Perinatal depression and adverse infant outcomes among Kenyan mother-infant pairs

Pregnancy and postpartum are periods of high vulnerability to mental disorder. More than 1 in 10 women experience a mental disorder during pregnancy and 13% after delivery, most commonly depression. Pregnancy and postpartum are critical time periods for the health and survival of mothers and their infants, yet maternal depression, remains underprioritized. Women in low- and middle-income countries (LMICs) are disproportionately affected by maternal depression. Despite the high burden of maternal mental health difficulties in LMICs, gaps remain in the evidence-base, particularly in LMICs of sub-Saharan Africa where maternal and neonatal morbidity remain high such that addressing perinatal depression could have high impact. Screening tools for depression have not been formally evaluated for their performance in busy sub-Saharan Africa maternal child health clinics. Further, manifestation and trajectory of maternal depression has not been adequately researched in sub-Saharan Africa. Links between maternal depression, adolescence, and poor neonatal health are well-established globally, but have not been extensively explored among Africa mother-infant pairs. In the following dissertation aims, we address these gaps. In Chapter 2, we synthesize evidence depicting relative strength (low, medium, high) of perinatal depression screening scales for use among African pregnant and postpartum women within four quadrants: 1) diagnostic performance, 2) cultural adaptation, 3) feasibility and ease of implementation, 4) evidence-base from SSA settings. In Chapter 3, we compared the Edinburgh Postnatal Depression Scale (EPDS), Patient Health Questionnaire-9 (PHQ-9), Patient Health Questionnaire-2 (PHQ-2), and Center for Epidemiologic Studies Depression Scale (CESD-10) for diagnostic yield, symptomatologies, detection of epidemiologic associations with known cofactors of perinatal depression, and diagnostic performance to detect depression. In Chapter 4, to our knowledge, our team performed the first perinatal depressive symptoms trajectory analysis in a LMIC setting that involved evaluation of time-varying correlates. In Chapter 5, we performed two evaluations among a cohort of Kenyan women living with HIV (WLWH). The first, Chapter 5a, we aimed to understand which WLWH are most at-risk for depression in pregnancy, as well as the magnitude of influence of associated correlates, thus we estimated the prevalence and cofactors of depression during pregnancy and the population attributable risk percent among this population. In Chapter 5b, we identified trajectories and predictors of postpartum depression among WLWH followed through 24 months postpartum to further inform efficient mental health resource allocation within PMTCT programs. In Chapter 6, we evaluated potential relationships between multiple psychosocial factors (depression, low social support, intimate partner violence) and multiple adverse perinatal outcomes (pregnancy loss, stillbirth, preterm birth, low birthweight, small-for-gestational age, and neonatal death) among a large cohort of Kenyan women. Altogether, these results highlight the need for integrated mental health, maternal child health, and HIV prevention and treatment services to alleviate maternal mental distress and linked maternal-infant health outcomes to promote dyadic well-being.