Ingrid M. le Roux

Depressed mood in pregnancy: Prevalence and correlates in two Cape Town peri-urban settlements

BackgroundThe disability associated with depression and its impact on maternal and child health has important implications for public health policy. While the prevalence of postnatal depression is high, there are no prevalence data on antenatal depression in South Africa. The purpose of this study was to determine the prevalence and correlates of depressed mood in pregnancy in Cape Town peri-urban settlements.MethodsThis study reports on baseline data collected from the Philani Mentor Mothers Project (PMMP), a community-based, cluster-randomized controlled trial on the outskirts of Cape Town, South Africa. The PMMP aims to evaluate the effectiveness of a home-based intervention for preventing and managing illnesses related to HIV, TB, alcohol use and malnutrition in pregnant mothers and their infants. Participants were 1062 pregnant women from Khayelitsha and Mfuleni, Cape Town. Measures included the Edinburgh Postnatal Depression Scale (EPDS), the Derived AUDIT-C, indices for social support with regards to partner and parents, and questions concerning socio-demographics, intimate partner violence, and the current pregnancy. Data were analysed using bivariate analyses followed by logistic regression.ResultsDepressed mood in pregnancy was reported by 39% of mothers. The strongest predictors of depressed mood were lack of partner support, intimate partner violence, having a household income below R2000 per month, and younger age.ConclusionsThe high prevalence of depressed mood in pregnancy necessitates early screening and intervention in primary health care and antenatal settings for depression. The effectiveness and scalability of community-based interventions for maternal depression must be developed for pregnant women in peri-urban settlements.Trial registrationClinicalTrials.gov: NCT00972699.

Food insecurity and its association with co-occurring postnatal depression, hazardous drinking, and suicidality among women in peri-urban South Africa

BACKGROUND Although the public health impacts of food insecurity and depression on both maternal and child health are extensive, no studies have investigated the associations between food insecurity and postnatal depression or suicidality. METHODS We interviewed 249 women three months after they had given birth and assessed food insecurity, postnatal depression symptom severity, suicide risk, and hazardous drinking. Multivariable Poisson regression models with robust standard errors were used to estimate the impact of food insecurity on psychosocial outcomes. RESULTS Food insecurity, probable depression, and hazardous drinking were highly prevalent and co-occurring. More than half of the women (149 [59.8%]) were severely food insecure, 79 (31.7%) women met screening criteria for probable depression, and 39 (15.7%) women met screening criteria for hazardous drinking. Nineteen (7.6%) women had significant suicidality, of whom 7 (2.8%) were classified as high risk. Each additional point on the food insecurity scale was associated with increased risks of probable depression (adjusted risk ratio [ARR], 1.05; 95% CI, 1.02-1.07), hazardous drinking (ARR, 1.04; 95% CI, 1.00-1.09), and suicidality (ARR, 1.12; 95% CI, 1.02-1.23). Evaluated at the means of the covariates, these estimated associations were large in magnitude. LIMITATIONS The study is limited by lack of data on formal DSM-IV diagnoses of major depressive disorder, potential sample selection bias, and inability to assess the causal impact of food insecurity. CONCLUSION Food insecurity is strongly associated with postnatal depression, hazardous drinking, and suicidality. Programmes promoting food security for new may enhance overall psychological well-being in addition to improving nutritional status.

A Cluster Randomised Controlled Effectiveness Trial Evaluating Perinatal Home Visiting among South African Mothers/Infants

Background Interventions are needed to reduce poor perinatal health. We trained community health workers (CHWs) as home visitors to address maternal/infant risks. Methods In a cluster randomised controlled trial in Cape Town townships, neighbourhoods were randomised within matched pairs to 1) the control, healthcare at clinics (n = 12 neighbourhoods; n = 594 women), or 2) a home visiting intervention by CBW trained in cognitive-behavioural strategies to address health risks (by the Philani Maternal, Child Health and Nutrition Programme), in addition to clinic care (n = 12 neighbourhoods; n = 644 women). Participants were assessed during pregnancy (2% refusal) and 92% were reassessed at two weeks post-birth, 88% at six months and 84% at 18 months later. We analysed 32 measures of maternal/infant well-being over the 18 month follow-up period using longitudinal random effects regressions. A binomial test for correlated outcomes evaluated overall effectiveness over time. The 18 month post-birth assessment outcomes also were examined alone and as a function of the number of home visits received. Results Benefits were found on 7 of 32 measures of outcomes, resulting in significant overall benefits for the intervention compared to the control when using the binomial test (p = 0.008); nevertheless, no effects were observed when only the 18 month outcomes were analyzed. Benefits on individual outcomes were related to the number of home visits received. Among women living with HIV, intervention mothers were more likely to implement the PMTCT regimens, use condoms during all sexual episodes (OR = 1.25; p = 0.014), have infants with healthy weight-for-age measurements (OR = 1.42; p = 0.045), height-for-age measurements (OR = 1.13, p<0.001), breastfeed exclusively for six months (OR = 3.59; p<0.001), and breastfeed longer (OR = 3.08; p<0.001). Number of visits was positively associated with infant birth weight ≥2500 grams (OR = 1.07; p = 0.012), healthy head-circumference-for-age measurements at 6 months (OR = 1.09, p = 0.017), and improved cognitive development at 18 months (OR = 1.02, p = 0.048). Conclusions Home visits to neighbourhood mothers by CHWs may be a feasible strategy for enhancing maternal/child outcomes. However, visits likely must extend over several years for persistent benefits. Trial Registration ClinicalTrials.gov NCT00996528

A randomized controlled trial of home visits by neighborhood mentor mothers to improve children's nutrition in South Africa

Malnourished children and babies with birth weights under 2500 g are at high risk for negative outcomes over their lifespans. Philani, a paraprofessional home visiting program, was developed to improve nutritional outcomes for young children in South Africa. One “mentor mother” was recruited from each of 37 neighborhoods in Cape Town, South Africa. Mentor mothers were trained to conduct home visits to weigh children under six years old and to support mothers to problem-solve life challenges, especially around nutrition. Households with underweight children were assigned randomly on a 2:1 ratio to the Philani program (n = 500) or to a standard care condition (n = 179); selection effects occurred and children in the intervention households weighed less at recruitment. Children were evaluated over a one-year period (n = 679 at recruitment and n = 638 with at least one follow-up; 94%). Longitudinal random effects models indicated that, over 12 months, the children in the intervention condition gained significantly more weight than children in the control condition. Mentor mothers who are positive peer deviants may be a viable strategy that is efficacious and can build community, and the use of mentor mothers for other problems in South Africa is discussed.

Alcohol use, partner violence, and depression: a cluster randomized controlled trial among urban South African mothers over 3 years

INTRODUCTION Pregnant South African women with histories of drinking alcohol, abuse by violent partners, depression, and living with HIV are likely to have their post-birth trajectories over 36 months significantly influenced by these risks. DESIGN All pregnant women in 24 Cape Town neighborhoods were recruited into a cluster RCT by neighborhood to either: (1) a standard care condition (n=12 neighborhoods, n=594 mothers); or (2) a home-visiting intervention condition (n=12 neighborhoods, n=644 mothers). SETTING/PARTICIPANTS Pregnant women residing in urban, low-income neighborhoods in Cape Town, South Africa. INTERVENTION Home visiting included prenatal and postnatal visits by community health workers (Mentor Mothers) focusing on general maternal and child health, HIV/tuberculosis, alcohol use, and nutrition. MAIN OUTCOME MEASURES Mothers were assessed in pregnancy and at 18 and 36 months post birth: 80.6% of mothers completed all assessments between 2009 and 2014 and were included in these analyses performed in 2014. Longitudinal structural equation modeling examined alcohol use, partner violence, and depression at the baseline and 18-month interviews as predictors of maternal outcomes at 36 months post birth. RESULTS Relative to standard care, intervention mothers were significantly less likely to report depressive symptoms and more positive quality of life at 36 months. Alcohol use was significantly related to use over time, but was also related to depression and HIV status at each assessment and partner violence at 36 months. CONCLUSIONS Alcohol, partner violence, and depression are significantly related over time. A home-visiting intervention improved the emotional health of low-income mothers even when depression was not initially targeted.

Value of a mobile information system to improve quality of care by community health workers

INTRODUCTION We will be unable to achieve sustained impact on health outcomes with community health worker (CHW)-based interventions unless we bridge the gap between small scale efficacy studies and large scale interventions. Effective strategies to support the management of CHWs are central to bridging the gap. Mobile phones are broadly available, particularly in low and middle income countries (LAMICs), where the penetration rate approaches 100%. In this article we describe how mobile phones may be combined with mobile web-based technology to assist in the management of CHWs in two projects in South Africa. METHODS This paper is a descriptive one, drawing lessons from two Randomised Controlled Trials (RCTs), outlining how a mobile phone information system can be utilized to enhance the quality of health interventions. We organized our comprehensive management and supervision system around a previously published management framework. The system is composed of mobile phones utilized by CHWs and a web-based interface utilized by CHW supervisors. Computerized algorithms were designed with intervention and assessment protocols to aid in the real-time supervision and management of CHWs. RESULTS CHWs used mobile phones to initiate intervention visits and trigger content to be delivered during the course of intervention visits. Supervisors used the web-based interface for real-time monitoring of the location, timing, and content of intervention visits. Additional real-time support was provided through direct support calls in the event of crises in the field. CONCLUSION Mobile phone-based information system platforms offer significant opportunities to improve CHW-delivered interventions. The extent to which these efficiency gains can be translated into realized health gains for communities is yet to be tested.

Community-based prenatal screening for postpartum depression in a South African township.

To assess the feasibility of using community health workers to administer short or ultra‐short screening instruments during routine community‐based prenatal outreach for detecting probable depression at 12 weeks postpartum.

The role of community health workers in the re-engineering of primary health care in rural Eastern Cape

Background: Primary Health Care in South Africa is being re-engineered to create a model of integrated care across different levels of the health care system. From hospitals to clinics, in the community and in the home, health care will focus more on prevention, health promotion, and advocacy for healthy lifestyles and well-being, in addition to clinical services. We provide a best-practice model of integrating community health workers (CHWs) trained as generalists into a multi-level health system in the Oliver Tambo district of the rural Eastern Cape. Methods: Based at Zithulele Hospital, a health care network between the hospital, 8 clinics, and 50 CHWs has been created. The functions of each tier of care are different and complementary. This article describes the recruitment, training, supervision, monitoring, and outcomes of CHWs who deliver maternal, child health, nutrition, and general care through home visits. Results: CHWs, especially in rural settings, can find and refer new TB/HIV cases, ill children, and at-risk pregnant women; rehabilitate malnourished children at home; support TB and HIV treatment adherence; treat diarrhoea, worm infestation, and skin problems; and distribute vitamin A. CHWs provide follow-up after clinic and hospital care, support families to apply health information, problem-solve the health and social challenges of daily living, and assist in accessing social grants. Case examples of how this model functions are provided. Conclusion: This generalist CHW home intervention is a potential model for the re-engineering of the primary health care system in South Africa.

The Philani Mentor Mothers Intervention: neighbourhood wide impact on child growth in Cape Town’s peri-urban settlements

ABSTRACT The purpose of this research was to determine whether or not routine home visiting (by the Philani Maternal Child Health and Nutrition Project) influences the prevalence of stunted, wasted and underweight children in Cape Town peri-urban settlements. The study was a cross-sectional cohort in which weight and height measurements were collected for all children from 24 matched neighbourhoods; three years earlier 12 of these neighbourhoods were randomized to receive the home visiting intervention and 12 did not. The research took place at all households located within the 24 neighbourhoods in Khayelitsha and Mfuleni peri-urban settlements. Participants included 8715 children aged 0–6 years old (4694 intervention; 4021 control). A total of 41.3% of children were stunted, 3.1% were underweight and 1.4% were wasted. Children in the intervention group were significantly less likely to be underweight or severely underweight for age than children in the control group. While the rates of stunting were also significantly lower in intervention areas, the effect was not clinically significant, and no significant differences were found between the study arms on the prevalence of wasting. The Philani model is effective in the prevention and rehabilitation of underweight children. Philani could strengthen their intervention by focussing specifically on screening for child stunting in addition to underweight children. The results also suggests that efforts to address the long-term adverse effects of undernutrition require structural and economic transformation, in addition to socio-medical interventions.

Mentor Mothers Program Improved Child Health Outcomes At A Relatively Low Cost In South Africa

In light of South Africas high prenatal HIV prevalence and infant mortality rate, a cluster randomized controlled trial was conducted to evaluate an intervention called Philani+, which used community health workers (known as Mentor Mothers) to deliver pre- and postnatal home visits in Cape Town, South Africa, to improve maternal and child health. We assessed the costs and benefits of this intervention and made comparisons with other scenarios that depicted increased capacity and provision of nurse-delivered care. The recurrent cost of the twenty-four-month intervention was US