Maternal depression, alcohol use, and transient effects of perinatal paraprofessional home visiting in South Africa: Eight-year follow-up of a cluster randomized controlled trial

Abstract

Background: South African mothers confront synergistic challenges from depression, alcohol use, and HIV/AIDS. The importance of maternal functioning for child development motivates interventions, yet long-term outcomes seldom are tracked. Furthermore, little is known about trajectories and the role of social-cultural factors in maternal depression and alcohol use across parenthood in low- and middle-income countries.

Methods: We examined maternal outcomes at 5- and 8-years' post-birth, from the Philani Intervention Program (PIP), a randomized controlled trial of a prenatally-initiated home visiting intervention lasting through 6 months' post-birth which yielded some benefits for children and mothers through 3 years. Longitudinal Bayesian mixed-effects models assessed intervention effects for maternal depression and alcohol use from pre-birth through 8 years post-birth. We plotted trajectories of depression and alcohol use and analyzed their relationship over time.

Results: Maternal benefits appeared limited and intervention outcomes differed at 5 and 8 years. Reduced depression in PIP versus standard care (SC) mothers at 3 years disappeared by 5 and 8 years. Depression prevalence declined from 35.1% prenatally to 5.5% at 8 years, independent of intervention or alcohol use. Alcohol use in both groups rebounded from a post-birth nadir; fewer PIP than SC mothers drank alcohol and reported problematic use at 5 but not 8 years. HIV+ prevalence did not differ by condition and increased from 26% to 45% over the reported period.

Conclusions: Dissipation of early child benefits from home visiting by age 8 years likely reflects lack of durable change in maternal behaviors compounded by social-cultural factors and cumulative effects of community deprivation. High prenatal rates warrant screening and treatment for depression in standard antenatal care. Low-and-middle income countries may need sustained interventions, including alcohol use reduction, to capitalize on initial gains from targeted interventions and address community social-cultural factors. HIV/AIDS continues to spread in this population.

Trial registration: ClinicalTrials.gov NCT00996528.

Keywords: Alcohol use; Community health worker; Cultural beliefs; Cultural values; HIV/AIDS; Home visiting; Maternal depression; Problematic alcohol abuse.