Reliability and validity of instruments for assessing perinatal depression in African settings: systematic review and meta-analysis

Alexander C Tsai, Jennifer A Scott, Kristin J Hung, Jennifer Q Zhu, Lynn T Matthews, Christina Psaros, Mark Tomlinson, Alexander C Tsai, Jennifer A Scott, Kristin J Hung, Jennifer Q Zhu, Lynn T Matthews, Christina Psaros, Mark Tomlinson

Abstract

Background: A major barrier to improving perinatal mental health in Africa is the lack of locally validated tools for identifying probable cases of perinatal depression or for measuring changes in depression symptom severity. We systematically reviewed the evidence on the reliability and validity of instruments to assess perinatal depression in African settings.

Methods and findings: Of 1,027 records identified through searching 7 electronic databases, we reviewed 126 full-text reports. We included 25 unique studies, which were disseminated in 26 journal articles and 1 doctoral dissertation. These enrolled 12,544 women living in nine different North and sub-Saharan African countries. Only three studies (12%) used instruments developed specifically for use in a given cultural setting. Most studies provided evidence of criterion-related validity (20 [80%]) or reliability (15 [60%]), while fewer studies provided evidence of construct validity, content validity, or internal structure. The Edinburgh postnatal depression scale (EPDS), assessed in 16 studies (64%), was the most frequently used instrument in our sample. Ten studies estimated the internal consistency of the EPDS (median estimated coefficient alpha, 0.84; interquartile range, 0.71-0.87). For the 14 studies that estimated sensitivity and specificity for the EPDS, we constructed 2 x 2 tables for each cut-off score. Using a bivariate random-effects model, we estimated a pooled sensitivity of 0.94 (95% confidence interval [CI], 0.68-0.99) and a pooled specificity of 0.77 (95% CI, 0.59-0.88) at a cut-off score of ≥ 9, with higher cut-off scores yielding greater specificity at the cost of lower sensitivity.

Conclusions: The EPDS can reliably and validly measure perinatal depression symptom severity or screen for probable postnatal depression in African countries, but more validation studies on other instruments are needed. In addition, more qualitative research is needed to adequately characterize local understandings of perinatal depression-like syndromes in different African contexts.

Conflict of interest statement

Competing Interests: ACT is a member of the PLoS ONE Editorial Board. MT is a member of the PLoS Medicine Editorial Board. This does not alter the authors’ adherence to all the PLOS ONE policies on sharing data and materials.

Figures

Figure 1. Quality of Reporting of Meta-Analyses…
Figure 1. Quality of Reporting of Meta-Analyses (QUORUM) flow chart depicting the number of reports screened and included in the systematic review.
Figure 2. Summary ROC curve plot of…
Figure 2. Summary ROC curve plot of diagnosis of perinatal depression based on EPDS ≥9.
The solid line depicts the summary ROC curve from the bivariate random-effects model. The solid square depicts the summary operating point, i.e., summary values for sensitivity and specificity. The dotted line depicts the 95% confidence region for the summary operating point.

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