Mental health conditions contribute to a significant proportion of global burden of disease during adolescence and are the leading causes of disability in young people (1). According to the World Health Organization (WHO), about 50% of all mental health disorders start at age 14 and 75% by mid 20s (1) with young women facing a double risk for common mental disorders compared to males (2). Additionally, adolescent pregnancy continues to be a serious public health and social problem globally. Approximately 12 million girls aged 15–19 years give birth each year in the developing regions (3). In Ghana, 14% of adolescent girls aged 15–19 are already mothers or pregnant with their first child (4). In addition to dealing with the developmental challenges of adolescence, pregnant adolescent girls and young women (AGYW age 15-24years) also need to navigate the physiological and psychosocial implications of usually premarital and unwanted pregnancy, therefore intensifying their vulnerability to mental illnesses particularly depression (5–7).
Depression is a common mental disorder, characterized by sadness, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, feelings of tiredness, and poor concentration (8). Antenatal depression is a form of clinical depression that can affect a woman during pregnancy (9). Apart from the risk of death and other medical complications associated with adolescent pregnancy and childbirth (10), psychological complications such as depression is also of particular public health importance because of its well documented devastating impact on the mother and offspring (11, 12). Among mothers, evidence shows increased functional impairment (13), prolonged labour and other birth complications (14). In addition to low birth weight and immunization rates (15, 16), increased risk of illness (17, 18) and stunting (19), evidence shows 70% increased risks of depression in offspring of mothers exposed to perinatal depression (20). Moreover, research demonstrates that the effects of antenatal depression have longer lasting consequences among adolescents and young mothers compared to adult women (21, 22).
Even though young age has been associated with maternal depression (23, 24), adolescents have not been given much attention in perinatal mental health research particularly in low- and middle-income countries (6, 25). Available evidence from predominantly developed countries report a prevalence of depression of 16–44% among adolescent mothers, much higher than the lifetime prevalence of major depression among non-pregnant adolescents (5–20%) (26) and pregnant adult women (10%) (27). A recent comparative study conducted by Oladeji and colleagues (22) also found higher prevalence of depression among pregnant adolescents (18%) as compared to adult women (7%) in Nigeria. In Ghana, the few studies on perinatal depression have primarily involved adult women with estimates ranging from 10% (14) to 27% (28) in rural and urban regions respectively.
Furthermore, research has documented high prevalence of gender-based violence, particularly sexual violence and intimate partner violence (IPV) among adolescent girls and young women (AGWY). Globally, about 24–26% of AGYW have experienced physical IPV, sexual violence or both at least once since the age of 15. These estimates are higher in low- and middle-income countries (LMICs) than in high income countries (29). A multi-site study carried out by Decker et al. (30) found past-year IPV among ever partnered adolescents to be 33% in Ibadan, Nigeria and 37% in Johannesburg, South Africa. Estimates of violence in urban Ghana reveal that 24% of school going adolescents reported sexual violence in the last twelve months, with nearly threefold increased risk in girls than boys (31). In a qualitative study of experiences of adolescent pregnant girls in Accra, Ghana, about 20% of the girls reported physically forced sex, including coercion from people they knew and outright rape (32). Besides, evidence has also shown the effects of violence and other stressful life events on the mental health of adolescents (30, 33). Previous studies show that pregnant adolescents who have been exposed to violence and other stressful life events are at multiple risks of mental health problems, particularly depression (24, 34–36). However, facility-based research on the association between violence, other stressful life events and antenatal depression among AGYW is lacking in Ghana. Also, high social support has been found to moderate the effect of violence on mental health vulnerability among pregnant adolescents (33).
The present study tends to close this gap using facility-based data in Accra, Ghana. With only eight years left to actualize the sustainable development goals (SDGs), the impact of adolescent perinatal depression threatens the attainment of SDG 3 (Good health and wellbeing). Measuring and documenting the burden of disease and identifying young women who may be at risk for perinatal depression could help to develop measures to prevent and avert long term effects for both mother and offspring (37). On the other hand, examining the negative impact of violence on antenatal depression will draw more attention to the topic and help to implement interventions towards reducing all forms of violence against women and girls in line with the SDG 5 (Achieve gender equality and empower all women and girls).
Specifically, this study examines the association between stressful life events (including sexual violence, intimate partner violence, loss of a parent, child, or spouse, loss of job, and break-up of a steady relationship) and antenatal depression among pregnant AGYW in Accra, Ghana. The study also investigates whether perceived social support (from family, significant other, and friend) moderates the association between stressful life events and antenatal depression.