Characteristics of sample
Overall, 23 participants completed 30 interviews (17 completed an interview during pregnancy, and 13 completed a postpartum interview, with seven participants completing interviews at both timepoints) between May 2022 and May 2023. On average, participants were 25.1 years old (SD=4.0), had a mean gestational age of 28.5 weeks (SD = 9.9), and had 2.1 (SD=1.0) lifetime pregnancies at the time of their baseline survey (see Table 1 for full details). Most participants identified as Black South African (n=20, 83.3%), and 70.8% of the sample (n=17) earned less than 3,000 ZAR (~$163) per month. With respect to likely mental health diagnoses, 12 met criteria for probable depression, two for probable PTSD, and nine for both.
Table 1. Sociodemographic and select characteristics of sample at baseline survey visit (N = 23)
|
Mean
|
SD
|
Age
|
25.1
|
4.0
|
Gestational age (wks) at baseline visit
|
28.5
|
9.9
|
Gestational age (wks) at time presenting for antenatal care
|
17.6
|
8.7
|
Total pregnancies, including current
|
2.1
|
1.0
|
Previous live births
|
1.7
|
1.0
|
Mental health symptom severity
Depression (SADS)
Depression (EPDS)
PTSD (PCL-5)
|
24.2
11.1
28.0
|
8.0
4.7
13.6
|
|
N
|
%
|
Race
Black South African
Black non-South African
|
20.0
3.0
|
87.0
13.0
|
Education
None
Through Grade 10/Std 8
Through Grade 12/Std 10
Vocational
Tertiary, university, Technikon degree
|
1.0
4.0
15.0
2.0
1.0
|
4.4
17.4
65.2
8.7
4.4
|
Monthly income in ZAR ($)
0 (0 USD)
Less than 3000 (162 USD)
3001-6000 (162-324 USD)
6001-9000 (324-485 USD)
9001-12000 (485-647 USD)
|
5.0
11.0
6.0
0.0
1.0
|
21.7
47.8
26.1
0.0
4.4
|
Source of income
Employment
Government grant
Money from partner(s)
Money from family
Other
None
|
8.0
9.0
4.0
2.0
2.0
5.0
|
34.8
39.1
17.4
8.7
8.7
21.7
|
Qualified for interview by
Depression
Posttraumatic stress
Depression and posttraumatic stress
|
13.0
3.0
7.0
|
56.5
13.0
30.0
|
In addition to topics related to PrEP use that are not discussed here, the qualitative interviews explored perspectives on the likely impact of partcipants’ mental health symptoms on their baby’s wellbeing, their ability to bond with their baby, and their ability to meet their baby’s needs (i.e., feeding and taking their baby to medical appointments). Three main themes that characterized these relationships emerged from the data: (1) a strong perceived connection between maternal mental health and baby’s wellbeing; (2) perceived strains on bonding with the baby; and (3) negative impact of mental health on likelihood of completing parenting tasks completing parenting tasks.
Theme 1: A Strong Perceived Connection Between Mental Health & Baby’s Wellbeing
Most participants endorsed a strong connection between their mental health and their baby’s wellbeing, both in utero and post-delivery. Two subthemes that described how participants understood their mental health to impact their baby’s health were identified: (1a) fear of mental health symptoms impairing their baby’s health through birth complications and via breastmilk, and (1b) avoidance of sadness (either cognitively or emotionally) as a strategy to protect their baby.
(1a) Fear of mental health symptoms impairing baby’s health through birth complications and via breastmilk.
Participants perceived a connection between their mental health symptoms and the possibility of pregnancy complications, including risk of pregnancy loss or miscarriage. For example, one participant stated, “People say that if you always cry it might affect the child, and you might get miscarriage, and that’s why I don’t think much of the [bad things] that happen…That’s why I don’t think much because I’m concerned about the baby that’s inside me” (age 21, pregnant). Another participant noted, “When I think a lot; I become very angry and hurt. I heard that in most cases when someone is going through stressful phase; miscarriage occurs” (age 22, pregnant). These concerns about symptoms leading to a potential miscarriage demonstrate a clear perceived link between maternal stress, depression symptoms, and severe consequences for the baby.
Further, participants also identified a perceived connection between their mental health symptoms and resulting complications for their baby postpartum. One participant shared, “Oh no [my stress] affects me just a little bit until I realize that the baby must not see me. It’s said that the baby can sense when you’re not alright” (age 31, postpartum). This comment suggests the social pressure of ensuring that the baby is not aware of or attuned to their mother’s negative emotions and/or thoughts. Another participant expressed a similar sentiment, and revealed that her mother told her that stress can meaningfully affect the health of the baby, “My mother would tell me that I should decrease my stress levels because the more I get stressed, this is going to affect the baby, she said I should stop having negative thoughts” (age 23, postpartum). Many participants were made aware of the connection between their mental health symptoms and their baby’s wellbeing from relatives or others in their community, which strengthened beliefs that their negative emotions or feelings may negatively impact their baby.
Participants were also told that their sadness or stress could transfer to their baby when breastfeeding postpartum. One postpartum participant explained, “When it’s time to breastfeed the baby, it is normally said that if you’re upset you must not breastfeed the baby” (age 31, postpartum). Taken together, particpants recognized the potential for their mental health symptoms to impact their baby’s health both in utero and while breastfeeding.
(1b) Avoidance of sadness (either cognitively or emotionally) was seen as a strategy to protect their baby
Participants discussed cognitively or emotionally avoiding their mental health symptoms to protect their baby during pregnancy. One participant mentioned actively trying to reduce her overthinking: “Things do happen, but we must not think too much of them, and they would say I must not think too much because it will get me sick and increase my blood pressure” (age 25, pregnant). This participant tried to avoid negative cognitions because she was told by others that the resulting physical effects will cause harm to both her and the baby. In a similar way, another participant stated, “My baby’s happiness comes first, so if I worry myself, that is also going to affect my baby and the nurses would notice this. So, I will try not to think about those things, let’s say I try to pretend…I will try to be present, just for my baby’s sake” (age 20, pregnant). This participant described the process of compartmentalizing her stress or “pretending” she was not experiencing anxiety toto protect her baby’s health and because she believed that the clinic nurses would be able to notice in her baby if she had been stressing..
Participants also believed they must continue to avoid or suppress their mental health symptoms while breastfeeding. One participant with likely posttraumtic stress clarified that when she has stress-related thoughts, she tries to ignore her negative cognitions so her baby is not impacted, “I don’t think a lot now like how I used to…Reason being, it’s said when you are breastfeeding the baby can sense when you’re stressed…So, whenever I have that feeling, I ignore it” (age 27, postpartum). This participant believed she must put aside her negative thoughts and associated distress to prioritize feeding her baby. Collectively, participants were highly aware of potential negative impacts of their mental health symptoms on their baby’s wellbeing, and they highlighted the importance of ensuring that their babies were protected, even if it was challenging to do so.
Theme 2: Perceived Strains on Bonding with the Baby
The second main theme that emerged was strains on bonding between mother and baby, with respect to the impact of mental health symptoms on the emotional aspects of parenting. Participants discussed two specific ways in which mental health contributed to strains on emotional bonding, both during pregnancy and postpartum: (2a) via increased anger and/or (2b) through a lack of emotional connection. A third subtheme emerged that highlights one pathway that may protect against strains on emotional bonding with the baby: (2c) a strong desire to parent in a way that breaks the cycle of their own negative experiences with their parents and/or other family members.
(2a) Increased anger and irritability
Some particpants experienced increased anger due to life stressors and current mental health symptoms, which either led to predictions that bonding might be negatively affected or negatively impacted bonding postpartum. One participant described the anticipated effects of anger on her feelings towards and interactions with her baby:
I don’t think I will have a relationship with my baby because I will look at him/her with angry eyes. I think I will not cope to do anything in his/her presence; I feel I will just burst in tears (age 22, pregnant).
Not only does this participant expect that her anger will impair their bond, she also predicts that she will not be able to cope or find strength in her baby’s presence, suggesting that the baby may continue to serve as a reminder of negative emotions or previous experiences.
Similarly, another participant felt that the stress associated with her life circumstances impacted her self-perception as a parent. She explained, “When I shout at [my other daughter] I feel like beating her up, but I am avoiding that. I don’t think I am a bad parent, but I feel like I am dealing with a lot” (age 24, pregnant). This finds herself projecting her anger onto her children, which she does not want to do. She copes by rationalizing that she is a good mother who is trying to handle a number of stressors. She expressed that this process may impact her ability to form a strong, longstanding emotional connection with her baby and her other children.
(2b) Lack of emotional connection
In addition to the negative impacts of anger on bonding, some participants felt that their anhedonia would result in no connection, or a very limited connection, with their babies. Among pregnant participants, primarily, current stress or sadness fueled the sense of emotional distance. One participant shared, “I think I won’t have a bond with my baby” (age 30, pregnant), and another stated, “I won’t have a relationship with this child, I don’t think I will” (age 21, pregnant). Due to feelings of sadness, other forms of negative affect, or general negative thoughts, participants anticipated forming no bond with their baby once they were born. This lack of bonding or emotional withdrawal could then exacerbate participants’ symptoms of depression, knowing they are not able to provide the care for their baby that they would like to. One participant explained, “I am not going to feel alright because the baby has to be taken care of, and yet I would be feeling like this feeling down and not wanting to talk” (age 28, pregnant). This participant is articulating that withdrawal, a primary symptom of depression, will ultimately prevent her from properly taking care of and communicating with her baby, which would, in turn, exacerbate her sadness.
(2c) A desire to parent in a way that breaks generational cycles
Importantly, although many participants assumed that they might either have an anger-driven relationship with their baby or no emotional connection at all, some participants were more likely to highlight that they would actively seek to build stronger connections with their babies compared to the connection they had with key adult figures when they were growing up. For example, several participants expressed a desire to break the negative generational cycle of poor parenting or abuse. This manifested through expressions of resilience and optimism about raising their babies in the context of very difficult personal circumstances and poor modeling from their own families. One participant described a discussion that she had with her own mother, which helped her clarify how she will make key parenting decisions:
[My mother] said something that made me realize that I don't want to be like her. She told me since she had me when she was in high school, she said ‘I didn't even want to fall pregnant. I didn't even want you. If I had a choice, I would have terminated you, but because of my mother, meaning my grandmother I couldn't. So, I hate you, I don't like you at all’. So even if I am sad, I don’t want to end the pregnancy because I feel like my child is my world. There's no one who loves me, but I feel like this child is going to love me (age 24, pregnant).
This participant’s lack of bond with her mother, paired with the sense that she did not receive the love that she wanted and deserved, profoundly influenced how she views her relationship with her future baby. This excerpt also displays the ways in which vicarious learning from previous generations influences parenting styles; she believes that her sadness will not interfere with her own loving relationship with her baby.
Other participants also endorsed a sense of hope and a desire to be strong for their babies, primarily because they wanted to be better parents than their parents. One participant articulated, “I am going to take care and show love to my baby because I don’t want my baby to have the anger I had, because I never received love from my parents” (age 25, pregnant). This is another example of how intergenerational negative experiences can impact the relationship between the mother and new baby; the participant decided to care for and love her baby, despite her anger, so that she may provide a more supportive upbringing than she experienced. Similarly, another participant shared, “I must be strong for my baby, I don’t know how to explain this, that’s where I get hope that I should leave everything in the past and just take care of my child” (age 25, postpartum). She draws strength from remembering her own upbringing and actively choosing to be a supportive mother for her own baby. Overall, participants expressed that their mental health symptoms may strain their relationship with their babies in different ways. However, some found resilience and hope for emotional connection out of a commitment to avoid reinforcing generational patterns of parenting that left them feeling unloved.
Theme 3: Negative Impact of Mental Health on Likelihood of Completing Parenting Tasks
In the context of mental health symptoms, participants anticipated challenges completing practical parenting tasks (e.g., feeding the baby, taking the baby to medical appointments) through the following pathways: (3a) reduced ability to or decreased likelihood of completing the tasks, and (3b) an increased sense of obligation to care for and prioritize the baby above all else, including intentional efforts to put the practical parenting tasks first despite their psychological distress; and (3c) finding sources of support when overcoming mental health symptoms to caregive.
(3a) Reduced ability to or decreased likelihood of completing the tasks
Most participants expected that their ability to complete practical parenting tasks would be disrupted, given their current mental health challenges. Some participants indicated that their ability to feed their baby would be impaired. For example, one participant expressed that her milk production was previously inhibited by her stress levels: “It affects me because I can't eat when stressed, I don't produce enough milk for the baby, and I don't have the patience” (age 30, pregnant). This comment highlights the strength of the association between poor mental health and physiological challenges or complications, much like the connection linking symptoms to likely miscarriage described previously. Other participants shared that their sadness would lead them to forget to feed their babies: “I am not going to feed my baby when I am feeling sad; I might as well forget to feed her” (age 30, pregnant). Not only will mental health symptoms inhibit milk production, but symptoms will also reduce attentiveness to their baby’s needs (i.e., providing nourishment).
Several participants also shared that their mental health symptoms would inhibit their ability to leave the house and attend appointments at the antenatal clinic. As a result of previous trauma, one participant worried that another distressing event would happen when she left the house to go to the clinic: “[My sadness] does affect me because now I don’t like being around other people. When I’m around people I would fear that something bad is going to happen because of thinking too much” (age 28, pregnant). This participant expected that their symptoms of withdrawal and avoidance to inhibit their ability to attend clinic. Similarly, another participant expressed,
I’m always uncomfortable when I come to the clinic, I’m scared that they might break-in my house, when they did that it was during the day, so I am always worried… I must make sure I rush back home. That disturbs me a lot, even when I’m at the clinic I must think about what might happen (age 25, postpartum).
This participant expressed increased stress and fear upon leaving her house in the aftermath of a traumatic house break-in, describing the ways in which her posttraumatic stress symptoms may impair her ability to attend to her baby’s medical needs.
(3b) An increased sense of obligation to care for and prioritize the baby
Conversely, some participants felt a sense of obligation or sacrifice to make sure that their baby’s needs will be met. One participant shared that her mental health symptoms would negatively affect the baby if she does not prioritize the baby above all else, at all times, despite her mental health challenges: “It is going to affect the baby because I have to take care of the baby at all times and if I don’t, this is going to affect the baby negatively” (age 28, pregnant). For the wellbeing of her baby, she believed she must overcome her mental health symptoms or put them aside to focus on the baby. When asked about how her mental health symptoms may impact feeding her baby, one participant described, “I will bottle-feed my unborn baby; I breastfeed [my first child] even when I am sad” (age 26, pregnant), indicating that her parental obligation would supercede any negative impacts of her symptoms. Another participant stressed this strong sense of obligation, “There is nothing I can do. I have to think about my baby, I have to feed the baby even if I have stress, I have to take care of my baby” (age 30, pregnant). Many participants used phrases like “I love my baby” and “for the sake of my baby” to describe their responsibility to bring their baby to the clinic. For example: “I will attend the clinic appointment because I love my baby, I have to sacrifice even if I’m feeling sad” (age 30, pregnant). The love and sense of duty as a new mother acts as a driving force to overcome symptoms of depression or stress that may otherwise impair their ability to complete everyday tasks.
(3c) Finding sources of support when overcoming mental health symptoms to caregive
In some cases, the sense of personal obligation or sacrifice required to parent led to the discovery of unanticipated sources of social support in other mothers. One participant discussed the importance of taking her baby to the clinic and going against the instincts to withdraw or avoid leaving the house:
I decided to come to the clinic so that my baby can be in good health…and I have gained a lot from talking to others [at the clinic], and sometimes you might think you are the only one with the problem but that is not true, some people have worse stories than yours. Then you must just take your treatment and move on with your life (age 31, pregnant).
While attending the clinic, she experienced the benefits of interacting with others in the queue and building community. Her interactions while bringing her baby to the clinic improved her own mental status. Other participants indicated that their stress was reduced at the clinic due to the support of nurses and staff. One participant went on to say, “It is much better when I am here [at the clinic]. I adhere properly [to appointments]. I enjoyed attending, because it is much better when I am here than being at home” (age 31, postpartum); “I feel like the clinic is a good place for my baby…it’s stressless for me and stress more for the nurses because they are the ones who must find out what is happening with my baby” (age 31, pregnant). This participant explains that bringing her baby to the clinic would put her at ease, rather than cause her more stress. She felt supported by the nurses and clinic staff to help her keep her baby healthy.