title: Antenatal depressive symptoms and maternal health care utilisation: a population-based study of pregnant women in Ethiopia.
abstract: Depressive symptoms during pregnancy can have multiple adverse effects on perinatal outcomes, including maternal morbidity and mortality. The potential impact of antenatal depressive symptoms on maternal health care use, however, has been little explored in low and middle-income countries (LMICs). This paper investigates whether maternal health care utilisation varies as a function of antenatal depressive symptoms.
  
  
  
  In a population-based cross-sectional survey, 1311 women in the second or third trimesters of pregnancy were recruited in Sodo district, Gurage Zone, southern Ethiopia. Depressive symptoms were measured using a locally validated version of the Patient Health Questionnaire (PHQ-9). The association between antenatal depressive symptoms and number of antenatal care (ANC) visits was examined using Poisson regression and the association of depression symptoms with emergency health care visits using negative binomial regression. Binary logistic regression was used to investigate the association of depressive symptoms with initiation, frequency and adequacy of antenatal care.
  
  
  
  At PHQ-9 cut off of five or more, 29.5 % of participants had depressive symptoms. The majority (60.5 %) of women had attended for one or more ANC visits. Women with depressive symptoms had an increased risk of having more non-scheduled ANC visits (adjusted Risk Ratio (aRR) = 1.41, 95 % CI: 1.20, 1.65), as well as an increased number of emergency health care visits to both traditional providers (aRR = 1.64, 95 % CI: 1.17, 2.31) and biomedical providers (aRR = 1.31, 95 % CI: 1.04, 1.69) for pregnancy-related emergencies. However, antenatal depressive symptoms were not significantly associated with initiation of ANC.
  
  
  
  Increased non-scheduled ANC and emergency health care visits may be indicators of undetected depression in antenatal women, and have the potential to overwhelm the capacity and resources of health care systems, particularly in LMICs. Establishment of a system for detection, referral and treatment of antenatal depression, integrated within existing antenatal care, may reduce antenatal morbidity and treatment costs and promote efficiency of the health care system.
authors.affiliation: Department of Psychiatry, College of Health Sciences School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia. tesera_bitew@dmu.edu.et.|Department of Psychology, College of Social Science and Humanities, Debre Markos University, Debre Markos, Ethiopia. tesera_bitew@dmu.edu.et.
authors.forename: Tesera
authors.initials: T
authors.lastname: Bitew
authors.affiliation: Department of Psychiatry, College of Health Sciences School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia.|Global Mental Health, Centre for Global Mental Health, Health Services and Population Research Department, Institute of Psychiatry, King's College London, London, UK.
authors.forename: Charlotte
authors.initials: C
authors.lastname: Hanlon
authors.affiliation: Department of Obstetrics and Gynecology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
authors.forename: Eskinder
authors.initials: E
authors.lastname: Kebede
authors.affiliation: Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia.
authors.forename: Girmay
authors.initials: G
authors.lastname: Medhin
authors.affiliation: Department of Psychiatry, College of Health Sciences School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia.|Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, Addis Ababa, Ethiopia.|Department of Psychological Medicine, Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
authors.forename: Abebaw
authors.initials: A
authors.lastname: Fekadu
mesh_terms: D000328:Adult; D003430:Cross-Sectional Studies; D003863:Depression / Q000523:psychology*; D005002:Ethiopia; D005260:Female; D006801:Humans; D016015:Logistic Models; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D016012:Poisson Distribution; D011247:Pregnancy; D011248:Pregnancy Complications / Q000523:psychology*; D011262:Pregnancy Trimester, Second / Q000523:psychology*; D011263:Pregnancy Trimester, Third / Q000523:psychology*; D011295:Prenatal Care / Q000706:statistics & numerical data*
keywords: Antenatal care; Antenatal care utilization; Antenatal depression; Ethiopia; Maternal depression; Maternal health care use; Sub-Saharan Africa