Antenatal Depression as a risk for postpartum depression, and the Effectiveness of a Web-based Psychoeducation Intervention on Antenatal Depression Help-Seeking Intention and Behavior in Eswatini

Introduction: Antenatal depression (AD) has been reported one of the major predictors of postpartum depression (PPD). With the proximity between antenatal and postpartum period, the effect of AD on PPD remains complex. Although a quarter of women in Eswatini experience AD, and numerous psychosocial interventions have been invented to prevent the development of PPD, help-seeking practices for AD remain suboptimal.

Objective: This study aims to (1) utilize a meta-analysis design to estimate the prevalence of PPD in women with AD, the association between AD and PPD across trimesters, and the population attributable fraction of PPD to AD; (2) use a cross-sectional design to explore predictors of AD help-seeking in Eswatini, based on the Theory of Planned Behavior (TPB); and (3) use a randomized controlled trial design to investigate the effectiveness of a web-based TPB-based psychoeducation intervention in improving antenatal depression help-seeking intention and behavior in Eswatini.

Methods: We searched PubMed, Embase, MEDLINE, CINAHL, and PsycINFO for cohort studies. The articles were evaluated using the modified Newcastle Ottawa Scale, and the data were analyzed using Comprehensive Meta-Analysis Version 3.0. In the cross-sectional study, we conducted convenience sampling to enroll 505 antenatal women aged 18–42 years from four primary health-care centers in Eswatini. Paper-based questionnaires were used to measure constructs of the theory of planned behavior (TPB; attitudes, subjective norms, perceived behavioral control), perceived need, perceived social support, and help-seeking intention for AD. Hierarchical multiple linear regression was performed to predict help-seeking intention for AD. The double-blinded, two-arm trial, which included a waitlist control, involved 70 antenatal women. Assessments were conducted at baseline, immediately post-intervention, and at one-month post-intervention, focusing on depression help-seeking intention, help-seeking behavior, antenatal depressive symptoms, stigma, and health beliefs. Data were analyzed using intention-to-treat analysis, and generalized estimating equations were applied to address the research questions.

Results: Eighty-eight cohort studies contributed to the meta-analysis. About 37% of women with AD also had PPD. Women with AD had four times higher odds of developing PPD (OR: 4.58; 95% CI = 3.52 – 5.96). The odds of having PPD were higher when AD was observed in the first or third trimester. About 12.8% of the observed PPD cases were attributable to AD. In the cross-sectional study, approximately 26.3% of the participants were classified as having AD symptoms. Attitudes (β = 0.12, p < .01), subjective norms (β = 0.11, p = .01), perceived behavioral control (β = 0.10, p = .03), and perceived social support (β = 0.40, p < .001) significantly predicted help-seeking intention for antenatal depression. Perceived social support alone explained 11% of the variance in help-seeking intention. The trial results showed that after adjusting for stigma, depressive symptoms, health beliefs, gestational age, help-seeking history and perceived need for care, women in the intervention group had significantly higher help-seeking intention scores at both post-intervention (β = 2.32, p = .03) and follow-up (β = 3.64, p < .001) compared to the control group. The noted increase in help-seeking behavior did not significantly differ by group over time (p = .98).

Conclusion and implications: Women with AD throughout the three trimesters, had four times higher odds of developing PPD. About an eighth of the observed PPD cases were attributable to AD. From the cross-sectional study, we learn that constructs of the TPB as well as social support significantly predict depression help-seeking intention during pregnancy. From the trial, findings support the use of a web-based psychoeducation program in improving AD help-seeking intention. Therefore, early screening and treating perinatal depressive symptoms as early as pregnancy is crucial in preventing PPD. Future studies should explore the attributable fraction of other predictors of PPD. The findings will inform future clinical guidelines in maternal and mental health care on AD screening time, frequence of screening and the follow-up period. The expanded TPB can serve as a framework for developing interventions to improve AD help-seeking intention. The trial forms a cornerstone for the adaptation of AD programs into routine maternal care in Eswatini. It supports the use of the constructs of the TPB to promote depression help-seeking behavior in the antenatal period.