Depression and Correlates of Suicidal Thoughts Among Mothers Who Are Female Sex Workers in Three Low-and Middle-Income Countries in Sub-Saharan Africa: A Cross-sectional Application of the Edinburgh Postnatal Depression Scale

Wendy L Macias-Konstantopoulos^1,2Regan Moss^2,3Brian Willis^2*

• ¹Center for Social Justice and Health Equity, Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, United States
• ²Global Health Promise, Portland, United States
• ³Social, Behavioral, Population Health Sciences, Weatherhead School of Public Health, Tulane University, New Orleans, United States

ABSTRACT Introduction: Depression is prevalent among female sex workers (FSW) in low-and middle-income countries (LMIC) and poses an elevated risk of suicide. The current study employs the Edinburgh Postnatal Depression Scale (EPDS) as a means of estimating "probable depression" and exploring correlates of suicidal thoughts in Kenyan, Nigerian, and Congolese mothers who are FSW (MFSW). Methods: This cross-sectional study surveyed a convenience sample of MFSW from eight cities in Kenya, Nigeria, and the Democratic Republic of the Congo (DRC). A sociodemographic questionnaire and the EPDS screener were administered. An EPDS cut-off score of 13 was used to define probable depression (score ≥14, 95% specificity). Descriptive statistics and thematic analysis of qualitative data volunteered by participants during the administration of the EPDS are reported. Results: Among 831 MFSW included, the mean age was 27.7 years and the majority had primary childcare responsibilities for up to 4 children. The highest mean EPDS scores were 24.6 in DRC and 23.3 among MFSW aged 18-24 years, respectively. The pooled mean EPDS score was 22.3 and the sample-based prevalence of probable depression was 96.5%. Correlates of suicidal thoughts based on participant responses pointed to themes of desperation, deprivation, isolation, marginalization, criminalization, and traumatization in daily life experiences with prominent correlates including feelings of despair, chronic food insecurity, financial insecurity, lack of work, unsafe living conditions, and traumatic experiences. Discussion: In the absence of more conventional scales for depression diagnosis and severity, the brief, low-cost, and low-resource EPDS screening tool may be useful among MFSW populations and reasonable for depression detection and referral to diagnosis and treatment. Contextual narratives volunteered in response to the EPDS self-harm question offer insights into the correlates of suicidal thoughts. This study highlights the urgent need for targeted interventions, including mental health services, social programs, policies, and legal protections, to address the mental health of MFSW in LMIC.