Open access Protocol Burden of mental health problems among pregnant and postpartum women in sub- Saharan Africa: systematic review and meta- analysis protocol Elizabeth Awini,1 Irene Akua Agyepong,1,2 David Owiredu,3 Leveana Gyimah,4,5 Mary Eyram Ashinyo,6 Linda Lucy Yevoo,1 Sorre Grace Emmanuelle Victoire Aye,1,2 Shazra Abbas,7 Anna Cronin de Chavez ,8 Sumit Kane ,7 Tolib Mirzoev ,8 Anthony Danso-A ppiah 3,9 To cite: Awini E, Agyepong IA, ABSTRACT Owiredu D, et al. Burden of Introduction Pregnancy and postpartum- related mental STRENGTHS AND LIMITATIONS OF THIS STUDY mental health problems among health problems pose serious public health threat to the ⇒ This study uses robust methods, best practices pregnant and postpartum society, but worryingly, neglected in sub- Saharan Africa and reporting guidelines to attempt to synthesise women in sub- Saharan Africa: evidence on the burden of maternal mental health systematic review and meta- (SSA). This review will assess the burden and distribution of maternal mental health (MMH) problems in SSA, with problems in sub- Saharan Africa to provide country analysis protocol. BMJ Open 2023;13:e069545. doi:10.1136/ the aim to inform the implementation of context sensitive and regional- specific estimates. bmjopen-2022-069545 interventions and policies. ⇒ Screening of articles, data extraction and quality as- Prepublication history and Methods and analysis All relevant databases, grey sessment will be done using validated tools by at ► least two independent reviewers to minimise bias. additional supplemental material literature and non- database sources will be searched. for this paper are available PubMed, LILAC, CINAHL, SCOPUS and PsycINFO, Google ⇒ The study uses comprehensive search terms and strategy, and involves relevant electronic databases online. To view these files, Scholar, African Index Medicus, HINARI, African Journals please visit the journal online Online and IMSEAR will be searched from inception to 31 and non-d atabase sources to attempt to retrieve all (http://dx.doi.org/10.1136/ May 2023, without language restriction. The reference potentially relevant studies. bmjopen-2022-069545). ⇒ A possible limitation is, there were no previous data lists of articles will be reviewed, and experts contacted to compare our systematic review to. Received 27 October 2022 for additional studies missed by our searches. Study Accepted 17 May 2023 selection, data extraction and risk of bias assessment will be done independently by at least two reviewers and any discrepancies will be resolved through discussion INTRODUCTION between the reviewers. Binary outcomes (prevalence Maternal mental health (MMH) problems, and incidence) of MMH problems will be assessed using occurring during pregnancy and postpartum pooled proportions, OR or risk ratio and mean difference constitute a serious public health problem for continuous outcomes; all will be presented with their globally, affecting about 10% of pregnant 95% CIs. Heterogeneity will be investigated graphically for 1–3 overlapping CIs and statistically using the I2 statistic and women and 13% of postpartum mothers. A where necessary subgroup analyses will be performed. systematic review on global depression among Random- effects model meta-a nalysis will be conducted postpartum women estimated prevalence of 4 when heterogeneity is appreciable, otherwise fixed- effect 17.2% worldwide. In high- income countries, model will be used. The overall level of evidence will be prevalence of postpartum depression ranged assessed using Grading of Recommendations Assessment, from 5% to 20%.5 Data from 2010 to 2015 Development and Evaluation. Northern Ireland Maternity System indicated Ethics and dissemination Although no ethical clearance that 18.9% of pregnant women reported a © Author(s) (or their employer(s)) 2023. Re- use or exemption is needed for a systematic review, this history of at least one mental disorder. 6 In the permitted under CC BY. review is part of a larger study on maternal mental health USA, 10% depression in mothers was reported Published by BMJ. which has received ethical clearance from the Ethics over 12 months.7 Analysis of Claims data from For numbered affiliations see Review Committee of the Ghana Health Service (GHS-E RC January to December 2008 involving 38 174 end of article. 012/03/20). Findings of this study will be disseminated pregnant women in Germany identified at through stakeholder forums, conferences and peer review Correspondence to least one mental health problem from four publications. Anthony Danso-A ppiah; main mental health disorders in 16 639 of PROSPERO registration number CRD42021269528. a danso- appiah@u g. edu.g h the women8 with somatoform/dissociative Awini E, et al. BMJ Open 2023;13:e069545. doi:10.1136/bmjopen-2022-069545 1 BMJ Open: first published as 10.1136/bmjopen-2022-069545 on 7 June 2023. Downloaded from http://bmjopen.bmj.com/ on June 20, 2023 by guest. Protected by copyright. Open access disorder being 24.2%, anxiety 16.9%, stress reactions interventions. MMH is an important health problem 11.7% and depression 9.3% . While reliable data are which should be given the needed attention but this has not readily available, existing estimates suggest that the often been neglected as a health priority.32–34 There is burden of MMH problems is relatively higher in low- much evidence that in LMICs, the vast majority of women income and middle- income countries (LMICs) with one who experience mental health problems during and in four women reporting depression during pregnancy after pregnancy do not receive the needed treatment.1 35 and 1 in five after delivery.9 A review of evidence from Although few systematic reviews have investigated mental LMICs on prenatal and postnatal depression reported health problems in SSA, none focused specifically on prevalence of 4.9%–50%,10 whereas a systematic review MMH.36 37 The only review that assessed risk factors for involving prenatal and postnatal women living in Africa antenatal depression, included only studies conducted in reported prevalence of depression during pregnancy at Ethiopia,36 and although a systematic review protocol has 11.3% and 18.3% after delivery.11 Another review in sub- been registered in PROSPERO,37 it intends to explore the Saharan Africa (SSA) reported 18.6% postpartum depres- role of MMH disorders and stillbirths. sion,12 with a range from 7% to 50.3%. This review will assess the burden of MMH problems The common mental health problems experienced among pregnant and postpartum women in SSA and by pregnant and postpartum women are depression and attempts to provide robust country and regional estimates anxiety.13–16 Depression can be mild, moderate or severe. of the burden of disease across countries in SSA. Specifi- Mild depression will normally not affect the individual’s cally, it will determine the prevalence and incidence and ability to undertake their day-t o- day activities such as self- describe the sociodemographic characteristics, general care and interpersonal relationships, whereas moderate obstetric histories and characteristics of women with to severe episodes can render the mother less capable MMH problems; assess effects of MMH problems on of undertaking their basic self-c are and that of their birth outcomes and analyse for differences in the burden newborn babies which could impact on breastfeeding of mental health problems among pregnant and post- and bonding.17 Other MMH disorders are postpartum partum women between rural and urban settings. The psychosis, pregnancy and postpartum obsessive–compul- review will answer the following specific questions: (1) sive disorder (OCD), birth-r elated post- traumatic stress What is the magnitude of MMH problems among preg- disorder (PTSD), intrusive thoughts and mania, schizo- nant and postpartum women living in SSA? (2) What phrenia, infanticide, substance use disorder, anorexia are the sociodemographic characteristics of pregnant nervosa, bulimia, suicidal ideation, bipolar affective and postpartum women with mental health problems disorder, paranoia, psychopathy, neurotic disorders and self- harm.18 19 in SSA? (3) What are the general obstetric histories and These disorders may develop as a result characteristics of pregnant and postpartum women in of experiences associated with childbirth, foetal loss, SSA with mental health problems? (4) Is there any differ- congenital malformations, intimate partner violence ence in the burden of pregnant and postpartum women during pregnancy, lack of partner support, history of with mental health problems between rural and urban abuse, unplanned pregnancy, complications in previous 20–24 settings? and (5) Are there any documented effects of pregnancy, higher perceived stress, lower self-e steem birth outcomes of pregnant women with mental health and many more. Individuals with predisposition to problems? bipolar affective disorders may develop manic episodes from pregnancy-r elated stress.20 Severity of MMH disor- ders can potentially progresses from mild or moderate to Review methods severe forms if not identified early and appropriate inter- This review protocol has been prepared following the vention instituted.25 26 Preferred Reporting Items for Systematic Review and Meta-A nalysis extension for protocols (PRISMA-P )38 Rationale for this systematic review (online supplemental file 1) and the PRISMA flow Mothers with mental health problems may not be able diagram (online supplemental file 2). The full review will to realise their abilities, work productively or cope with be prepared in line with the Preferred Reporting Items the normal stresses of life.3 MMH disorders can have for Systematic Review and Meta- Analysis (PRISMA). The negative effects on both the mother and the child.27 In full review is expected to start on 1 May 2023, analysis 1 severe cases, depressed mothers may have symptoms of a September and completed by 30 November 2023. psychosis.4 Affected mothers often cannot function prop- erly, with some having suicidal tendencies.3 Evidence Patient and public involvement shows that MMH problems are associated with nega- The review questions and outcome measures have been tive birth outcomes and may adversely affect cognitive developed collaboratively with the relevant patient and development of the infant,28 29 nutritional status of their consumer involvement and informed by their priori- infants30 and early child well- being.31 There is, however, ties, experience and preferences in line with GRIPP2 limited knowledge to inform policy makers on the burden reporting checklists. The review findings will be shared of MMH disorder in SSA to inform on the selection and with relevant wider patient communities who will also be implementation of locally relevant, feasible and effective involved in the results dissemination. 2 Awini E, et al. BMJ Open 2023;13:e069545. doi:10.1136/bmjopen-2022-069545 BMJ Open: first published as 10.1136/bmjopen-2022-069545 on 7 June 2023. Downloaded from http://bmjopen.bmj.com/ on June 20, 2023 by guest. Protected by copyright. Open access Criteria for considering studies for this review Secondary outcomes Types of studies ► Proportion of MMH conditions captured in the Any study (cohort, case–control and cross-s ectional community studies) conducted in SSA that assessed burden of MMH ► Predisposition socio-d emographic characteristics of problems among pregnant and postpartum women will pregnant and postpartum women with mental health be eligible for inclusion. This review is not an interven- problems tion effectiveness review and randomised controlled trials ► Predisposition obstetric histories and characteris- (RCTs) are not the focus but if a RCT reported baseline tics of pregnant and postpartum women in SSA with number of cases and used a well- defined sample to serve as mental health problems the denominator to allow the calculation of proportion/ ► Psychiatric predisposition (pre-e xisting mental health prevalence/incidence in pregnant or postpartum women, issues triggered during or after pregnancy). such an RCT will be eligible for inclusion. Reviews will not ► Burden of mental health problems among pregnant be eligible for inclusion. However, we will go through the and post-p artum women between rural and urban reviews to identify potentially eligible studies missed by settings our searches. If the study is a global review having, for example, SSA or subregional subset, we will extract the Search strategy studies conducted in SSA for inclusion in this review. If We will search the following electronic databases: the study reported a country or regional estimate without PubMed, PsycINFO, LILAC and CINAHL from inception a well- defined sample (representative sample or subsa- to 31 May 2023 without language restriction and using mple of the source population), it will not be eligible for the search terms in table 1. We will also search Google inclusion. In cases where the results of a multicountry Scholar, African Index Medicus, HINARI, African Jour- study have been lumped together and there is no way of nals Online, IMSEAR and relevant preprint repositories. disaggregating the data, such studies will not be included. Grey literature including dissertations and conference Case studies and case series (these are atypical and not proceedings will be searched. Reference list of retrieved representative of the source population), commentaries articles will be reviewed, and experts in the field of MMH or opinions, will not be eligible for inclusion. will be contacted for studies not captured by our searches (see table 1 for search strategy developed for PubMed). Participants The search strategy will be adapted as appropriate for Pregnant and postpartum (postpartum is defined as up to other databases. All searches will be rerun just before the 12 months after delivery) women living in SSA, diagnosed final analyses and any further eligible studies identified of any mental health disorder (depression, anxiety, post- will be included. partum psychosis, bipolar disorders, substance misuse disorders, dysthymia, OCD, PTSD, schizophrenia, infanti- Study selection cide, suicidal ideation, paranoia, psychopathy, neurosis/ The search output will be managed, collated and dedu- neurotic disorders, self-h arm, anorexia nervosa, bulimia, plicated using EndNote. The deduplicated articles will 42 etc.) will be eligible for inclusion. The tool or criteria for be exported to Rayyan for screening and selection. diagnosis should be stated, for example, standard oper- At least two reviewers will screen titles and abstracts of ational diagnostic criteria such as Research Diagnostic identified studies independently using prespecified and Criteria (RDC),39 the 10th edition of the International piloted eligibility flowchart (figure 1). The full text of Classification of Diseases (ICD-1 0)40 or Diagnostic and potentially relevant studies will also be reviewed inde- Statistical Manual of Mental Disorders (DSM- V).41 Preg- pendently for inclusion. The PRISMA flow diagram will nant or postpartum women whose diagnosis of mental be used to document the flow of studies and reasons for health disorder could not be confirmed will be excluded. exclusion. Discrepancies will be resolved through discus- sion between the reviewers. Interventions This systematic review is not intervention review. Data extraction and management A validated data extraction sheet adapted from the Comparison Cochrane Collaboration (online supplemental file 3) This is non-c omparative review but where outcomes or will be used by the reviewers to independently extract variables permit comparison, we will attempt to compare. relevant data. Data to be extracted include characteris- tics of the studies such as year study was conducted, year Outcomes study was published (for published studies), country Primary outcomes where study was conducted, study design and sample ► Burden of MMH problems measured as prevalence, size; sociodemographic characteristics of the participants incidence, etc. (age, setting, socioeconomic status, level of education ► Birth outcomes (maternal and foetal outcomes) up to and occupation); obstetric factors (parity, maternal age, 12 months postpartum age at first delivery, history of miscarriage and history of ► Type of MMH conditions (for diagnosed cases) stillbirth), mental health conditions (depression, anxiety, Awini E, et al. BMJ Open 2023;13:e069545. doi:10.1136/bmjopen-2022-069545 3 BMJ Open: first published as 10.1136/bmjopen-2022-069545 on 7 June 2023. Downloaded from http://bmjopen.bmj.com/ on June 20, 2023 by guest. Protected by copyright. Open access Table 1 Search strategy for PubMed (to be adapted for the other databases) Search Query Results #1 Search: (((((((((((((((((((((((((‘mental health’(Title/Abstract)) OR (‘mental disorder’(Title/Abstract))) OR (‘mental illness’(Title/Abstract))) OR (‘mental problem’(Title/Abstract))) OR (‘chronic mental illness’(Title/Abstract))) OR (‘psychiatric illness’(Title/Abstract))) OR (‘chronic psychiatric illness’(Title/Abstract))) OR (‘chronic insanity’(Title/Abstract))) OR (insanity(Title/Abstract))) OR (‘chronic mental disorder’(Title/Abstract))) OR (‘dementia praecox’(Title/Abstract))) OR (schizophrenia(Title/Abstract))) OR (psychoses(Title/Abstract))) OR (psychosis(Title/Abstract))) OR (‘schizophrenic psychosis’(Title/Abstract))) OR (depression(Title/Abstract))) OR (‘mental sickness’(Title/Abstract))) OR (‘mental disease’(Title/Abstract))) OR (maladjustment(Title/ Abstract))) OR (‘emotional disorder’(Title/Abstract))) OR (‘nervous disorder’(Title/Abstract))) OR (‘nervous breakdown’(Title/Abstract))) OR (neurosis(Title/Abstract))) OR (‘neurotic disorder’(Title/Abstract))) OR (psychopathy(Title/Abstract))) OR (paranoia(Title/Abstract)) #2 Search: (((((((((((((‘pregnant women’(Title/Abstract)) OR (prepartum(Title/Abstract))) OR (peripartum(Title/ Abstract))) OR (perinatal(Title/Abstract))) OR (prenatal(Title/Abstract))) OR (antenatal(Title/Abstract))) OR (‘during pregnancy’(Title/Abstract))) OR (postpartum(Title/Abstract))) OR (maternal(Title/Abstract))) OR (maternity(Title/Abstract))) OR (parturient(Title/Abstract))) OR (antepartum(Title/Abstract))) OR (‘post- delivery’(Title/Abstract))) OR (puerperium(Title/Abstract)) #3 Search: (#1) AND (#2) #4 Search: ((((((((((((((((((((((((((((((((((((((((((((((((‘sub-S aharan Africa’) OR (SSA)) OR (Angola)) OR (Benin)) OR (Botswana)) OR (‘Burkina Faso’)) OR (Burundi)) OR (Cameroon)) OR (‘Cape Verde’)) OR (‘Central African Republic’)) OR (Chad)) OR (Comoros)) OR (Congo)) OR (‘Cote d'Ivoire’)) OR (Djibouti)) OR (‘Equatorial Guinea’)) OR (Ethiopia)) OR (Gabon)) OR (‘The Gambia’)) OR (Ghana)) OR (Guinea)) OR (‘Guinea-B issau’)) OR (Kenya)) OR (Lesotho)) OR (Liberia)) OR (Madagascar)) OR (Malawi)) OR (Mali)) OR (Mauritania)) OR (Mauritius)) OR (Mozambique)) OR (Namibia)) OR (Niger)) OR (Nigeria)) OR (Rwanda)) OR (‘Sao Tome and Principe’)) OR (Senegal)) OR (Seychelles)) OR (‘Sierra Leone’)) OR (Somalia)) OR (‘South Africa’)) OR (Sudan)) OR (Swaziland)) OR (Tanzania)) OR (Togo)) OR (Uganda)) OR (Zaire)) OR (Zambia)) OR (Zimbabwe) #5 Search: (#3) AND (#4) postpartum psychosis, dysthymia/persistent depressive on the Cochrane ROB tool. The Cochrane criteria for disorder, pregnancy and postpartum OCD, birth-r elated reporting ROB in the included studies will be used to PTSD, intrusive thoughts and mania, schizophrenia, assess prespecified outcomes of interest. The ROB will infanticide, substance use disorder, anorexia nervosa, be rated as ‘low’ if protocol of the study is available and bulimia, suicidal ideation, bipolar affective disorder, all prespecified outcomes of interest as specified in the paranoia, psychopathy, neurotic disorders and self-h arm) protocol, or the protocol is not available but it is clear and quality domains for the assessment of quality of the that all prespecified and expected outcomes of interest included studies for risk of bias (ROB). Data on burden have been reported. The ROB will be rated as ‘high’ for of the disease (such as prevalence, incidence and dura- a study if outcomes are not reported as prespecified or tion of the MMH problem) will be extracted. The corre- expected and ‘unclear’ when there is not enough infor- sponding authors of the primary studies will be contacted mation to make clear judgement. Other prespecified for missing data or unclear information. Where it is not biases pertaining to the methods, source of funding, etc, possible to obtain the missing information, data will be will be assessed and rated. The ROB tool for prevalence analysed based on those with complete outcome data and studies will be assessed using the tool by Hoy et al44 (online the amount of data missing with reasons will be provided. supplemental file 4) on four domains: selection bias, non- If necessary, data will be coded and recoded before use response bias, measurement bias and bias related to data in the analysis. The extracted data will be verified inde- analysis for prevalence studies. Each ROB domain will pendently and any disagreement will be resolved through be graded as ‘low risk’, ‘high risk’ and ‘unclear’ ROB. discussion. Any disagreements will be resolved through discussion between the reviewers, and if necessary, a third reviewer Assessment of quality of the included studies will be consulted. At least two reviewers will assess quality of the included studies for ROB (methodology and reporting) inde- Data analysis pendently using the appropriate ROB assessment Binary outcomes will be assessed using OR or risk ratio tools. Since this review is not focusing on randomised (RR), and for continuous data, we will use mean differ- controlled trials (RCTs), the domains on the Cochrane ence (MD) or standardised mean difference (SMD) ROB tool43 will not be covered fully. Selective outcome for means that used different scales. Meta- analysis, the and analysis reporting bias (which occurs when studies statistical component of systematic review, will be used to with positive and significant results are likely to be combine study outcomes. OR, RR and MD of the indi- reported or published) are the domains to be considered vidual studies will be pooled and presented with their 4 Awini E, et al. BMJ Open 2023;13:e069545. doi:10.1136/bmjopen-2022-069545 BMJ Open: first published as 10.1136/bmjopen-2022-069545 on 7 June 2023. Downloaded from http://bmjopen.bmj.com/ on June 20, 2023 by guest. Protected by copyright. Open access Figure 1 Study selection flowchart. Awini E, et al. BMJ Open 2023;13:e069545. doi:10.1136/bmjopen-2022-069545 5 BMJ Open: first published as 10.1136/bmjopen-2022-069545 on 7 June 2023. Downloaded from http://bmjopen.bmj.com/ on June 20, 2023 by guest. Protected by copyright. Open access 95% CI. Random- effects model will be used in the meta- 7Nossal Institute for Global Health, Melbourne School of Population and Global analysis when heterogeneity is high, otherwise fixed- effect Health, The University of Melbourne, Melbourne, Victoria 3010, Australia 8 model will be used. Descriptive statistics will be used to Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK describe proportions (prevalence and incidence). 9Centre for Evidence Synthesis and Policy, University of Ghana, Legon, Accra, Ghana Heterogeneity and subgroup analysis Twitter Tolib Mirzoev @tmirzoev Heterogeneity arises because of variation in the study Acknowledgements We thank Dr Caleb Othieno, University of Nairobi, Kenya, Mrs design, characteristics of participants or outcomes Ruth Owusu- Antwi, Komfo Anokye Teaching Hospital, Kwame Nkrumah University between or within studies.45 Heterogeneity will be inves- of Science and Technology, Kumasi, Ghana and Stephanie Catsaros, Université tigated both graphically and statistically. The I2 statistic Paris Cité, France for peer- reviewing this manuscript and providing very useful comments. This systematic review was part of capacity building initiative by the which describes the percentage of variability that is due to UG Centre for Evidence Synthesis and Policy (UGCESP), Africa Communities of heterogeneity rather than chance will be estimated. The I2 Evidence Synthesis and Translation (ACEST) and the RESPONSE Project that are is classified into four levels: 0%, 1%–29%, 30%–59% and jointly training experts in evidence synthesis and translation across low-i ncome and 60%–100%46 and I2>50% indicates significant heteroge- middle- income countries (LMICs). neity.47 Subgroup analysis which is used to estimate an Contributors Protocol conceptualisation and design: EA, IAA, SK, TM and AD- A. Drafting the work or revising it critically for important intellectual content: EA, effect of indicator within each subgroup or subset will be IAA, DO, LG, MEA, LY, SGEVA, SA, ACC, SK, TM and AD- A. Acquisition, analysis or used to address heterogeneity due to variation in effects interpretation of data: EA, IAA, DO, LG, MEA, LY, SGEVA, SA, ACC, SK, TM and AD- A. in each subgroup mixed-e ffect model. Thus, the burden Agreement to be accountable for accuracy or integrity of all aspects of the work: of MMH problems will be estimated separated for urban EA, IAA, DO, LG, MEA, LY, SGEVA, SA, ACC, SK, TM and AD- A. Final approval of the version to be published: EA, IAA, DO, LG, MEA, LY, SGEVA, SA, ACC, SK, TM and AD- and rural and for each age group. Subgroup analysis will A. Supervised this work: AD- A. also be done for gestational age and postpartum period. Funding This review is part of a wider RESPONSE study, which received funding If we find sufficient number of studies, subgroup analysis from the Joint MRC/ESRC/DFID/Wellcome Health Systems Research Initiative will also be based on perinatal mental disorder type, study (grant ref: MR/T023481/2). The views expressed in this publication are those of the design, parity and location. author(s) and not necessarily those of the funders. Competing interests None declared. Grading the evidence Patient and public involvement Patients and/or the public were involved in the The overall evidence of the systematic review will be design, or conduct, or reporting or dissemination plans of this research. Refer to the graded using Grading of Recommendations Assessment, Methods section for further details. Development and Evaluation (GRADE)48 (available from Patient consent for publication Not required. guidelinedevelopment.org/handbook). The GRADE Provenance and peer review Not commissioned; externally peer reviewed. system assesses the following domains: ROB, imprecision, Data availability statement Data sharing not applicable as no data sets inconsistency, indirectness and publication bias, and clas- generated and/or analysed for this study. All data relevant to the study are included sifies the quality of evidence as high, moderate, low and in the article or uploaded as supplementary information. very low. If evidence from a study is graded high quality, Supplemental material This content has been supplied by the author(s). It has it implies further research is very unlikely to change the not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-r eviewed. Any opinions or recommendations discussed are solely those confidence in the estimate of effect while a grading of very of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and low quality implies an estimate of effect is very doubtful. responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error ETHICAL APPROVAL AND DISSEMINATION and/or omissions arising from translation and adaptation or otherwise. Although no ethical clearance or exemption is needed Open access This is an open access article distributed in accordance with the for a systematic review, this review is part of a larger study Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits on MMH that involves primary data collection and which others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, has received ethical clearance from the ethics review and indication of whether changes were made. See: https://creativecommons.org/ committee of the Ghana Health Service (GHS- ERC licenses/by/4.0/. 012/03/20). The results of the review will be presented to ORCID iDs stakeholders (policymakers and practitioners). It will also Anna Cronin de Chavez http://orcid.org/0000-0002-4050-4276 be disseminated through conferences and peer review Sumit Kane http://orcid.org/0000-0002-4858-7344 publications. Tolib Mirzoev http://orcid.org/0000-0003-2959-9187 Anthony Danso-A ppiah http://orcid.org/0000-0003-1747-0060 Author affiliations 1Research and Development Division, Dodowa Health Research Centre, Ghana Health Service, Dodowa, Ghana 2Faculty of Public Health, Ghana College of Physicians and Surgeons, Accra, Ghana REFERENCES 3Department of Epidemiology and Disease Control, School of Public Health, 1 Kathree T, Selohilwe OM, Bhana A, et al. Perceptions of postnatal University of Ghana, Legon, Ghana depression and health care needs in a South African sample: 4 the "mental" in maternal health care. BMC Womens Health Department of Psychiatry, Pantang Hospital, Accra, Ghana 2014;14:.:140. 5Faculty of Psychiatry, Ghana College of Physicians and Surgeons, Accra, Ghana 2 McCauley M, Brown A, Ofosu B, et al. I just wish it becomes part 6Institutional Care Division, Ghana Health Service, Accra, Ghana of routine care": Healthcare providers’ knowledge, attitudes and 6 Awini E, et al. BMJ Open 2023;13:e069545. doi:10.1136/bmjopen-2022-069545 BMJ Open: first published as 10.1136/bmjopen-2022-069545 on 7 June 2023. Downloaded from http://bmjopen.bmj.com/ on June 20, 2023 by guest. Protected by copyright. Open access perceptions of screening for maternal mental health during and after 24 Koh M, Ahn S, Kim J, et al. Pregnant Women’s Antenatal Depression pregnancy: a qualitative study. BMC Psychiatry 2019;19:.:304. and Influencing Factors. Korean J Women Health Nurs 2019;25:112. 3 WHO. Who | maternal mental health. 2020. Available: https://www. 25 Sadock BSV. Postpartum Psychiatric Syndromes. Comprehensive who.int/mental_health/maternal-child/maternal_mental_health/en Textbook of Psychiatry. Vol 1. 7 ed:. Lippincott & Wilkins Publishers, [Accessed 20 Dec 2020]. 2000: 992–1053. 4 Wang Z, Liu J, Shuai H, et al. Mapping global prevalence of 26 Semple D, Smyth R. Oxford handbook of psychiatry. In: Disorders depression among postpartum women. Transl Psychiatry related to childbirth. Oxford Handbook of Psychiatry. 3rd ed. Oxford: 2021;11:1–13. 10.1038/s41398-021-01663-6 Oxford University Press, 2013: 470–2. 5 Nilaweera I, Doran F, Fisher J. Prevalence, nature and determinants 27 O'Hara MW, McCabe JE. Postpartum depression: current status and of postpartum mental health problems among women who have future directions. Annu Rev Clin Psychol 2013;9:379–407. Available migrated from South Asian to high-i ncome countries: a systematic https://www.annualreviews.org/toc/clinpsy/9/1 review of the evidence. J Affect Disord 2014;166:213–26. 28 Tran TD, Biggs B-A , Tran T, et al. Impact on infants' cognitive 6 Mongan D, Lynch J, Hanna D, et al. Prevalence of self-r eported development of antenatal exposure to iron deficiency disorder and mental disorders in pregnancy and associations with adverse common mental disorders. PLoS One 2013;8:e74876. neonatal outcomes: a population- based cross- sectional study. BMC 29 Paschetta E, Berrisford G, Coccia F, et al. Perinatal Pregnancy Childbirth 2019;19:412. psychiatric disorders: an overview. Am J Obstet Gynecol 7 Ertel KA, Rich-E dwards JW, Koenen KC. Maternal depression in the 2014;210:S0002- 9378(13)01047- 8:501–9.:. United States: nationally representative rates and risks. J Womens 30 Hassan BK, Werneck GL, Hasselmann MH. Maternal mental health Health (Larchmt) 2011;20:1609–17. and nutritional status of six- month-o ld infants. Rev Saude Publica 8 Wallwiener S, Goetz M, Lanfer A, et al. Epidemiology of mental 2016;50:7. disorders during pregnancy and link to birth outcome: a large- 31 MacGinty RP, Lesosky M, Barnett W, et al. Associations between scale retrospective observational database study including 38,000 maternal mental health and early child wheezing in a South African pregnancies. Arch Gynecol Obstet 2019;299:755–63. birth cohort. Pediatr Pulmonol 2018;53:741–54. 9 Gelaye B, Rondon MB, Araya R, et al. Epidemiology of 32 O’Mahony JM, Donnelly TT. How does gender influence immigrant maternal depression, risk factors, and child outcomes in low- and refugee women’s postpartum depression Help‐Seeking income and middle-i ncome countries. Lancet Psychiatry experiences J Psychiatr Ment Health Nurs 2013;20:714–25. 2016;3:S2215- 0366(16)30284-X :973–82.:. 33 Bagadia A, Chandra PS. Starting the conversation-i ntegrating 10 Parsons CE, Young KS, Rochat TJ, et al. Postnatal depression and mental health into maternal health care in India. Indian J Med Res its effects on child development: a review of evidence from Low- and 2017;145:267–9. middle-i ncome countries. Br Med Bull 2012;101:57–79. 34 Cheung FK, Snowden LR. Community mental health and ethnic 11 Sawyer A, Ayers S, Smith H. Pre-a nd postnatal psychological minority populations. Community Ment Health J 1990;26:277–91. wellbeing in Africa: a systematic review. J Affect Disord 35 Fonseca A, Canavarro MC. Women’s intentions of informal and 2010;123:17–29. formal help-s eeking for mental health problems during the perinatal 12 Woldeyohannes D, Tekalegn Y, Sahiledengle B, et al. Effect of period: the role of perceived encouragement from the partner. postpartum depression on exclusive breast- feeding practices in sub- Midwifery 2017;50:S0266-6 138(17)30255- 3:78–85.:. Saharan Africa countries: a systematic review and meta- analysis. 36 Getinet W, Amare T, Boru B, et al. Prevalence and risk factors for BMC Pregnancy Childbirth 2021;21:113:113.:. Antenatal depression in Ethiopia: systematic review. Depress Res 13 Atif N, Lovell K, Rahman A. Maternal mental health: The missing Treat 2018;2018:3649269. “m” in the global maternal and child health agenda. Seminars in 37 Adane AA, Bailey HD, Marriott R, et al. Role of maternal mental Perinatology 2015;39:345–52. health disorders on Stillbirth and infant mortality risk: a protocol for a 14 Banti S, Mauri M, Oppo A, et al. From the third month of pregnancy systematic review and meta-a nalysis. BMJ Open 2020;10:e036280. to 1 year postpartum. prevalence, incidence, recurrence, and new 38 Moher D, Shamseer L, Clarke M, et al. Preferred reporting items for onset of depression: results from the perinatal depression–research systematic review and meta-a nalysis protocols (PRISMA- P) 2015 and screening unit study. Compr Psychiatry 2011;52:343–51. statement. Syst Rev 2015;4:1–9. 15 Garthus- Niegel S, von Soest T, Knoph C, et al. The influence 39 Spitzer RL, Endicott J, Robins E. Research diagnostic criteria: of women’s preferences and actual mode of delivery on post- rationale and reliability. Arch Gen Psychiatry 1978;35:773–82. traumatic stress symptoms following childbirth: a population-b ased, 40 WHO. The ICD- 10 classification of mental and behavioural disorders. longitudinal study. BMC Pregnancy Childbirth 2014;14:191:1–10.:. Clinical Description and Diagnostic Guidelines 1993. 16 Falah-H assani K, Shiri R, Dennis C- L. Prevalence and risk factors for 41 Nuckols CC, Nuckols CC. The diagnostic and statistical manual of comorbid postpartum depressive Symptomatology and anxiety. J mental disorders. Philadelphia: American Psychiatric Association, Affect Disord 2016;198:S0165-0 327(15)30383- 9:142–7.:. 2013. 17 Solomon CG, Park LT, Zarate CA Jr. Depression in the primary care 42 Harrison H, Griffin SJ, Kuhn I, et al. Software tools to support title setting. N Engl J Med 2019;380:559–68. and abstract screening for systematic reviews in Healthcare: an 18 Bauer A, Parsonage M, Knapp M, et al. The costs of perinatal mental evaluation. BMC Med Res Methodol 2020;20:7. health problems. London: Centre for Mental Health and London 43 Higgins JPT, Altman DG, Gøtzsche PC, et al. The Cochrane School of Economics, 2014. collaboration's tool for assessing risk of bias in randomised trials. 19 Collardeau F, Corbyn B, Abramowitz J, et al. Maternal unwanted BMJ 2011;343:d5928. and intrusive thoughts of infant-r elated harm, obsessive-c ompulsive 44 Hoy D, Brooks P, Woolf A, et al. Assessing risk of bias in prevalence disorder and depression in the perinatal period: study protocol. BMC studies: modification of an existing tool and evidence of interrater Psychiatry 2019;19:94. agreement. J Clin Epidemiol 2012;65:934–9. 20 Biaggi A, Conroy S, Pawlby S, et al. Identifying the women at risk 45 Spineli LM, Pandis N. Exploring heterogeneity in meta-a nalysis: of Antenatal anxiety and depression: a systematic review. J Affect subgroup analysis. Part 1. American Journal of Orthodontics and Disord 2016;191:62–77. Dentofacial Orthopedics 2020;158:302–4. 21 Silva MMdeJ, Nogueira DA, Clapis MJ. Anxiety in pregnancy: 46 Koletsi D, Fleming PS, Michelaki I, et al. Heterogeneity in Cochrane prevalence and associated factors. Rev Esc Enferm USP 2017;51. and non- Cochrane meta-a nalyses in orthodontics. J Dent 22 Ogbo FA, Eastwood J, Hendry A, et al. Determinants of antenatal 2018;74:S0300-5 712(18)30110- 6:90–4.:. depression and postnatal depression in Australia. BMC Psychiatry 47 Chang TH, Chou CC, Chang LY. Effect of obesity and body mass 2018;18:1–11. index on Coronavirus disease 2019 severity: a systematic review and 23 Milgrom J, Hirshler Y, Reece J, et al. Social Support—A protective Meta‐Analysis. Obes Rev 2020;21:e13089. factor for depressed perinatal women? Int J Environ Res Public 48 Schünemann H. The grade. handbook: Cochrane Collaboration, Health 2019;16:1426. 2013. Awini E, et al. BMJ Open 2023;13:e069545. doi:10.1136/bmjopen-2022-069545 7 BMJ Open: first published as 10.1136/bmjopen-2022-069545 on 7 June 2023. Downloaded from http://bmjopen.bmj.com/ on June 20, 2023 by guest. Protected by copyright.