Thoughts of self-harm in early and late pregnancy in urban South Africa: Investigating prevalence, predictors and screening options.

BACKGROUND: Thoughts of self-harm (TSH) are an important marker of mental health risk, and risk for attempted and completed suicide. While there is increasing attention being paid to mental health problems in pregnancy in South Africa (SA), TSH have received less attention despite some cross-sectional studies suggesting that prevalence may be high (12 - 39%). There is a dearth of longitudinal research to inform prevention and treatment. OBJECTIVES: To examine the rates of TSH across pregnancy in a longitudinal SA cohort and to investigate factors associated with the onset and persistence of TSH, as well as the relationship between TSH, depression and/or anxiety. METHODS: Women were enrolled in a prospective pregnancy cohort (S1000) in Soweto, SA between 2014 and 2016, and assessed using validated screening measures (Edinburgh Postnatal Depression Scale (EPDS) and State Trait Anxiety Index short form) in early and later pregnancy. Data were available for 649 women. TSH were determined using EPDS item 10. Logistic regression and bifactor models were used to determine factors associated with TSH across pregnancy. RESULTS:  Of the 649 women, 18% reported TSH at some stage during their pregnancy. Prevalence of TSH was slightly higher in early pregnancy (12.5%) than later in pregnancy (11.6%). TSH were associated with a history of mental illness (adjusted odds ratio (aOR) 4.17; 95% confidence interval (CI) 1.3 - 13.7; p=0.020), concurrent depression (aOR 4.8; 95%CI 2.7 - 8.6; p<0.001); marital stress (aOR 1.74; 95% CI 1.0 - 3.0; p=0.040); and practical support (aOR 0.43; 95% CI 0.2 - 1.0; p=0.040) using a multivariate logistic regression. Bifactor analysis examining depression and anxiety scales showed that TSH contributed the highest variance to a shared depression and anxiety factor in early pregnancy. Logistic regressions showed that early depression was a strong predictor of later reports of TSH. CONCLUSIONS:  The present study shows that the risk of TSH during pregnancy is relatively common, and starts early during pregnancy. Screening approaches could be simplified to encourage healthcare practitioners working in busy and over-burdened public healthcare settings to engage in identifying at-risk women. Efforts in improving early identification of mental health risk in pregnancy should be matched with strengthening of current treatment and referral options. Since practical support and a good marital relationship reduce the risk of TSH, these may be important avenues of focus for designing interventions.