Predictors and occurrence of antenatal depressive symptoms in Galle, Sri Lanka: a mixed-methods cross-sectional study

BACKGROUND: There is a high prevalence of antenatal depression in low-or-middle-income countries, but information about risk factors in these settings is still lacking. The purpose of this study is to measure the prevalence of and explore risk factors associated with antenatal depressive symptoms in Galle, Sri Lanka. METHODS: This study used a mixed-method approach. The quantitative portion included 505 pregnant women from Galle, Sri Lanka, with health record data, responses to psychometric questionnaires (MSPSS and PRAQ-R2), and antenatal depression screening (EPDS). The qualitative portion included interviews with public health midwives about their experiences and routine clinical practices with women with antenatal depressive symptoms. RESULTS: Prevalence of antenatal depressive symptoms was 7.5%, highest in women over the age of 30 (13.0%, OR = 3.88, 95%CI = 1.71 – 9.97), with diabetes (21.9%, OR = 3.99, 95%CI = 1.50 – 9.56), or pre-eclampsia in a previous pregnancy (19.4%, OR = 3.32, 95%CI = 1.17 – 8.21). Lower prevalence was observed in the primiparous (3.3%, OR = 0.29, 95%CI = 0.12 – 0.64) employed outside the home (3.6%, OR = 0.33, 95%CI = 0.13 – 0.72), or upper-middle class (2.3%, OR = 0.17, 95%CI = 0.04 – 0.56). Anxiety levels were elevated in depressed women (OR = 1.13, 95%CI = 1.07 – 1.20), while perceived social support was lower (OR = 0.91, 95%CI = 0.89 – 0.93). After multivariable adjustment, only parity (OR = 0.20, 95%CI 0.05 – 0.74) and social support from a “special person” (OR = 0.94, 95%CI = 0.77 – 0.95) remained significantly associated with depressive symptoms. Qualitative findings also identified antenatal health problems and poor social support as risk factors for depressive symptoms. They also identified different contributing factors to poor mental health based on ethnicity, higher stress levels among women working outside the home, and misinformation about health conditions as a cause of poor mental health. CONCLUSIONS: Prevalence of antenatal depressive symptoms in Galle is lower than the recorded prevalence in other regions of Sri Lanka. Risk factors for antenatal depressive symptoms were identified on biological, psychological, and social axes. These variables should be considered when developing future guidelines for mental health and obstetric treatment in this context.