoffman 1, Claire van der Westhuizen 3, Lesley Workman 4, Heather J Zar 4,5, Dan J Stein 1,6
PMCID: PMC8484378  NIHMSID: NIHMS1709418  PMID: 33792768

Abstract

Purpose:

Suicidal ideation and behaviour (SIB) in the perinatal period is prevalent in low- and middle-income countries (LMICs). Past work has been limited by reliance on self-rated scales, and there are few data on SIB severity in such settings. We collected cross-sectional data on SIB using a clinician-administered scale and explored risk factors associated with the presence of SIB and SIB severity.

Methods:

Data were collected from the Drakenstein Child Health Study cohort antenatally and at 6 months postpartum. SIB was measured using the Mini International Neuropsychiatric Interview and potential sociodemographic, psychosocial, and psychiatric risk factors were assessed. Multivariable analysis determined cross-sectional risk factors. Multinomial regressions determined predictors of SIB risk categories.

Results:

Among 748 women the antenatal SIB prevalence was 19.9% and postpartum 22.6%. SIB was associated with younger age (antepartum), PTSD (postpartum), and depression (ante- and postpartum). Depression and PTSD predicted belonging to the high risk SIB group. The medium risk group was more likely to have depression, alcohol use during pregnancy and substance abuse. Depression, PTSD, food insecurity, recent intimate partner violence (IPV), and childhood trauma were associated with the low risk group versus the no risk group.

Conclusion:

Screening is needed for perinatal SIB. Associations of perinatal SIB with younger age and major depression are consistent with previous work. The association with PTSD is novel, and underscores the importance of assessment of trauma exposure and outcomes in this population. Different risk categories of SIB may have different causal pathways and require different interventions.

Keywords: Suicidal Ideation, Suicidal Behaviour, Perinatal, Pregnancy, Postpartum, South Africa

Introduction

Suicide is the leading cause of death among peripartum women (Oates 2003; Chang et al. 2005), accounting for 0.65 to 3.55% of pregnancy-related mortality in LMICs (Fuhr et al. 2014). In South Africa 1% of maternal deaths between 2014 and 2016 were attributable to suicide (National Committee for Confidential Enquiries into Maternal Deaths 2018). Suicidal ideation (SI) during pregnancy is one of the strongest predictors of suicide ideation, suicide attempts, and completed suicide postpartum (Lindahl et al. 2005). In South African women a population survey found that the 12-month prevalence for suicidal ideation was 10.1%, 3.2% for a suicide plan and 4.8% for an attempt (Joe et al. 2009). Similar to international findings (Nock et al. 2008, Kessler et al. 2005), SI predicted the development of a suicidal plan and the occurrence of a suicide attempt and 50% of planned first attempts occurred within 1 year of the onset of ideation (Joe et al. 2009). The World Health Organization (WHO) estimated that there were 12.3 deaths by suicide for every 100,000 people in South Africa in 2015.

Suicidal ideation and behaviour (SIB) encompasses the passive or active wish to die as well as any behaviour directed towards ending one’s life, including but not limited to, writing a suicide note, acquiring lethal means, and taking steps to avoid detection. SIB in the perinatal period is particularly prevalent in low- and middle-income countries (LMICs) with prevalence rates during pregnancy ranging from 5 to 14% (Lindahl et al. 2005) and 3 to 33% (Gelaye et al. 2016), depending on the sampled population (higher in clinical populations) and chosen method of assessing the outcome (variable results). Postpartum women also report higher rates of suicidal ideation compared to adults in general (Howard et al. 2011; Rodriguez et al. 2018) with prevalences comparable to those during pregnancy (Kim et al. 2015; Muzik et al. 2016; Sit et al. 2015; Howard et al., 2011; Pope et al. 2013; Doi & Fujiwara 2019; Mauri et al. 2012), but again varying depending on the sampled population and assessment methods. Factors associated with suicidal ideation in peripartum women include sociodemographic risk factors (i.e. failure to complete high school, younger age), psychosocial stressors (i.e. intimate partner violence, childhood maltreatment) and psychiatric illness (i.e. depression, anxiety disorders)(Gelaye et al. 2016; Howard et al. 2011; Muzik et al. 2016).

The literature on SIB in peripartum women has several limitations. First, very few studies employ clinician-rated measures to assess perinatal SIB (Tavares et al. 2012; Vaz et al. 2014). Second, prediction models focus on the presence versus absence of perinatal SIB rather than on more fine-grained analyses of SIB severity; only one study attempted to separate the heterogenous constructs and different severity levels contained in SIB (Onah et al. 2017). Third, few of these studies are from low- and middle-income countries such as South Africa (Shamu et al. 2016; Rochat et al. 2013; Dewing et al. 2013; Onah et al. 2017; Rodriguez et al. 2018).

The Drakenstein Child Health Study (DCHS) is a South African birth cohort study, which is focused on a peri-urban population (Zar et al. 2015; Stein et al. 2015). The main study outcomes are child lung health and child health more broadly. A range of factors potentially influencing these outcomes are measured longitudinally, including maternal health measures. A clinician-rated measure of maternal suicidal ideation provides information on SIB severity categories. In this paper we use data from the DHCS to assess the prenatal and postnatal prevalence of SIB and sociodemographic, psychosocial, and psychiatric correlates, via stratified analyses, of SIB presence and severity.

Materials and Methods

Study Design

This paper reports cross-sectional ante- and postnatal data from the DCHS, a birth cohort investigating the epidemiology and etiology of childhood respiratory disease. Data regarding multiple risk factors that may influence child health more broadly, including maternal mental health, were collected (Zar et al. 2015). This paper is a secondary analysis of a subset of the larger cohort. Data collection timepoints were pre-determined by the DCHS protocol – data from the second antenatal visit and 6 month post-partum visit were the most relevant for the questions asked here.

Study setting

The Drakenstein sub-district is a peri-urban area (adjacent to the town of Paarl) containing the relatively stable, low socioeconomic communities of Mbekweni and Paarl East. The Drakenstein Municipality has a population of 273 066 with roughly 70 000 children, 17000 elderly and 185 000 working age people (2018 local government data). Participants were recruited from two primary health care clinics that serve these communities respectively – Mbekweni Clinic (serving a black African population) and TC Newman Clinic (serving a mixed ancestry population). These communities are characterized by a high prevalence of substance use, exposure to trauma, HIV infection and poverty (Stein et al. 2015).

Participant selection

From March 2012 until September 2015 consenting pregnant women aged 18 or older who were of 20–28 weeks’ gestation were recruited. Exclusion criteria, designed to maximize generalizability of findings, was limited to women not primarily residing in the catchment areas or those planning to leave the area within the following year.

Study procedures

Pregnant women were assessed at an antenatal visit between 28 and 32 weeks’ gestation and at 6 months postpartum. Experienced field workers assisted with a battery of self-report questionnaires and a medical officer assessed maternal mental health. Interviews were conducted and measures were available in the language of choice (Xhosa, English or Afrikaans) with the aid of translators when needed.

Measures

The interviewer-administered Sociodemographic questionnaire was adapted from a questionnaire used in the South African Stress and Health Study (SASH), (Myer et al. 2008). A composite SES score was developed in order to categorise participants into quartiles providing an internal comparison for the study sample. The SES score was calculated based on current employment status, educational attainment, household income and a composite asset index.

The Household Food Insecurity Access Scale (HFIAS) was used to assess food security (Coates, Swindale & Bilinsky 2006). This questionnaire asks nine questions about household access to food and household members’ experiences and perceptions of hunger during the preceding four weeks. These 9 questions are grouped into 3 themes; anxiety about access to food, quality of diet (i.e. food variety and choice) and food consumption (i.e. skipping meals). An affirmative response to two or more items was coded as “food insecure” and one affirmative response or less was coded as “food secure” (Pellowski et al. 2017).

The Planning of Birth/Partner Support Questionnaire was adapted from questions used in the SASH (Myer et al. 2008) to assess pregnancy intention. The item “At the time you became pregnant, were you trying to have a baby?” was used with the response options of Yes or No.

The Childhood Trauma Questionnaire (CTQ) assesses childhood abuse and neglect during the first 12 years (Bernstein et al. 1994) and has shown excellent sensitivity and specificity (Bernstein and Fink 1998; Villano et al. 2004). Cut-off scores for each clinical domain as defined in the CTQ manual (Bernstein & Fink 1998) were used. Participants scoring within the “none or minimal” range were defined as below threshold; any higher score was defined as above-threshold (Koen et al. 2014).

The World Mental Health Traumatic Life Events Questionnaire (TLEQ) (Kubany et al. 2000) is a 17-item tool which assesses exposure to stressful/negative life events during the preceding 12 months. The questionnaire used in this study is based on the items used in the SASH study in South Africa (Myer et al. 2008). A participant’s total score is obtained by adding the number of life events reportedly experienced during the preceding 12 months; higher scores thus indicate exposure to more stressful life events.

The Intimate Partner Violence (IPV) Questionnaire used in this study was adapted from the WHO multi-country study (Jewkes 2002) and the Women’s Health Study, Zimbabwe (Shamu et al. 2011) and assessed lifetime and recent (past-year) exposure to emotional, physical and sexual abuse. Scoring guidelines were devised for the purposes of the DCHS, and were based on prior work in similar South African studies (Koen et al. 2014; Dunkle et al. 2004). A binary variable was generated by separating women who never had IPV or only one episode from women who had more than one episode of IPV.

HIV tests in cases where the status was unknown were voluntary and included pre- and post-test counselling. HIV testing is routinely offered in South African antenatal clinics.

The Edinburgh Postnatal Depression Rating Scale (EPDS) (Cox et al.1987) is a self-report measure regarding recent depressive symptoms. It has shown good psychometric properties in studies evaluating validity abroad (Eberhard-Gran et al. 2001) and locally (Lawrie et al. 1998; De Bruin et al. 2004). A binary variable was created by using 13 as a cut-off score; this threshold has been established by a similar study conducted in a LMIC context in South Africa (Hartley et al. 2011). In the DCHS population, postpartum, the EPDS conferred a sensitivity of 67% and specificity of 88% when used at the cut-off score of 13 compared to the MINI as diagnostic gold standard (Van der Westhuizen et al. 2018).

The Modified Posttraumatic Stress Disorder Symptom Scale (MPSS) (Foa et al. 1993) is a 17-item self-report questionnaire evaluating posttraumatic stress disorder (PTSD. ) As no cut-off score for PTSD has been clearly established (Binder et al. 2008), the DSM-IV criteria were applied to the MPSS items to confirm or exclude a PTSD diagnosis with high probability (Koen et al. 2014).

The self-report Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), developed by the WHO for use in primary care settings, was used to assess substance abuse during and after pregnancy. The ASSIST has shown good reliability, feasibility and validity in international, multisite studies (WHO ASSIST Working Group 2002; Humeniuk et al. 2008). Only data for alcohol and smoking were extracted for analyses since other substances were reported with negligible frequency. Any alcohol use or cigarette smoking was deemed enough for belonging to the “smoking” or “drinking” groups compared to the sober and non-smoking groups.

The clinician-administered Mini International Neuropsychiatric Interview for DSM-IV (MINI-IV) is an abridged version of the Structured Clinical Interview for DSM-IV and is extensively used, including in South Africa (Myer et al. 2008; Spies et al. 2009) and has well established validity (Lecrubier et al. 1997; Sheehan et al. 1997,1998). The MINI provides information on common psychiatric diagnoses; using operationalised DSM-IV criteria the presence or absence of suprathreshold PTSD and MDD was diagnosed. Suicidal Ideation and Behaviour (SIB) as the outcome of interest was assessed by section B of the MINI (Sheehan et al. 1998). This contains heterogeneous questions and encompasses symptoms from the last month (B1-B13) as well as previous suicide attempts (B14). This measure was categorised in two ways: 1) dichotomous (SIB = 0 indicating no SIB; SIB > 0 indicating SIB; and 2) scores are divided into four risk categories: None (0), Low (1–8), Medium (9–16) and High (≥ 17) (MINI version 6.0.0., published 10 October 2010) The MINI risk assessment of SIB is based on questions that move progressively from passive (“feeling hopeless, thinking you’d be better off dead”) to active ideation (“wanting to die”) and then suicide planning (writing a note, choosing a date) to acts of deliberate self-harm (e.g. starting attempt but interrupted). Progressively more serious items are given weighted scores so that they increase the score exponentially. The last item enquires about past suicide attempts, as a history of suicide attempts increases the risk of future attempts and completed suicide. While the “low risk” category might overlap with the construct of passive suicidal ideation and the “high risk” category with active ideation, these are not synonymous, nor were these categories designed to be used interchangeably with any other subcategories of SIB.

Statistical Analysis

Data analysis was performed using STATA 14.2 (StataCorp Inc., College Station, Texas, USA). Prevalence ratios were used to describe the prevalence of SIB and other psychiatric disorders at cross-sectional time points; during pregnancy and at 6 months postpartum. Baseline sociodemographic differences between those who reported SIB at any time point (SIB > 0) and those who never endorsed SIB (SIB = 0) were explored with bivariate analyses (χ2 for categorical variables, independent t-tests for continuous variables). For participants who completed the MINI at both time points, the assessment at ANC was utilized unless the participant reported no SIB at ANC but did report any SIB at 6 months postpartum.

Binary logistic regressions were used to separately describe predictors of the presence of SIB at ANC and 6 months postpartum. The set of independent variables was divided into 3 groups; sociodemographic factors (ethnicity, age, food security, SES score), physical health (HIV positive, unplanned pregnancy,) and psychosocial and psychiatric factors (IPV, childhood trauma, traumatic life events, MDD, PTSD, alcohol and substance abuse). Variables found to be significantly associated with suicidality in bivariate analyses at p<0.05 were included in multivariable regression models at ANC and 6 months postpartum. Odds ratios (ORs) and 95% confidence intervals (CIs) were obtained. To determine predictors of the risk categories of SIB (None = 0, Low = 1–8, Medium = 9–16, and High ≥ 17), multinomial regressions were used. Variables found to be significantly associated (p<0.05) with at least one categories of SIB risk in the bivariate models were included in the multivariable model. For the multinomial multivariate regression, betas and 95% CIs are reported.

Results

Sample size

The prenatal sample size was n = 347 and at 6 months postpartum, 522 women were assessed. There were 121 women who were seen at both visits. A total of 748 individuals were assessed during at least one time point.

Mental disorders

The 1 month prevalence of antenatal SIB was 19.9% and of postpartum SIB was 22.6%. At the antenatal assessment, 19.3% of women reported a lifetime major depressive episode on the MINI and 20% of women reported this at the 6 month postpartum assessment. Similar findings were obtained with the EPDS, with 20.4% of women reporting depression antenatally and 14.3% reporting depression postpartum. The diagnosis of lifetime PTSD was confirmed by the clinician-administered MINI in 17.7% of women during pregnancy and 15.2% at 6 months postpartum. On the MPSS self-reported PTSD was present in 12.0% participants antenatally. With the MINI almost 1 in 10 (9.29%) women met criteria for alcohol abuse or dependence during pregnancy, and the proportion halved to 4.45% postpartum. On the MINI, less than 2% of participants had drug use during the perinatal period. However self-report of alcohol use indicated that 16.5% of participants drank alcohol during pregnancy and 21.1% postpartum. One in four women smoked while pregnant (26.81%) and three quarters were smoking by the time their babies were 6 months old (76.9 %).

Baseline Characteristics of participants and of Suicidal versus Non-Suicidal Groups

Of the 748 individuals who completed the MINI questionnaire about 60% where from the Mbekweni and 40% from the TC Newman area. Most women had only a primary school education with some secondary schooling (64.6%). Three quarters were unemployed (77.7%), half received a government social grant (51.7%) and a third (34.6%) experienced food insecurity. More than half were single (59.2%) and more than two thirds (69.6%) did not plan their pregnancies. A quarter (24.4%) of the women were living with HIV. A third reported recent IPV (35%) and a third experienced childhood trauma (32.3%).

Comparison of women who endorsed SIB at any time point vs those who did not indicated that SIB was more common in women at the TC Newman clinic, and in younger, lower weight, less educated, unemployed and more food insecure participants (Table 1). SIB was not predicted by HIV status in this sample. In addition, perinatal SIB was significantly associated with childhood trauma, traumatic life events and recent IPV. Finally, although SIB was not associated with PTSD on the self-report MPSS it was associated with clinician-assessed MINI PTSD diagnosis. SIB was also significantly more common in patients with depression, comorbid depression and PTSD, smoking, and alcohol abuse.

Table 1:

Baseline characteristics of mothers who were administered the MINI at either ANC or 6 months postpartum by suicidality at either time point (N=748)

Variables Total Not Suicidal Suicidal p-value
Number of mothers: 748 574 174
Sociodemographics N (%) N (%) N (%)
Site:
Mbekweni 441 (58.96) 360 (62.72) 81 (46.55) <0.001***
TC Newman 307 (41.04) 214 (37.28) 93 (53.45)
SES:
Lowest SES 198 (26.47) 152 (26.48) 46 (26.44) 0.027*
Low-moderate SES 201 (26.87) 141 (24.56) 60 (34.48)
Moderate-high SES 201 (26.87) 157 (27.35) 44 (25.29)
High SES 148 (19.79) 124 (21.60) 24 (13.79)
Education:
Primary and some secondary 483 (64.57) 359 (62.54) 124 (71.26) 0.035*
Completed Secondary and Any tertiary 265 (35.43) 215 (37.46) 50 (28.74)
Unemployed 581 (77.67) 435 (75.78) 146 (83.91) 0.024*
Government grant 386 (51.74) 298 (52.01) 88 (50.87) 0.793
Food insecure 241 (34.63) 171 (32.14) 70 (42.68) 0.013*
Marital status:
Married/co-habiting 305 (40.83) 232 (40.49) 73 (41.95) 0.731
Single 442 (59.17) 341 (59.51) 101 (58.05)
Maternal Age (Median [IQR]) 25.54 [21.65, 30,72] 26.01 [21.84, 31.04] 24.40 [21.31, 28.90] 0.021*
Physical Health and pregnancy
Weight (Median [IQR]) 67.95 [57.1, 82.25] 69.0 [58.3, 83.6] 62.6 [53.0, 78.0] <0.001***
Multigravida 481 (64.30) 369 (64.29) 112 (64.37) 0.984
HIV-infected 180 (24.36) 143 (25.27) 37 (21.39) 0.298
Unintended pregnancy 520 (69.61) 403 (70.33) 117 (67.24) 0.438
Psychosocial variables
IPV any recent (Above threshold) 238 (34.90) 151 (28.82) 87 (55.06) <0.001***
Childhood Trauma (Above threshold) 220 (32.26) 129 (24.62) 91 (57.59) <0.001***
EPDS (Above threshold) 161 (23.61) 95 (18.13) 66 (41.77) <0.001***
Major depressive episode (MINI) 144 (19.38) 59 (10.35) 85 (49.13) <0.001***
Life time Events (Median [IQR]) 1 [0, 3] 1 [0, 2] 2 [1, 5] <0.001***
Suspected PTSD (MPSS) 25 (11.57) 18 (10.78) 7 (14.29) 0.779
Trauma Exposed 21 (9.72) 16 (9.58) 5 (10.20)
PTSD (MINI) 113 (15.31) 60 (35.29) 53 (9.33) <0.001***
Co-morbid PTSD and Major depressive Disorder 66 (8.99) 20 (3.54) 46 (27.22) <0.001***
Alcohol dependence (MINI) 46 (6.25) 24 (4.24) 22 (12.94) <0.001***
Substance dependence (MINI) 12 (1.62) 4 (0.70) 8 (4.71) <0.001***
Alcohol use during pregnancy 104 (15.36) 65 (12.48) 39 (25.00) <0.001***
Tobacco use during pregnancy 177 (26.03) 114 (21.84) 63 (39.87) <0.001***
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*

p<0.05

**

p<0.01

***

p<0.001

Antenatal SIB correlates

Bivariate analyses (Table 3) indicate that antenatal SIB was significantly associated with study site (TC Newman), younger age, lower weight and food insecurity. In terms of psychosocial predictors, the risk for antenatal SIB was increased by a factor of 3 in the presence of recent IPV and childhood trauma in bivariate analyses. SIB during pregnancy was also associated with stressful life events in the last year. Antenatal SIB was significantly associated with depression, PTSD and tobacco use during pregnancy. In the multivariable regression (Table 2), younger maternal age (AOR = 0.92, p = 0.020), and depression measured by the MINI (AOR = 4.84, p<0.001) were significant predictors of SIB antenatally.

Table 3:

Bivariate and multivariable regressions for predictors of suicidality at 6 months postpartum

Bivariate Regressions Multivariable Regression (N=294)
N Unadjusted OR 95% CI LL 95% CI UL p-value Adjusted OR 95% CI LL 95% CI UL p-value
Site
Mbekweni 522 (Reference)
TC Newman 2.09 1.38 3.16 0.001** 1.23 0.58 2.60 0.596
SES
Lowest SES 522 (Reference)
Low-moderate SES 1.00 0.58 1.72 0.988
Moderate-high SES 0.65 0.37 1.16 0.142
High SES 0.69 0.38 1.26 0.228
Completed Secondary and Any tertiary 522 0.71 0.46 1.09 0.117
Unemployed 522 0.85 0.52 1.40 0.524
Government grant 500 0.96 0.57 1.63 0.885
Food insecure 444 1.20 0.54 2.70 0.653
Married/co-habiting 496 1.29 0.85 1.96 0.237
Maternal Age 522 0.97 0.94 1.01 0.15
Physical Health and Pregnancy
Multigravida 522 1.10 0.71 1.69 0.672
HIV-infected 519 0.79 0.48 1.28 0.339
Unintended pregnancy 522 1.39 0.89 2.15 0.144
Psychosocial Variables
IPV any recent (Above threshold) 475 4.12 2.63 6.46 <0.001*** 2.16 1.09 4.29 0.027*
Childhood Trauma (Above threshold) 393 6.50 3.56 11.86 <0.001*** 1.86 0.94 3.67 0.075
Major depressive episode (MINI) 394 1.33 1.18 1.50 <0.001*** 4.22 2.01 8.86 <0.001***
Life time Events (Median [IQR]) 517 4.09 1.76 9.54 0.001** 1.07 0.92 1.25 0.395
PTSD (MINI) 515 5.53 3.32 9.21 <0.001*** 2.29 1.03 5.07 0.041
Alcohol dependence (MINI) 517 4.09 1.76 9.54 0.001**
Substance dependence (MINI) 519 21.92 2.61 184.05 0.004**
Alcohol use during pregnancy 394 1.95 1.13 3.36 0.016* 1.10 0.47 2.58 0.818
Tobacco use during pregnancy 394 0.76 0.44 1.32 0.329
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*

p<0.05

**

p<0.01

***

p<0.001

Table 2:

Bivariate and multivariable regressions for predictors of suicidality at ANC

Bivariate regressions Multivariate regressions (N=287)
Sociodemographics N Unadjusted OR 95% CI LL 95% CI UL p-value Adjusted OR 95% CI LL 95% CI UL p-value
Mbekweni 347 (Reference)
TC Newman 1.71 1.01 2.91 0.047* 0.90 0.32 2.53 0.84
Lowest SES 347 (Reference)
Low-moderate SES 1.45 0.70 3.03 0.317
Moderate-high SES 0.74 0.34 1.62 0.457
High SES 0.85 0.38 1.90 0.69
Completed Secondary and Any tertiary 347 0.66 0.37 0.21 0.148
Unemployed 347 0.85 0.44 1.63 0.627
Government grant 347 0.74 0.44 1.25 0.259
Food insecure 330 1.96 1.14 3.38 0.015* 1.49 0.69 3.22 0.32
Married/co-habiting 347 0.76 0.44 1.31 0.322
Maternal Age 347 0.95 0.90 0.99 0.042* 0.92 0.86 0.99 0.020*
Physical health
Weight 344 0.97 0.96 0.99 0.003** 0.99 0.97 1.01 0.38
Multigravida 347 0.84 0.49 1.46 0.543
HIV-infected 341 0.86 0.44 1.67 0.65
Unintended pregnancy 346 0.87 0.49 1.53 0.624
Psychological
IPV any recent (Above threshold) 319 3.10 1.76 5.46 <0.001*** 1.96 0.96 3.98 0.064
Childhood Trauma (Above threshold) 319 3.00 1.70 5.27 <0.001*** 1.61 0.78 3.33 0.195
Major depressive episode (MINI) 327 6.14 3.35 11.25 <0.001*** 4.84 2.19 10.70 <0.001***
Life time Events 318 1.22 1.09 1.37 0.001** 1.10 0.94 1.29 0.233
PTSD (MINI) 328 3.73 2.01 6.90 <0.001*** 2.20 0.95 5.07 0.065
Alcohol dependence (MINI) 323 2.16 0.96 4.88 0.063
Substance dependence (MINI) 324 2.02 0.36 11.30 0.422
Alcohol use during pregnancy 316 1.62 0.81 3.21 0.171
Tobacco use during pregnancy 317 2.32 1.30 4.15 0.004** 1.29 0.52 3.21 0.590
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*

p<0.05

**

p<0.01

***

p<0.001

Postpartum SIB correlates

In bivariate analyses, SIB at 6 months postpartum was strongly associated with study site (TC Newman), recent IPV, childhood trauma and stressful life events. Postpartum SIB was also positively associated with MDD, PTSD, self-reported alcohol use during pregnancy and postpartum alcohol and substance dependence (both MINI diagnoses). In the multivariable regression, MDD (AOR = 4.22, p<0.001) and PTSD (AOR = 2.29, p = 0.041), both measured by the MINI, were significant predictors of postpartum SIB.

SIB Severity and correlates

Table 4 explores risk factors associated with SIB severity (at any time point). Compared to those with no SIB, participants in the low risk SIB group were more likely to have experienced food insecurity (ß = 0.64, p = 0.02), have recent experiences with IPV (ß = 0.74, p = 0.004), have met criteria for childhood trauma (ß = 0.74, p = 0.005), have MDD (ß = 1.58, p<0.001) and PTSD (ß = 0.93, p = 0.005). For those in the medium SIB group, participants were more likely to have MDD (ß = 2.03, p = 0.001) compared to those in the no risk group. The medium risk group self-reported more alcohol use during pregnancy (ß = 1.31, p = 0.046) and on the MINI was diagnosed more frequently with substance dependence (ß = 2.86, p = 0.04). Finally, for those in the high SIB group, participants were more likely to have MDD (ß = 2.96, p<0.001) and PTSD (ß = 1.93, p = 0.003) compared to those in the no risk group.

Table 4:

Multinomial multivariable regression predicting categories of SIB

Group 0 Group 1 Group 2 Group 3
None (0; n=574) Low (1–8; n=137) Medium (9–16; n=17) High (17 or greater; n=20)
Variables (referent group) Adjusted OR 95% CI LL 95% CI UL p-value Adjusted OR 95% CI LL 95% CI UL p-value Adjusted OR 95% CI LL 95% CI UL p-value
Site:
Mbekweni (reference) - - - (reference) - - - (reference) - - -
TC Newman - 0.65 −0.01 1.31 0.055 −0.86 −2.46 0.74 0.29 0.45 −1.14 2.04 0.58
Education (Matriculated) - −0.08 −0.62 0.45 0.76 0.05 −1.13 1.23 0.94 −0.18 −1.59 1.23 0.80
Food insecurity - 0.64 0.09 1.18 0.02* 0.08 −1.13 1.29 0.90 1.11 −0.19 2.42 0.10
Married/co-habiting - −0.15 −0.70 0.40 0.58 −0.26 −1.58 1.06 0.70 0.98 −0.36 2.32 0.51
Maternal age - −0.05 −0.09 0.00 0.06 −0.10 −0.21 0.01 0.08 −0.09 −0.20 0.03 0.141
IPV any recent (Above threshold) - 0.74 0.24 1.25 0.004** −0.10 −1.29 1.09 0.87 0.07 −1.19 1.33 0.92
Childhood Trauma (Above threshold) - 0.74 0.23 1.25 0.005** 0.63 −0.54 1.81 0.29 1.40 −0.08 2.89 0.06
Major depressive episode (MINI) - 1.58 1.00 2.16 <0.001*** 2.03 0.90 3.26 0.001** 2.96 1.50 4.41 <0.001***
Life time Events - −0.002 −0.12 0.11 0.96 0.12 −0.09 0.34 0.25 0.17 −0.04 0.37 0.12
PTSD (MINI) - 0.93 0.29 1.57 0.005** 1.03 −0.26 2.31 0.12 1.93 0.66 3.19 0.003**
Alcohol dependence (MINI) - 0.47 −0.39 1.32 0.29 0.53 −1.25 2.30 0.56 −0.08 −2.06 1.86 0.94
Substance dependence (MINI) - 0.92 −0.86 2.70 0.31 2.86 0.12 5.61 0.04* 2.17 −0.53 4.88 0.12
Alcohol use during pregnancy - 0.33 −0.33 0.99 0.33 1.31 0.02 2.60 0.046* 1.28 −0.07 2.64 0.06
Tobacco use during pregnancy - 0.11 −0.54 0.77 0.73 −0.37 −2.11 1.36 0.68 −0.86 −2.48 0.77 0.30
Open in a new tab
*

p<0.05

**

p<0.01

***

p<0.001

Discussion

This study had three main findings. First, in this peri-urban African (LMIC) setting, a high prevalence of SIB was found during pregnancy as well as at 6 months postpartum. Second, factors independently predicting the presence of SIB were younger age and depression during pregnancy, and PTSD and depression at 6 months postpartum. Third, belonging to the higher risk SIB group perinatally was predicted by depression and PTSD, and membership of the lower risk SIB group in the perinatal period was associated with depression and PTSD again, but also with recent IPV, food insecurity, and childhood trauma.

The prevalence of antepartum SIB here (19.9%) is consistent with previous work using clinical-rated measures of SIB in South Africa (18%: Onah et al. 2017) and in another LMIC, Brazil (19.7%: Vaz et al. 2014). However postpartum SIB (22.6%) was more prevalent than found in two other postpartum studies also using the MINI from South Africa (7.6%: Dewing et al. 2013) and Brazil (11.5%: Tavares et al. 2012). Our findings add to the growing evidence that SIB during pregnancy in LMICs is common, and indicate that in our study population there may be specific factors that make women particularly vulnerable to ongoing high rates of SIB postpartum.

Our findings regarding risk factors are consistent with previous work showing that SIB is associated with depression and anxiety disorders (Onah et al. 2017; Tavares et al. 2012), IPV (Onah et al. 2017), food insecurity (Onah et al. 2017; Dewing et al. 2013) and childhood trauma (Giallo et al. 2018; Doi & Fujiwara 2019). Our results converged with local studies failing to find associations between SIB and lower education levels (Rochat et al. 2013, Rodriguez et al. 2018), contrary to a review establishing correlation between SIB and educational duration less than 12 years in other LMICs (Gelaye et al. 2016). Our finding of an association of SIB with PTSD is consistent with prior work in Brazil (Tavares et al. 2012), and our finding of an association between lower risk SIB and food insecurity is partly consistent with prior work in South Africa (Dewing et al. 2013). Taken together, current mental illness, psychosocial stressors (IPV, food insecurity) as well as recent trauma (leading to PTSD) and remote (childhood) trauma are all relevant factors to consider in exploring causal pathways of perinatal SIB, and in addressing SIB at a clinical and public health level.

Our findings that different factors are associated with higher severity SIB (mainly mental illness) compared to lower severity SIB (mental illness and psychosocial stressors) are novel, and suggest that different causal pathways may be involved. Further research is needed to consolidate this point, for example applying pathway analysis. It is possible that women who are exposed to more psychosocial stressors early on (childhood trauma) are less likely to complete education leading to poverty and higher likelihood of choosing partners who are violent. Early trauma may also lead to maladaptive coping skills. Potential interventions would therefore include early detection of childhood adversity and parenting programs, preschool school readiness programs, early intervention for educational failure, employment support, male mental health support (to prevent IPV), couples counselling to improve interpersonal conflict skills, and screening for mental illness in order to provide timely intervention.

The prevalence of perinatal SIB is similar to that of the general population in South Africa; RSA had the highest frequency of suicidal ideation (25.4%) in the WHO multisite intervention study on suicidal behaviours (SUPRE-MISS) among eight LMICs (Bertolote et al., 2005). Findings from the South African Stress and Health (SASH) study suggest that PTSD, number of mental disorders, female gender, younger age and lower education are all predictive of suicidal ideation and behaviour among the general population (Joe et al. 2009; Khasakhala et al. 2011). Our study population had much higher rates of Depression (〜20%) and PTSD (〜16%) compared to SASH prevalences in the 18–34 age group (8.9 and 1.8% respectively) (Herman et al. 2009). While the assessment of SIB was not as comprehensive in these studies, the prevalence of perinatal SIB seems comparable to SIB in the general population, with mental illness and younger age emerging as important risk factors in both populations.

A number of limitations deserve emphasis. First, the sample was based on consecutive cases seen, and it is possible that women with more severe mental illness may not have presented for care. Second, cross-sectional analyses does not allow inferences regarding causality; only a minority of women were seen at both time points, precluding longitudinal analysis. Third, the group was not representative of all ages: adolescent mothers were excluded due to ethical considerations regarding conducting research with minors. Younger people are more likely to experience SIB during pregnancy (Freitas et al., 2002) and arguably have fewer personal and financial resources to deal with the implications of pregnancy. Fourth, there is limited information on a number of risk factors (e.g., personality disorder). Fifth, no follow-up data regarding subsequent suicide attempts and completed suicide were available.

Nevertheless, the study has a number of important strengths. First, the comprehensive assessment of SIB with a clinician-administered, internationally validated tool allows for the reliable and valid assessment of the presence and severity of SIB, both in the antenatal and postpartum period. Second, the collection of data on a large number of potential risk factors facilitates a comprehensive assessment and description of antecedents and potential causes of SIB. Finally, the demographic characteristics of the study population represent both the most vulnerable mothers as well as reflect a large proportion of women living in South Africa today, allowing for generalization of findings and relevance to health policy makers.

Conclusion

In conclusion, our findings support previous research on the prevalence of and risk factors for SIB in LMIC settings, and also provide some new directions. First, the associations of perinatal SIB with younger age and major depression found here are consistent with previous work in LMICs, and emphasize the need for sensitive and specific screening for perinatal SIB. Second, the association of perinatal SIB with PTSD is a relatively novel one, and underscores the particular importance of assessment of trauma exposure and outcomes in this population. Third, the finding that different risk factors are associated with higher risk SIB (mainly mental illness) and lower risk SIB (mainly mental illness and psychosocial stressors), suggests that these involve different causal pathways and require different interventions, and points to the need for further research to replicate and extend these observations.

Acknowledgements

We thank the entire onsite Drakenstein clinical and research team for its tireless work and commitment and all the mothers and infants enrolled in the Drakenstein Child Health Study. Support for this study was provided by the Bill and Melinda Gates Foundation (Grant OPP1017641), the National Institute of Mental Health Brain Disorders in the Developing World: Research Across the Lifespan program (Grant 1R21MH098662- 01), and the National Research Foundation and the South African Medical Research Council.

Funding

Support for this study was provided by the Bill and Melinda Gates Foundation (Grant OPP1017641), the National Institute of Mental Health Brain Disorders in the Developing World: Research Across the Lifespan program (Grant 1R21MH098662– 01), and the National Research Foundation and the South African Medical Research Council.

Footnotes

Declarations

Conflicts of interest/Competing interests The authors have no relevant financial or non-financial interests to disclose.

Ethics approval The DCHS received approval from the University of Cape Town (UCT: HREC 401/2009) and Stellenbosch University (SU) Human Research Ethics Committees (HREC) as well as from the Western Cape Provincial Research Committee. The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments.

Consent to participate and for publication Study participants provided written informed consent before data collection commenced. This included consent for data analysis and publication of research findings with the understanding that personal identifying information will be kept strictly confidential.

Availability of data and material The datasets generated during and analysed during the current study are available from the corresponding author on reasonable request. Some restrictions may apply as DCHS data analysis is ongoing.

References

  1. Bernstein DP, Fink L, Handelsman L, Foote J, Lovejoy M, Wenzel K, Sapareto E, & Ruggiero J (1994). Initial reliability and validity of a new retrospective measure of child abuse and neglect. The American journal of psychiatry, 151(8), 1132–1136. 10.1176/ajp.151.8.1132 [DOI] [PubMed] [Google Scholar]
  2. Bernstein D, Fink L (1998) Childhood trauma questionnaire: a retrospective self-report. The Psychological Corporation, San Antonio [Google Scholar]
  3. Bertolote JM, Fleischmann A, De Leo D, Bolhari J, Botega N, De Silva D, Thanh HTT, Phillips M, Schlebusch L, Vijayakumar L & Wasserman D. (2005). Suicide attempts, plans, and ideation in culturally diverse sites: The WHO SUPRE-MISS community survey. Psychological Medicine, 35(10), 1457–1465. 10.1017/S0033291705005404 [DOI] [PubMed] [Google Scholar]
  4. Binder EB, Bradley RG, Liu W, Epstein MP, Deveau TC, Mercer KB, Tang Y, Gillespie CF, Heim CM, Nemeroff CB, Schwartz AC, Cubells JF, & Ressler KJ (2008). Association of FKBP5 polymorphisms and childhood abuse with risk of posttraumatic stress disorder symptoms in adults. JAMA, 299(11), 1291–1305. 10.1001/jama.299.11.1291 [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Coates J, Swindale A, Bilinsky P. Household Food Insecurity Access Scale (HFIAS) for Measurement of Household Food Access: Indicator Guide, 3rd ed.; Food and Nutrition. Technical Assistance Project: Washington, DC, USA, 2007. [Google Scholar]
  6. Cox JL, Holden JM, Sagovsky R. (1987) Detection of postnatal depression: development of the 10- item Edinburgh Postnatal Depression Scale. Br J Psychotherapy 1987;150:782–6. 10.1192/bjp.150.6.782 [DOI] [PubMed] [Google Scholar]
  7. Chang J, Berg C, Saltzman LE & Herndon J. (2005). Homicide: A Leading Cause of Injury Deaths Among Pregnant and Postpartum Women in the United States, 1991–1999. Am J Public Health, 95(3): 471–477. 10.2105/AJPH.2003.029868 [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. De Bruin GP, Swartz L, Tomlinson M, Cooper PJ, & Molteno C. (2004). The Factor Structure of the Edinburgh Postnatal Depression Scale in a South African Peri-Urban Settlement. South African Journal of Psychology, 34(1), 113–121. 10.1177/008124630403400107 [DOI] [Google Scholar]
  9. Dewing S, Tomlinson M, le Roux IM, Chopra M, & Tsai AC. (2013). Food insecurity and its association with co-occurring postnatal depression, hazardous drinking, and suicidality among women in peri-urban South Africa. Journal of affective disorders, 150(2), 460–465. 10.1016/j.jad.2013.04.040 [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Doi S and Fujiwara T. (2019) Combined effect of adverse childhood experiences and young age on self-harm ideation among postpartum women in Japan. Journal of Affective disorders, Vol 25: 410–418. 10.1016/j.jad.2019.04.079 [DOI] [PubMed] [Google Scholar]
  11. Dunkle LK, Jewkes RK, Brown HC, Gray GE, Mcintyre JA, Harlow SD. (2004) Gender-Based Violence, Relationship Power, And Risk of HIV Infection in women attending antenatal clinics in South Africa Lancet 363 (9419):1415–1421. 10.1016/S0140-6736(04)16098-4 [DOI] [PubMed] [Google Scholar]
  12. Eberhard-Gran M, Eskild A, Tambs K, Opjordsmoen S, & Samuelsen SO. (2001). Review of validation studies of the Edinburgh Postnatal Depression Scale. Acta psychiatrica Scandinavica, 104(4), 243–249. 10.1034/j.1600-0447.2001.00187.x [DOI] [PubMed] [Google Scholar]
  13. Foa EB, Riggs DS, Dancu CV and Rothbaum BO. (1993), Reliability and validity of a brief instrument for assessing post-traumatic stress disorder. J. Traum. Stress, 6: 459–473. 10.1002/jts.2490060405 [DOI] [Google Scholar]
  14. Freitas GV, & Bottega NJ. (2002) Prevalence of depression, anxiety and suicide ideation in pregnant adolescents. Rev Assoc Med Bras, 48(3), 245–9. 10.1590/s0104-42302002000300039 [DOI] [PubMed] [Google Scholar]
  15. Fuhr DC, Calvert C, Ronsmans C, Chandra PS, Sikander S, De Silva MJ, & Patel V. (2014). Contribution of suicide and injuries to pregnancy-related mortality in low-income and middle-income countries: A systematic review and meta-analysis. The Lancet Psychiatry, 1(3), 213–225. 10.1016/S2215-0366(14)70282-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Gelaye B, Kajeepeta S, Williams MA (2016) Suicidal Ideation in pregnancy, an epidemiologic review. Arch Womens Ment Health 19:741–751 10.1007/s00737-016-0646-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Giallo R, Pilkington P, Borschmann R, Seymour M, Dunning M & Brown S. (2018). The prevalence and correlates of self-harm ideation trajectories in Australian women from pregnancy to 4-years postpartum. Journal of Affective Disorders, 229, 152–158. 10.1016/j.jad.2017.12.064 [DOI] [PubMed] [Google Scholar]
  18. Hartley M, Tomlinson M, Greco E, Comulada WS, Stewart J, Le Roux I, Mbewu N & Rotheram – Borus MJ. (2011) Depressed mood in pregnancy: Prevalence and correlates in two Cape Town peri-urban settlements. Reprod Health, (8) 9. 10.1186/1742-4755-8-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Herman AA, Stein DJ, Seedat S, Heeringa SG, Moomal H, Williams DR. (2009) The South African Stress and Health (SASH) study: 12-month and lifetime prevalence of common mental disorders. S Afr Med J 2009;99(5 Pt 2):339–344. [PMC free article] [PubMed] [Google Scholar]
  20. Howard LM, Flach C, Mehay A et al. (2011) The prevalence of suicidal ideation identified by the Edinburgh Postnatal Depression Scale in postpartum women in primary care: findings from the RESPOND trial. BMC Pregnancy Childbirth 11, 57 (2011). 10.1186/1471-2393-11-57 [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Humeniuk R, Ali R, Babor TF, Farrell M, Formigoni ML, Jittiwutikarn J, de Lacerda RB, Ling W, Marsden J, Monteiro M, Nhiwatiwa S, Pal H, Poznyak V, & Simon S. (2008). Validation of the Alcohol, Smoking And Substance Involvement Screening Test (ASSIST). Addiction (Abingdon, England), 103(6), 1039–1047. 10.1111/j.1360-0443.2007.02114.x [DOI] [PubMed] [Google Scholar]
  22. Jewkes R (2002) Intimate partner violence: causes and prevention. Lancet, 359(9315):1423–9. 10.1016/S0140-6736(02)08357-5 [DOI] [PubMed] [Google Scholar]
  23. Joe S, Baser RS, Neighbors HW, Caldwell CH, Jackson JS. 12-month and lifetime prevalence of suicide attempts among black adolescents in the National Survey of American Life. J Am Acad Child Adolesc Psychiatry. 2009. March;48(3):271–282. 10.1097/CHI.0b013e318195bccf [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Kessler RC, Chiu WT, Demler O, Merikangas KR, & Walters EE. (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of general psychiatry, 62(6), 617–627. 10.1001/archpsyc.62.6.617 [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Khasakhala L, Sorsdahl KR, Harder VS, Williams DR, Stein DJ, Ndetei DM. Lifetime mental disorders and suicidal behaviour in South Africa. Afr J Psychiatry (Johannesbg) 2011;14(2):134–139. 10.4314/ajpsy.v14i2.5 [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Kim JJ, La Porte LM, Saleh MP, Allweiss S, Adams MG, Zhou Y & Silver RK. (2015) Suicide risk among perinatal women who report thoughts of self-harm on depression screens. Obstetrics and Gynecology 125, 885–893. 10.1097/AOG.0000000000000718 [DOI] [PubMed] [Google Scholar]
  27. Koen N, Wyatt GE, Williams JK, Zhang M, Myer L, Zar HJ, & Stein DJ. (2014). Intimate partner violence: Associations with low infant birthweight in a South African birth cohort. Metabolic Brain Disease, 29(2), 281–299. 10.1007/s11011-014-9525-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Kubany ES, Leisen MB, Kaplan AS, Watson SB, Haynes SN, Owens JA, & Burns K. (2000). Development and preliminary validation of a brief broad-spectrum measure of trauma exposure: The Traumatic Life Events Questionnaire. Psychological Assessment, 12(2), 210–224. 10.1037/1040-3590.12.2.210 [DOI] [PubMed] [Google Scholar]
  29. Lawrie TA, Hofmeyr GJ, de Jager M, & Berk M. (1998). Validation of the Edinburgh Postnatal Depression Scale on a cohort of South African women. South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde, 88(10), 1340–1344. https://doi.org/ [PubMed] [Google Scholar]
  30. Lecrubier Y, Sheehan D, Weiller E, Amorim P, Bonora I, Sheehan K, Janavs J, Dunbar G. (1997). The Mini International Neuropsychiatric Interview (MINI). A short diagnostic structured interview: Reliability and validity according to the CIDI. European Psychiatry, 12(5), 224–231. 10.1016/S0924-9338(97)83296-8 [DOI] [Google Scholar]
  31. Lindahl V, Pearson JL, & Colpe L. (2005, June). Prevalence of suicidality during pregnancy and the postpartum. Archives of Women’s Mental Health. 10.1007/s00737-005-0080-1 [DOI] [PubMed] [Google Scholar]
  32. Mauri M, Oppo A, Borri C, Banti S, & PND-ReScU group (2012). SUICIDALITY in the perinatal period: comparison of two self-report instruments. Results from PND-ReScU. Archives of women’s mental health, 15(1), 39–47. 10.1007/s00737-011-0246-y [DOI] [PubMed] [Google Scholar]
  33. Murray D, & Cox JL. (1990). Screening for depression during pregnancy with the Edinburgh Depression Scale (EPDS). Journal of Reproductive and Infant Psychology, 8(2), 99–107 10.1080/02646839008403615 [DOI] [Google Scholar]
  34. Muzik M, Brier Z, Menke RA, Davis MT, & Sexton MB. (2016). Longitudinal suicidal ideation across 18-months postpartum in mothers with childhood maltreatment histories. Journal of affective disorders, 204, 138–145. 10.1016/j.jad.2016.06.037 [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Myer L, Stein DJ, Grimsrud A, Seedat S, & Williams DR. (2008). Social determinants of psychological distress in a nationally-representative sample of South African adults. Social science & medicine (1982), 66(8), 1828–1840. 10.1016/j.socscimed.2008.01.025 [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Nock MK, Borges G, Bromet EJ, Alonso J, Angermeyer M, Beautrais A, Bruffaerts R, Chiu WT, de Girolamo G, Gluzman S, de Graaf R, Gureje O, Haro JM, Huang Y, Karam E, Kessler RC, Lepine JP, Levinson D, Medina-Mora ME, Ono Y, … Williams D. (2008-b). Cross-national prevalence and risk factors for suicidal ideation, plans and attempts. The British journal of psychiatry : the journal of mental science, 192(2), 98–105. 10.1192/bjp.bp.107.040113 [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Oates M, (2003) Perinatal psychiatric disorders: a leading cause of maternal morbidity and mortality. British Medical Bulletin 67(1):219–229. 10.1093/bmb/ldg011 [DOI] [PubMed] [Google Scholar]
  38. Onah MN, Field S, Bantjes J, Honikman S. (2017) Perinatal suicidal ideation and behaviour: psychiatry and adversity. Arch Womens Ment Health 20, 321–331 (2017). 10.1007/s00737-016-0706-5 [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Pellowski JA, Barnett W, Kuo CC, Koen N, Zar HJ, & Stein DJ. (2017). Investigating tangible and mental resources as predictors of perceived household food insecurity during pregnancy among women in a South African birth cohort study. Social Science and Medicine, 187, 76–84. 10.1016/j.socscimed.2017.06.022 [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. Pope CJ, Xie B, Sharma V, & Campbell MK. (2013). A prospective study of thoughts of self-harm and suicidal ideation during the postpartum period in women with mood disorders. Archives of women’s mental health, 16(6), 483–488. 10.1007/s00737-013-0370-y [DOI] [PubMed] [Google Scholar]
  41. Rochat TJ, Bland RM, Tomlinson M, & Stein A. (2013). Suicide ideation, depression and HIV among pregnant women in rural South Africa. Health, 05(03), 650–661. 10.4236/health.2013.53a086 [DOI] [Google Scholar]
  42. Rodriguez VJ, Mandell LN, Babayigit S, Manohar RR, Weiss SM, Jones DL. (2018) Correlates of Suicidal Ideation During Pregnancy and Postpartum Among Women Living with HIV in Rural South Africa. AIDS and Behavior (2018) 22:3188–3197 10.1007/s10461-018-2153-y [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Shamu S, Abrahams N, Temmerman M, Musekiwa A, Zarowsky C (2011) A Systematic Review of African Studies on Intimate Partner Violence against Pregnant Women: Prevalence and Risk Factors. PLoS ONE 6(3): e17591. 10.1371/journal.pone.0017591 [DOI] [PMC free article] [PubMed] [Google Scholar]
  44. Shamu S, Zarowsky C, Roelens K, Temmerman M, & Abrahams N. (2016). High-frequency intimate partner violence during pregnancy, postnatal depression and suicidal tendencies in Harare, Zimbabwe. General hospital psychiatry, 38, 109–114. 10.1016/j.genhosppsych.2015.10.005 [DOI] [PubMed] [Google Scholar]
  45. Sheehan DV, Lecrubier Y, Sheehan KH, Janavs J, Weiller E, Keskiner A, Schink J, Knapp E, Sheehan MF, Dunbar GC. (1997) The validity of the Mini International Neuropsychiatric Interview according to the SCID-P and its reliability. European Psychiatry Vol 12(5), 232–241 10.1016/S0924-9338(97)83297-X [DOI] [Google Scholar]
  46. Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, Hergueta T, Baker R, & Dunbar GC. (1998). The Mini-International Neuropsychiatric Interview (M.I.N.I): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. The Journal of Clinical Psychiatry, 59(Suppl 20), 22–33. [PubMed] [Google Scholar]
  47. Sit D, Luther J, Buysse D, Dills JL, Eng H, Okun M, Wisniewski S, & Wisner KL. (2015). Suicidal ideation in depressed postpartum women: Associations with childhood trauma, sleep disturbance and anxiety. Journal of psychiatric research, 66–67, 95–104. 10.1016/j.jpsychires.2015.04.021 [DOI] [PMC free article] [PubMed] [Google Scholar]
  48. Stein DJ, Koen N, Donald KA, Adnams CM, Koopowitz S, Lund C, Marais A, Myers B, Roos A, Sorsdahl K, Stern M, Tomlinson M, van der Westhuizen C, Vythilingum B, Myer L, Barnett W, Brittain K, & Zar HJ. (2015). Investigating the psychosocial determinants of child health in Africa: The Drakenstein Child Health Study. Journal of neuroscience methods, 252, 27–35. 10.1016/j.jneumeth.2015.03.016 [DOI] [PMC free article] [PubMed] [Google Scholar]
  49. Spies G, Stein D, Roos A, Faure S, Mostert J, Seedat S, Vythilingum B (2009). Validity of the Kessler 10 (K-10) in detecting DSM-IV defined mood and anxiety disorders among pregnant women. Archives of Women’s Mental Health 12, 69–74. 10.1007/s00737-009-0050-0 [DOI] [PubMed] [Google Scholar]
  50. Tavares D, Quevedo L, Jansen K, Souza L, Pinheiro R, & Silva R. (2012). Prevalence of suicide risk and comorbidities in postpartum women in Pelotas. Revista brasileira de psiquiatria (Sao Paulo, Brazil : 1999), 34(3), 270–276. 10.1016/j.rbp.2011.12.001 [DOI] [PubMed] [Google Scholar]
  51. Van der Westhuizen C, Brittain K, Koen N, Maré K, Zar HJ, & Stein DJ. (2018). Sensitivity and Specificity of the SRQ-20 and the EPDS in Diagnosing Major Depression Ante- and Postnatally in a South African Birth Cohort Study. International Journal of Mental Health and Addiction, 16(1), 175–186. 10.1007/s11469-017-9854-8 [DOI] [Google Scholar]
  52. Vaz JS, Kac G, Nardi AE, & Hibbeln JR. (2014). Omega-6 fatty acids and greater likelihood of suicide risk and major depression in early pregnancy. Journal of affective disorders, 152–154, 76–82. 10.1016/j.jad.2013.04.045 [DOI] [PMC free article] [PubMed] [Google Scholar]
  53. Villano CL, Cleland C, Rosenblum A, Fong C, Nuttbrock L, Marthol M, & Wallace J. (2004). Psychometric utility of the childhood trauma questionnaire with female street-based sex workers. Journal of trauma & dissociation : the official journal of the International Society for the Study of Dissociation (ISSD), 5(3), 33–41. 10.1300/j229v05n03_03 [DOI] [PMC free article] [PubMed] [Google Scholar]
  54. WHO ASSIST Working Group (2002) The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): development, reliability and feasibility. Addiction 97(9):1183–1194. 10.1046/j.1360-0443.2002.00185.x [DOI] [PubMed] [Google Scholar]
  55. Zar HJ, Barnett W, Myer L, Stein DJ & Nicol MP. (2015). Investigating the early-life determinants of illness in Africa: the Drakenstein Child Health Study. Thorax, 70(6), 592–594. 10.1136/thoraxjnl-2014-206242 [DOI] [PMC free article] [PubMed] [Google Scholar]

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