**Abstract**

Depression significantly contributes to the disease burden of pregnant women. However, depression is often under diagnosed by health professionals especially in antenatal clinics. This is the situation in Malawi where there is no routine screening for depression in antenatal clinics. Nonetheless, screening can enable the effective management of pregnant women with depression at antenatal clinics. There is therefore a need to integrate screening for depression into routine antenatal services to enhance the early identification of antenatal depression and intervention to improve and maintain the well-being of pregnant women and contribute towards achieving the efforts of the Government of Malawi in scaling up the treatment of depression.

**Keywords:** depression, antenatal, screening, midwives, pregnancy

#### **1. Introduction**

Depression affects pregnant women during all stages of their pregnancy [1]. Currently, there is no reliable comprehensive epidemiological statistics about the prevalence of depressive disorders during pregnancy in Malawi, though one study in a rural district reported prevalence of depression as 10.7% (major depression) and 21.1% (minor depression) [2]. These figures fall within prevalence range of depressive disorders during pregnancy (8.3–41%) reported in sub-Saharan Africa [3] with highest prevalence (47%) registered in rural parts of South Africa [4]. There are numerous risk factors which are linked to antenatal depression. In Malawi, a previous study found that lower social support and intimate partner violence were linked with antenatal depression [2]. Similarly, another study revealed that being single, poverty, stressful life events, unplanned pregnancy, childhood trauma, and intimate partner violence predicted antenatal depression [5].

Evidence indicates that antenatal depression and its associated risk factors may be addressed through psychosocial interventions including screening to reduce burden they may cause on an individual [2, 6]. Depression is often under diagnosed by treating health professionals [7] which leads to poorer prognosis of co-morbid physical health conditions in primary healthcare settings [8]. This is likely to put pressure on the poor resources available in antenatal clinics in low resource settings and add an additional burden to pregnant women themselves. The lack of routine screening can also delay identification and treatment of women who are affected by antenatal depression. Delayed diagnosis and treatment of antenatal depression may lead to the early disruption of mother-infant relationships and prolong distress for a mother [6].

Antenatal depression thus causes adverse effects on the mother, family, and community which necessitate interventions of health professionals. Screening for depression can help in timely detection of pregnant women with depression [9]. Currently, there are many instruments for the screening of antenatal depression that are validated in low resource settings [10–12]. Some of these instruments were not specifically developed for use during pregnancy but have been used in these settings. Nevertheless, screening instruments for depression must be accurate (be sensitive and specific) in identifying individuals who have a condition [sensitivity (Se)] and those without a condition [specificity (Sp)] [13].

Currently, pregnant women are not routinely screened for depression in antenatal clinics in Malawi. However, mental health is integrated in general healthcare system at policy level in Malawi [14], so that people could have increased access to mental health services. This means that pregnant women should also receive mental healthcare at antenatal clinics along with the usual antenatal care as needed. Services at antenatal clinics in Malawi include history taking, physical and laboratory examination, antenatal drugs and vaccines and antenatal education [15]. This is similar to what happens in South Africa where antenatal care generally focuses on physical examinations [16].

Integrating mental health with antenatal care requires midwives to assess and deal with mental health problems affecting pregnant women in antenatal care settings in Malawi. Nonetheless, some policy makers fear that mental health interventions may deter midwives from concentrating on other 'priority' interventions [9]. Furthermore, many general healthcare workers, including midwives, in Malawi are not confident and competent enough deal with mental health problems [17]. Research studies have asserted that midwives may lack skills and confidence in screening and treating antenatal depression [18]. This is corroborated by Mathibe-Neke, Rothberg [19] who asserted that midwives from sub-Saharan Africa are not skilled enough to assess and treat common perinatal mental disorders even though they encounter many pregnant women with psychosocial problems. Nonetheless, there is evidence that nurses and midwives can effectively intervene to reduce depressive symptoms during pregnancy [6].

Dealing with antenatal depression can assist in achieving the 17 Sustainable Development Goals (SDGs), particularly, goal number three which focuses on ensuring healthy lives and promoting well-being for all ages [20]. The government of Malawi is already making efforts to achieve SDG 3 (good health and well-being) through the Essential Health Package (EHP) [21] which includes mental disorders as priority conditions for the first time. The government has gone a step further in the Malawi Health Sector Strategic Plan II 2017–2022 to emphasise the first line treatment of depression for the entire population at community, primary and secondary levels of care [22]. It is estimated that there are 847 767 people who are in need of treatment for depression, and the Government has targeted providing access to treatment for 27 822 people by 2022 [22]. In this regard, the Government of Malawi has prioritised research on mental health in the National Health Research Agenda for Malawi (2012– 2016) to promote the development of innovative and appropriate treatment strategies for mental health problems affecting the population [23].

#### **1.1 Antenatal care**

Antenatal care includes the health assessment of pregnant women, encouraging good health habits, addressing pregnancy related complications and providing

#### *Screening for Antenatal Depression by Midwives in Low Resource Settings in Primary Care… DOI: http://dx.doi.org/10.5772/intechopen.97411*

social and psychological support [24]. The World Health Organisation (WHO) recommends the implementation of new focused antenatal care which consists of a minimum of eight contacts between the pregnant woman and the healthcare providers with their first contact during the first 12 weeks' gestation, then following contacts taking place at 20, 26, 30, 34, 36, 38 and 40 weeks' gestation [25]. Malawi adopted focused antenatal care more than a decade ago [15, 26] with the aim of helping women to maintain normal pregnancies through identification of preexisting health conditions, early detection of complications arising during pregnancy, health promotion, disease prevention, birth preparedness and complication readiness planning [27]. It encourages careful identification of pregnant women with special health conditions or risk factors for complications [28]. As described in literature, detection and treatment of diseases, is one of the essential elements of care during pregnancy [29].

In Malawi midwives are frequently the first health professionals who could identify antenatal depression, or to whom a pregnant woman with antenatal depression or any other common perinatal mental disorders may go to seek for help. The country has low mental health specialists to patients ratios (0.01 psychiatrists per 100 000 and 0.22 psychiatric nurses per 100 000) [30] for more than16 million people. This shows that pregnant women attending antenatal clinics may have limited access to mental health specialists. Despite a gross shortage of mental health specialists in the country, midwives therefore could participate in the detection of pregnant women with depression when providing antenatal care.

#### **1.2 Clinical and public health significance of antenatal depression**

The lancet series on maternal mental health have established the clinical and public health importance of antenatal depression [31–34]. There is evidence that antepartum depression is highly prevalent in low resource settings [31]. Literature show that antenatal depression is associated with increased rates of adverse child outcomes in low resource settings where pregnant women have increased exposure to risk factors for depression [35]. The adverse mental health outcomes for the child include an increased risk of anxiety, depression, attention deficit hyperactivity disorder, and conduct disorder [35]. It is documented that pregnant women with untreated depression have a higher likelihood of obstetric complications, premature deliveries, and low birthweight infants [34].

Antenatal depression and HIV infection form a vicious cycle, whereby the symptoms of each disease worsen the status of the other, and each needs to be sufficiently treated for the pregnant woman to become healthy [32]. It is of public health concern that pregnant women with co-morbidity of depression and HIV infection are less likely to adhere to antiretroviral therapy, which is critical for her survival and prevention of HIV transmission to the child [33]. Stringer, Meltzer-Brody [32] recommended integration depression-screening technique in antenatal services that could identify a large proportion of affected women to break the cycle of depression and HIV infection interaction. It is documented that integrating mental health services into primary care may be the most viable way of closing treatment gap for mental health in low resource settings [31]. An important step in this direction is the incorporation of the capacity to prevent, recognise, and treat depression within antenatal care [36]. This may help to meet the immediate mental health needs of a pregnant woman, ensure better maternal and child outcomes, and contribute towards success of HIV/AIDS services [32].

Integrated antenatal services aimed at identifying and treating women with antenatal depression are needed because antenatal care is typically the first and only time of interaction with the healthcare system for many women in low resource

settings [31]. As such, antenatal care visits provide critically important opportunities for mental health interventions to occur. There is a need to develop protocols for early identification, treatment and preventing the adverse effects of antenatal depression in low resource settings because they do not exist [31]. There is also a need to develop, refine and rigorously evaluate the predictive validity and reliability of instruments for screening of antenatal depression in low resource settings [31].
