Abstract
Purpose:
Measuring perinatal depression in women with HIV poses a particular challenge to accurate assessment. South Africa has particularly high rates of perinatal depression, with antenatal depression rates ranging from 21–47% and postnatal depression rates ranging from 17.1–50.3%; South Africa also has high rates of perinatal HIV. With the goal of providing an examination of the psychometric properties of the Edinburgh Postnatal Depression Scale (EPDS) in a population at greater risk for depression, the current manuscript examined the factor structures and reliability of the English and Zulu versions of the EPDS among pre- and postnatal women with HIV in South Africa.
Methods:
This study included n = 1,179 women who completed the EPDS in Zulu (n = 709) and English (n = 470) antenatally, and n = 866 women were analyzed at 12-months after birth (n = 494 in Zulu and n = 372 in English).
Results:
Using factor analytic and item response theory approaches, the English and Zulu versions of the EPDS were compared. Although a few items performed poorly, particularly item 4, the construct validity of the English and Zulu versions of the pre- and postnatally administered EPDS was supported; the reliability of the scale was also supported.
Discussion:
This study contributes to improved measurement of depressive symptoms among vulnerable women in a resource constrained setting. The early and accurate detection of depressive symptoms ante- and postnatally among perinatal women living with HIV can facilitate increased treatment which may in turn help prevent the negative maternal and neonatal outcomes associated with depression.
Keywords: Measurement, Item Response Theory, South Africa, Edinburgh Postnatal Depression Scale
Introduction
The lifetime prevalence of major depressive disorder (MDD), according to population-based surveys, ranges from 1.0% (Czech Republic) to 16.9% (United States) (Kessler & Bromet, 2013); women’s risk of major depression is about twice that of men. Perinatal depression (depression during the ante- or postnatal period) has a similarly high prevalence. As with MDD, the prevalence of ante-l and postnatal depression varies by country. Estimates of antenatal depression range from 7–15% in high-income countries and from 19–25% in low- and middle-income countries (Gelaye et al., 2016). The prevalence of postnatal depression is estimated to be about 10% in high-income countries and about 20% in low- and middle-income countries (Gelaye et al., 2016). Postnatal depression may last for months or years after delivery in some women (Goodman, 2004), and depression is more likely to recur among women following symptoms consistent with postnatal depression (Meltzer-Brody & Stuebe, 2014). Perinatal depression has been associated with impaired infant physical, cognitive, and emotional development (Gelaye et al., 2016) and with an elevated risk for suicidality in the mother (Orsolini et al., 2016). However, a high number of cases of perinatal depression may go undiagnosed and untreated (Biaggi et al., 2016; Evagorou et al., 2016).
Given the prevalence of perinatal depression, its associated risks and its potential impact on infants, the measurement and accurate detection of perinatal depression is important. Several measures of depression been used with varying degrees of psychometric soundness when examining perinatal women. Among the limited research on this topic in Africa (Tsai et al., 2013), the most commonly used and most psychometrically sound instrument is the Edinburgh Postnatal Depression Scale (EPDS) (Cox et al., 1987), which was originally developed to assess postnatal depression but has also been used to assess antenatal depression (Gibson et al., 2009).
South Africa has particularly high rates of perinatal depression, with antenatal depression rates ranging from 21–47% and postnatal depression rates ranging from 17.1–50.3% (Pellowski et al., 2019). South Africa also has high rates of HIV (Avert, 2020). The measurement of perinatal depression in women living with HIV (WLHIV) poses a particular challenge to accurate assessment. Individuals living with HIV already report high rates of depression (Bernard et al., 2017), and even in the absence of a depressive disorder, people living with HIV also often experience somatic symptoms that are similar to depressive symptoms (Kalichman et al., 2000). Similarly, some symptoms of pregnancy may also overlap with somatic depressive symptoms (Yonkers et al., 2009). Thus, it especially important to use depression screening tools such as the EPDS that minimize assessment of somatic symptoms. Moreover, as perinatal depression measurement tools used in South Africa often require translation to other languages (e.g., Zulu, Sotho, Xhosa), faulty translations may add an extra barrier to accuracy.
Items in translated measures must convey the same meaning as in the original language (Fuggle et al., 2002), and sociocultural differences and differing education levels may present difficulties in measuring constructs cross-culturally (Aydin et al., 2004). Overall, previous research suggests that translations of EPDS have been successfully validated and psychometrically sound (de Bruin et al., 2004; van der Westhuizen et al., 2018). However, as Kubota and colleagues (2018) explain, the factor structure of the EPDS is not clear and seems to vary by study and sometimes by whether women were assessed antenatally or postnatally. One-factor, two-factor, and three-factor (depression, anxiety, and anhedonia) structures have been described. Cultural differences in symptom profiles could also potentially influence this finding, as individuals in different cultures often experience depression, including postnatal depression (Evagorou et al., 2016), in different ways (Juhasz et al., 2012).
With the goal of providing a robust examination of the psychometric properties of the EPDS in a population at greater risk for depression, the current manuscript examined the factor structures and reliability of the English and Zulu versions of the EPDS among pre- and postnatal WLHIV in South Africa. In addition, this study compared how the functioning of these items between the English and Zulu versions of the EPDS using factor analytic and item response theory (IRT) approaches. Based on previous research, it was hypothesized that the EPDS in both the English and Zulu versions would be shown to have three factors representing depression, anxiety, and anhedonia, providing evidence of construct validity in both languages. With regard to comparative analyses, based on past research, it was hypothesized that items 6 and 10 would function differently between languages.
Methods
Ethical approval
Before beginning this study, the researchers obtained ethical approval from the University of Miami School of Medicine, the Human Sciences Research Council Institutional Review Board, and the Mpumalanga Provincial Government. Participants provided written informed consent prior to study procedures.
Participants and Procedures
Participants were N = 1399 pregnant women in South Africa participating in a randomized controlled trial (RCT) of an intervention designed to prevent mother-to-child transmission (PMTCT) of HIV. The complete protocol for the RCT has been previously published (Jones et al., 2014). After providing informed consent, all of the women completed the EPDS (Cox et al., 1987) during antenatal assessments in their preferred language; women had the option to choose English, Zulu, or Sotho, all official languages of South Africa. The women completed the EPDS and other study instruments using Questionnaire Development System’s (QDS) Audio Computer-Assisted Self-Interview (ACASI) software. ACASI allows participants to read the questions presented while also hearing the questions or statements read aloud over headphones to compensate for varying degrees of literacy. Antenatally, a total of N = 1,399 pregnant between 6 and 30 weeks of pregnancy completed the EPDS. Given the low of number of women completing the EPDS in Sotho (n = 220), the final sample size in this study included n = 1,179 women who completed the EPDS in Zulu (n = 709) and English (n = 470). Women completed additional assessments 12 months after birth; at 12-month follow-up, there were n = 957 women who completed the EPDS. However, a smaller proportion of women completed the EPDS in Sotho, who were not included due to having an insufficient number of people (n = 91). A total of n = 866 women were analyzed at 12-month follow-up; these included n = 494 who completed the EPDS in Zulu and n = 372 who completed the EPDS in English.
Measure
The EPDS (Cox et al., 1987) was used to assess antenatal and postnatal depression for this study. The EPDS is a 10-item instrument that asks participants to rate how often they have experienced different symptoms associated with postnatal depression in the past 7 days. All of the items are scored on a scale of 0 through 3, although each item uses different labels for items choices. Scores on this measure can range from 0 through 30, in which scores of 10 can indicate possible depression in the United States; however, the cutoff was raised to 12 in South Africa (Rochat et al., 2013). In addition, one item (item 10) assesses suicidal ideation. Supplemental Table 1 lists all scale items as well as their respective item choices in Zulu and English.
Analytic Plan
Frequencies, means and standard deviations were first used to response frequencies. Item discrimination indices were also calculated and represent the correlation between the item and the rest of the items on the scale, the corrected item-total correlation.
The factor structure of the EPDS at antenatally (6 to 30 weeks of pregnancy) and 12 months postnatal was assessed in Zulu and English using a series of exploratory factor analyses (EFAs) and a geomin rotation. One- to three-factor models were estimated using diagonally weighted least squares (WLSMV), which has no distributional assumptions. Model fit was assessed using Root Mean Square Error of Approximation (RMSEA) < .05 (Hair et al., 2009), Comparative Fit Index (CFI) greater than .95 (Hu & Bentler, 1999), Tucker Lewis Index (TLI) greater than .90 (Bentler & Bonett, 1980), and < .08 for standardized root mean squared residual (SRMR; Hooper, Coughlan, & Mullen, 2008). Lower RMSEA and SRMR values, and higher TLI and CFI values indicate improved model fit, suggesting a better model. Exploratory factor analyses were conducted on Mplus v8.4.
The equivalence of EPDS items by language was tested using the lordif software package in R (Choi, Gibbons, & Crane, 2011). Lordif utilizes ordinal logistic regression to evaluate differential item functioning (DIF). Specifically, DIF refer to whether women completing the English version of the EPDS endorse item response options at the same rate as women completing the Zulu version of the EPDS at different score levels. When there is a differential probability of responding depending on the language despite having different total scores, two different type of DIF can be detected. Uniform DIF suggests that there is a consistently different performance between groups across all score groups, whereas non-uniform DIF refers to an inconsistent probability of responding between groups. These models are tested at α = 0.01 level. Item characteristic curves are then plotted for all items exhibiting DIF. Item characteristic curves show the probability of endorsing an item response option (0 to 3) at standard deviations of the underlying latent variable, depressive symptoms. In large sample sizes, −2 likelihood ratio tests may overestimate DIF. As such, empirical thresholds to detect DIF were computed using Monte Carlo simulations in DIF-free samples (α = 0.01; 1,000 replications). Then, the highest calculated empirical threshold from the Monte Carlo simulations was used to re-examine uniform DIF and non-uniform DIF (Choi et al., 2011).
Finally, the reliability of the EPDS was assessed antenatally and at 12 months postnatal. Cronbach’s α was used to assess internal consistency. Conventions suggest that α values greater than .70 indicate adequate reliability.
Results
Sociodemographic Characteristics of Women and Prevalence of Ante- and Postnatal Depression
The mean age of the women (n = 1,179) was 28.44 (SD = 5.85), and the majority reported their race to be Black African (97%); the remainder (3%) identified as “other” or “colored”. All women had partners as part of the original study design; 79% were not married, and 21% were married. Slightly more than half of women (58%) had completed at least 10 years of school and had an average monthly income of 1049.72 South African Rand (USD$57.30). A cutoff of ≥13 has been used to define depression in previous research among South Africans (Rochat et al., 2013). Antenatally, 42% of women were above this cutoff according to the English version; 47% were above this cutoff using the Zulu version. Postnatally, 33% were classified as having probable depression using the English version, compared with 40% in the Zulu version.
Item Discrimination of EPDS Items Ante- and Postnatally
Item discrimination indices are presented in Supplemental Table 2. Antenatally, items 1, 2, and 4 in the English version showed low discrimination values; in the Zulu version, only item 1 had a low discrimination value. Postnatally, items, 2, and 4 in the English version showed low discrimination values; in the Zulu version, only item 1 showed a low discrimination index.
Exploratory Factor Analyses for Antenatal EPDS
A series of factor analyses were performed for Zulu and English versions. Model fit indices for one- to three-factor models are shown in Supplemental Table 3. A three-factor model for the English version of the EPDS did not converge. In addition, although the three-factor model showed the best fit for the Zulu version, the third factor only included one item (Item 4), which also loaded significantly on another factor indistinguishably. Item 4 in two-factor models showed low correlations in both Zulu (.205 and .165 on factors 1 and 2) and English (.324 and .226) versions. As such, the two-factor models (shown in Table 1) were retained in future iterations. The first factor was identified as anhedonia and the second factor as depression; in previous research, the factors have been identified as anhedonia, anxiety, and depression (Kubota et al., 2018). The second set of EFAs showed that the two-factor model without item 4 had a similarly adequate fit for both languages (Supplemental Table 4).
Table 1.
Two-factor Models of Zulu and English Versions of the EPDS Antenatally
| Zulu | English | |||
|---|---|---|---|---|
| Factor 1 | Factor 2 | Factor 1 | Factor 2 | |
|
| ||||
| Item 1 | .529* | .834* | −.004 | |
| Item 2 | .741* | .606* | .016 | |
| Item 3 | .461* | .536* | ||
| Item 4 | -- | -- | -- | -- |
| Item 5 | .610* | .579* | ||
| Item 6 | .517* | .625* | ||
| Item 7 | .700* | .611* | ||
| Item 8 | .812* | .783* | ||
| Item 9 | .790* | .656* | ||
| Item 10 | .504* | .630* | ||
Note.
significant at 5% level. The first factor was identified as anhedonia and the second factor as depression.
Differential Item Functioning of the EPDS by Language Antenatally
Ordinal logistic regression models tested whether participants completing the EPDS in different languages endorsed items at a different rate. Six items (1, 2, 4, 5, 6, and 9) were flagged for DIF at α = 0.01 (Table 2). Five of these items (1, 2, 4, 6, and 9) showed uniform DIF, whereas item 5 showed non-uniform DIF. Item true score functions were plotted for items flagged for DIF and are shown on Supplemental Figure 1. Items 1, 2, and 9 of the Zulu version appeared to overestimate EPDS scores at low and high levels of depressive symptoms. Items 4 and 6, conversely, underestimated depressive symptoms at multiple levels of scores in the Zulu version. Item 5 of the Zulu version underestimated scores at low level of depressive symptoms, but overestimated scores at high levels of depressive symptoms. Monte Carlo simulations were then performed to determine the highest cutoff to detect DIF in R2 values. The highest Monte Carlo threshold was Nagelkerke ΔR212 = 0.0067 for uniform DIF; only Item 2 was above this cutoff. For non-uniform DIF, the empirical threshold was Nagelkerke ΔR2 = 0.0058; no items were above this cutoff.
Table 2.
Differential Item Functioning of the EPDS by Language Antenatally
| Uniform DIF |
Nagelkerke R212 | Total DIF |
Nagelkerke R213 | Non-Uniform DIF |
Nagelkerke R223 | |
|---|---|---|---|---|---|---|
| Item | Models 1 vs. 2 p |
Models 1 vs. 3 p |
Models 2 vs. 3 p |
|||
|
| ||||||
| 1 | < .001 | .019 | < .001 | .008 | .150 | .001 |
| 2 | < .001 | .068 | < .001 | .027 | .044 | .002 |
| 3 | .177 | -- | .108 | .105 | -- | |
| 4 | .007 | .003 | .002 | .005 | .022 | .002 |
| 5 | .251 | .000 | < .001 | .010 | < .001 | .009 |
| 6 | < .001 | .010 | < .001 | .011 | .041 | .001 |
| 7 | .169 | -- | .388 | -- | .954 | -- |
| 8 | .324 | -- | .557 | -- | .659 | -- |
| 9 | < .001 | .004 | < .001 | .006 | .019 | .002 |
| 10 | .371 | -- | .297 | -- | .202 | -- |
Note. Bold denotes items flagged for DIF at α = .01.
Exploratory Factor Analyses Postnatally
A series of factor analyses were conducted for Zulu and English EPDS versions that were administered postnatally. Model fit indices were one-factor to three-factor models of the EPDS are presented in Supplemental Table 5; the three-factor solutions in both languages showed the best fit. However, factors were composed of different items in both of the languages (Table 3). In the Zulu version, items in Factor 2 did not have significant factor loadings. In the English version, although item 4 did not load onto a separate factor, this item showed low, non-significant factor loadings on all factors. As such, item 4 was removed from subsequent analyses, and a second set of EFAs were conducted. The results of the second set of EFAs are presented in Table 4. EPDS items completed postnatally in Zulu loaded onto two factors, which were interpreted as anhedonia and depressive symptoms. Based on past research, the three factors of the English version were interpreted as anhedonia cognitive depressive symptoms, and behavioral depressive symptoms.
Table 3.
Exploratory Factor Analyses of Zulu and English Versions of the EPDS Postnatally
| Zulu | English | |||||
|---|---|---|---|---|---|---|
| Factor 1 | Factor 2 | Factor 3 | Factor 1 | Factor 2 | Factor 3 | |
|
| ||||||
| Item 1 | .598* | -- | -- | .512* | ||
| Item 2 | .416* | -- | -- | .797* | ||
| Item 3 | -- | -- | .515* | .603* | ||
| Item 4 | -- | -- | -- | -- | -- | -- |
| Item 5 | -- | -- | .703* | .675* | ||
| Item 6 | -- | -- | .614* | .606* | ||
| Item 7 | -- | -- | .646* | .521* | ||
| Item 8 | -- | -- | .800* | .461* | ||
| Item 9 | -- | -- | .798* | .912* | ||
| Item 10 | -- | -- | .482* | .507* | ||
Note.
significant at 5% level.
Table 4.
Exploratory Factor Analyses of Zulu and English Versions of the EPDS Postnatally Without Item 4
| Zulu | English | ||||
|---|---|---|---|---|---|
| Factor 1 | Factor 2 | Factor 1 | Factor 2 | Factor 3 | |
|
| |||||
| Item 1 | .615* | .440* | |||
| Item 2 | .432* | .904* | |||
| Item 3 | .523* | .624* | |||
| Item 5 | .716* | .677* | |||
| Item 6 | .615* | .606* | |||
| Item 7 | .641* | .530* | |||
| Item 8 | .810* | .471* | |||
| Item 9 | .804* | .916* | |||
| Item 10 | .477* | .495* | |||
Note.
significant at 5% level.
Differential Item Functioning of the EPDS by Language Postnatally
Tests of DIF were performed using ordinal logistic regression models to determine differences in the probability of endorsement by language. Four items (3, 4, 5, and 7) were flagged for DIF at α = 0.01, as shown on Table 5. Item 3 exhibited only non-uniform DIF. Three items (4, 5, and 7) exhibited both uniform and non-uniform DIF. Item true score functions were plotted for DIF items and are shown on Supplemental Figure 2. Items 3 and 7 of the Zulu version overestimated scores at low levels of depressive symptoms, but underestimated scores at high levels of depressive symptoms. Items 4 and 5, on the contrary, underestimated depressive symptoms at low levels of EPDS scores, but overestimated scores at high levels. The highest Monte Carlo threshold for postnatal EPDS scores was Nagelkerke ΔR212 = 0.0083 for uniform DIF; no items were above this cutoff. For non-uniform DIF, the empirical threshold was Nagelkerke ΔR2 = 0.0091; item 4 was above this cutoff.
Table 5.
Differential Item Functioning of the EPDS by Language Postnatally
| Uniform DIF |
Nagelkerke R212 | Total DIF |
Nagelkerke R213 | Non-Uniform DIF |
Nagelkerke R223 | |
|---|---|---|---|---|---|---|
| Item | Models 1 vs. 2 p |
Models 1 vs. 3 p |
Models 2 vs. 3 p |
|||
|
| ||||||
| 1 | .127 | .098 | .128 | |||
| 2 | .533 | .332 | .178 | |||
| 3 | .018 | .002 | .001 | .006 | .005 | .003 |
| 4 | < .001 | .007 | < .001 | .017 | .000 | .010 |
| 5 | .003 | .004 | < .001 | .009 | .001 | .005 |
| 6 | .977 | .507 | .244 | |||
| 7 | < .001 | .007 | . < .001 | .015 | < .001 | .008 |
| 8 | .741 | .938 | .891 | |||
| 9 | .507 | .401 | .239 | |||
| 10 | .047 | .118 | .558 | |||
Note. Bold denotes items flagged for DIF at α = .01.
Reliability
Finally, reliability estimates were calculated for Zulu and English versions of the EPDS ante- and postnatally. Antenatally, the EPDS had adequate reliability in Zulu (α = .78) and English (α = .78). Postnatally, the EPDS had adequate reliability in Zulu (α = .82) and English (α = .77).
Discussion
This study examined the factor structures of the English and Zulu versions of the EPDS administered pre- and postnatally among WLHIV in South Africa. Using factor analytic and item response theory (IRT) approaches, the English and Zulu versions of the EPDS were compared. Although a few items performed poorly, particularly item 4, the construct validity of the English and Zulu versions of the pre- and postnatally administered EPDS was supported; the reliability of the scale was also supported. Contrary to expectations, items 6 and 10 performed well in both versions. Previous studies have examined the psychometric properties of a Zulu version of the EPDS (Rochat, 2011; Rochat et al., 2013), but this is the first study to examine its factor structure and establish measurement equivalence with an English version.
In the multiple psychometric assessments of the EPDS performed in this study, item 4 was consistently shown to be low performing relative to other items in the scale. Specifically, item 4 had low discriminating power, performing worse in the English version. In the series of factor analyses conducted ante- and postnatally, item 4 had to be excluded from the factor structure of the EPDS due to low factor loadings, which indicates a low amount of variance was explained by the item in the construct of depression. These findings suggest that this item did not contribute to the total score significantly, supporting its removal. Item 4 was also shown to function differently in the English and Zulu versions of the EPDS, underestimating symptoms of depression in Zulu. Given the consistent low performance of item 4 in both languages, the inclusion of this item in EPDS scales among WLHIV in South Africa may provide inaccurate estimates of the overall burden of depression. The low performance of this item may have been related to the phrasing of this item, “I have been anxious or worried for no good reason”. Among WLHIV in a resource constrained setting with very reasonable worries about the transmission of HIV to their infants, the term “for no good reason” may have introduced confusion, thereby making a small contribution to inaccurate measurement of depressive symptoms in this setting. Because item 4 is included in briefer Zulu versions of the EPDS, including the EPDS-3 (Rochat et al., 2013), the poor psychometric performance of this item may be a barrier for women entering treatment for depression in a setting where mental health resources are already scarce (Docrat et al., 2019). The removal of item 4 may be warranted when assessing women in comparable settings.
The validity and reliability of both versions of the EPDS were supported in this study by adequate internal reliability and factor structures that were consistent with previous research (Kubota et al., 2018). Specfically, the factor structure of the Zulu version was consistent across the peripartum period, but this was not the case for the English version. Different factor structures have been known to emerge depending on whether the EPDS is completed ante- or postnatally (Kubota et al., 2018). The differences in factors and items loading onto factors may thus be explained by differences in the perinatal period in which women were assessed. Kubota et al. (2018) assessed women one month postnatally, whereas women in this study were assessed 12 months postnatally; it is possible that the factor structures may have differed because of time since birth. The differences in factor structures between the two versions in the postnatal period indicates a lack of dimensional measurement invariance, suggesting a need to modify these scales to achieve equivalence.
Using EPDS cutoffs developed in South Africa from previous literature (Rochat et al., 2013), the prevalence rates of both ante- and postnatal depression were high, ranging from 33% (postnatal English version) to 47% (antenatal Zulu version). Prevalence estimates for antenatal depression range from 7–15% in high-income countries and 19–25% in low-income and middle-income countries (Gelaye et al., 2016). Postnatally, these rates range from 10% in high-income countries and about 20% in low-income and middle-income countries (Gelaye et al., 2016). Particularly higher prevalence rates of perinatal depression have been reported in South Africa, where rates of antenatal depression have ranged from 21–47% and postnatal depression rates from 17.1–50.3% (Pellowski et al., 2019). However, studies have used different cutoffs (Tsai et al., 2013), which complicates the comparison of these prevalence estimates to previous research. The prevalences reported in this study were in the range of previously reported estimates, which supports the validity of the scale in this context.
Limitations
The psychometric evaluation of the EPDS has limitations. Structured clinical interviews, which are considered the gold standard in the process of validating self-report measures, were not conducted to validate the EPDS. Second, although a number of women completed the EPDS in Sotho ante- and postnatally, the factor structure of the Sotho version could not be analyzed due to a small sample size.
Conclusions
Brief screening measures such as the EPDS can help identify the burden of depression among perinatal WLHIV across a range of settings but strong psychometric properties are needed to ensure that this scale does so accurately, especially when adapted and translated. This study therefore contributes to improved measurement of depressive symptoms among vulnerable women in a resource constrained setting. The early and accurate detection of depressive symptoms ante- and postnatally among perinatal WLHIV can facilitate increased treatment which may in turn help prevent the negative maternal and neonatal outcomes associated with depression.
Supplementary Material
Sources of Funding:
This study was funded by a grant from the National Institute of Child Health and Human Development (R01HD078187), with the support of the Miami Center for AIDS Research at the University of Miami Miller School of Medicine, funded by a grant from the National Institutes of Health (P30AI073961). VJR’s work on this study was supported by a Ford Foundation Fellowship, administered by the National Academies of Science, a PEO Scholar Award from the PEO Sisterhood, and a grant from the National Institute of Mental Health of the National Institutes of Health under Award Number R36MH127838.
Footnotes
Conflicts of Interest: No conflicts of interest to disclose.
Declarations
Consent to Participate: All participants consented to participate in the study, in accordance with the Helsinki Declaration.
Ethical approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Ethical approval was obtained from the University of Miami Miller School of Medicine Institutional Review, Human Sciences Research Council Research Ethics Committee, and the Mpumalanga Provincial Government.
References
- Avert. (2020). South Africa exceeds national mother-to-child transmission target. Retrieved June 8, 2020 from https://www.avert.org/global-hiv-and-aids-statistics
- Aydin N, Inandi T, Yigit A, & Hodoglugil NN (2004, Jun). Validation of the Turkish version of the Edinburgh Postnatal Depression Scale among women within their first postpartum year. Soc Psychiatry Psychiatr Epidemiol, 39(6), 483–486. [DOI] [PubMed] [Google Scholar]
- Bernard C, Dabis F, & de Rekeneire N (2017). Prevalence and factors associated with depression in people living with HIV in sub-Saharan Africa: A systematic review and meta-analysis. PLoS One, 12(8), e0181960. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Biaggi A, Conroy S, Pawlby S, & Pariante CM (2016, Feb). Identifying the women at risk of antenatal anxiety and depression: A systematic review. J Affect Disord, 191, 62–77. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Cox JL, Holden JM, & Sagovsky R (1987, Jun). Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry, 150, 782–786. [DOI] [PubMed] [Google Scholar]
- 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. [Google Scholar]
- Docrat S, Besada D, Cleary S, Daviaud E, & Lund C (2019). Mental health system costs, resources and constraints in South Africa: a national survey. Health policy and planning, 34(9), 706–719. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Evagorou O, Arvaniti A, & Samakouri M (2016, Mar). Cross-Cultural Approach of Postpartum Depression: Manifestation, Practices Applied, Risk Factors and Therapeutic Interventions. Psychiatr Q, 87(1), 129–154. [DOI] [PubMed] [Google Scholar]
- Fuggle P, Glover L, Khan F, & Haydon K (2002). Screening for postnatal depression in Bengali women: preliminary observations from using a translated version of the Edinburgh Postnatal Depression Scale (EPDS) [Article]. Journal of Reproductive & Infant Psychology, 20(2), 71–82. [Google Scholar]
- Gelaye B, Rondon MB, Araya R, & Williams MA (2016, Oct). Epidemiology of maternal depression, risk factors, and child outcomes in low-income and middle-income countries. Lancet Psychiatry, 3(10), 973–982. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Gibson J, McKenzie-McHarg K, Shakespeare J, Price J, & Gray R (2009, May). A systematic review of studies validating the Edinburgh Postnatal Depression Scale in antepartum and postpartum women. Acta Psychiatr Scand, 119(5), 350–364. [DOI] [PubMed] [Google Scholar]
- Goodman JH (2004, Jul-Aug). Postpartum depression beyond the early postpartum period. J Obstet Gynecol Neonatal Nurs, 33(4), 410–420. [DOI] [PubMed] [Google Scholar]
- Jones DL, Peltzer K, Weiss SM, Sifunda S, Dwane N, Ramlagan S, Cook R, Matseke G, Maduna V, & Spence A (2014, Oct 27). Implementing comprehensive prevention of mother-to-child transmission and HIV prevention for South African couples: study protocol for a randomized controlled trial. Trials, 15. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Juhasz G, Eszlari N, Pap D, & Gonda X (2012). Cultural differences in the development and characteristics of depression. Neuropsychopharmacol Hung, 14(4), 259–265. [PubMed] [Google Scholar]
- Kalichman SC, Rompa D, & Cage M (2000, Oct). Distinguishing between overlapping somatic symptoms of depression and HIV disease in people living with HIV-AIDS. J Nerv Ment Dis, 188(10), 662–670. [DOI] [PubMed] [Google Scholar]
- Kessler RC, & Bromet EJ (2013). The epidemiology of depression across cultures. Annu Rev Public Health, 34, 119–138. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Kubota C, Inada T, Nakamura Y, Shiino T, Ando M, Aleksic B, Yamauchi A, Morikawa M, Okada T, Ohara M, Sato M, Murase S, Goto S, Kanai A, & Ozaki N (2018, Dec 5). Stable factor structure of the Edinburgh Postnatal Depression Scale during the whole peripartum period: Results from a Japanese prospective cohort study. Sci Rep, 8(1), 17659. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Meltzer-Brody S, & Stuebe A (2014, Jan). The long-term psychiatric and medical prognosis of perinatal mental illness. Best Pract Res Clin Obstet Gynaecol, 28(1), 49–60. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Orsolini L, Valchera A, Vecchiotti R, Tomasetti C, Iasevoli F, Fornaro M, De Berardis D, Perna G, Pompili M, & Bellantuono C (2016). Suicide during Perinatal Period: Epidemiology, Risk Factors, and Clinical Correlates. Front Psychiatry, 7, 138. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Pellowski JA, Bengtson AM, Barnett W, DiClemente K, Koen N, Zar HJ, & Stein DJ (2019, Dec 1). Perinatal depression among mothers in a South African birth cohort study: Trajectories from pregnancy to 18 months postpartum. J Affect Disord, 259, 279–287. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Rochat TJ (2011). Depression among pregnant women testing for HIV in rural South Africa [Dissertation, University of Stellenbosch]. https://scholar.sun.ac.za/handle/10019.1/6843 [Google Scholar]
- Rochat TJ, Tomlinson M, Newell ML, & Stein A (2013, Oct). Detection of antenatal depression in rural HIV-affected populations with short and ultrashort versions of the Edinburgh Postnatal Depression Scale (EPDS). Arch Womens Ment Health, 16(5), 401–410. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Tsai AC, Scott JA, Hung KJ, Zhu JQ, Matthews LT, Psaros C, & Tomlinson M (2013). Reliability and validity of instruments for assessing perinatal depression in African settings: systematic review and meta-analysis. PLoS One, 8(12), e82521. [DOI] [PMC free article] [PubMed] [Google Scholar]
- van der Westhuizen C, Brittain K, Koen N, Maré K, Zar HJ, & Stein DJ (2018, 2018/02/01). 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. [Google Scholar]
- Yonkers KA, Smith MV, Gotman N, & Belanger K (2009, Jul-Aug). Typical somatic symptoms of pregnancy and their impact on a diagnosis of major depressive disorder. Gen Hosp Psychiatry, 31(4), 327–333. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.