The results of this study suggest high prevalences of depression, anxiety, or both, in a sample of urban West-African women during the last trimester of their pregnancy. Both conditions contribute substantially to disability. In Ghana, one fourth of the women scored within the range of clinically relevant depression, while in Côte d'Ivoire, one third of the studied participants did. Although in the upper limits of the spectrum, our results are in line with the patchy data available from Africa. Sawyer et al. (2009) found a mean prevalence of antepartum depression of 11.3%, summarizing five studies from three African countries 
. Only recently, 39% of pregnant women in a South African sample were classified as depressed 
. Antepartum anxiety was assessed in two studies from Nigeria. While Esimai et al. 
reported 5.8%, Adewuya et al. 
found 39%. Our findings lend evidence to the assumption that CMD during gestation is not a culture-bound Western phenomenon 
The proportion of depressed women in both countries substantially exceeded the respective figures for anxiety. It is well recognized that the clinical presentation of depression and anxiety partly overlap, complicating discrimination between the two 
. Substantial comorbidity between antenatal anxiety and depression has been found, accounting for up to 50% of affected women 
. In our study, we chose the PHQ-9 and GAD-7 as screening instruments, which are constructed alike with respect to DSM-IV diagnostic criteria. The PHQ-9 explicitly relinquishes anxiety symptoms from its scale to address depression only, which allows exploration of two distinguished symptom sets in our subjects with no overlap between items. In Ghana, 7.7% women had both PHQ-9 and GAD-7 scores ≥10, indicative of comorbidity of depression and anxiety. In Côte d'Ivoire, this figure was 12.6%. We conclude that substantial comorbidity exists in our sample.
The significant differences in CMD prevalence between Ghanaian and Ivorian women could not be explained by differences in socioeconomic status, although Ivorian women appeared to be more disadvantaged. Thus, we can only speculate about the causes of this finding. One difference between both countries is the political situation. While Ghana remained stable for almost two decades, Côte d'Ivoire was exposed to severe political unrest and warfare between 2002 and 2007, and again 6 months after we started recruitment. This ongoing threat may have led to increased mental distress, reducing the impact of socioeconomic risks. Pervasive high prevalences of CMD have been widely documented in people afflicted by war 
The WHO defines disability as “the negative aspects of the interaction between an individual and that individuaĺs contextual factors” 
, shifting focus from cause to impact of any health impairment. We explored whether psychological distress in pregnant African women was related to disability. The WHO-DAS 2.0 aims at identifying individual activity and participation restrictions. It may be used to compare group differences within countries but care is recommended when interpreting cross-national differences 
. There is no agreed cut-point for identifying persons with substantial disability, and norms for Ghanaian or Ivorian pregnant women have not yet been established. Nonetheless, the multinational World Mental Health Survey reported that most respondents in large population samples had zero scores in each domain of the WHO-DAS 2.0 scale 
. In an Australian population based survey, subjects scoring >10 on the 12-item version scale (scores 0–48) were in the top 10% of the population distribution of scores, and were likely to have clinically significant disability. The mean WHO-DAS 2.0 score for people with a common mental disorder was 6.3 (SD
7.1). In a subgroup with a mental but no physical disorder the disability score was M
Late pregnancy itself may be a burdensome condition, and we expected some degree of disability in the third trimester. Women who were classified as not depressed and not anxious (n
658) had a mean score of 10.0 (SD
6.08) on the WHO-DAS 2.0 disability scale. Mean score increases in women with depression, anxiety, or both were about 6, 3.5, and 9.5, respectively. Older women appeared to have higher disability score increases as compared to younger women. Increasing disability with age has been reported before 
. We can only speculate that physical strain due to late pregnancy may have accounted for the high “background disability” in our sample. Increases above this background disability result in high disability scores in women with CMD, but these increases, though not the absolute values are somewhat in line with the Australian data 
. Comorbidity of depression and anxiety, on average, doubled disability scores.
Depression and anxiety were clearly associated with high disability scores. Affected women did not only experience psychological distress, but also felt substantially disabled by their symptoms. Global data demonstrating depression to be a leading cause of disability 
are reflected in our sample.
Worldwide, Africa has the highest proportion of people living in extreme poverty, which highly correlates with CMD 
. We found some indication of SES being associated with depression and anxiety but effect sizes were small. This may indicate a relative socio-economic homogeneity of our sample. SES per se did not contribute to disability. A similar pattern has been reported in a different population from Korea 
Severe pregnancy complications are common in sub-Saharan Africa, and according to a recent meta-analysis, the incidence/prevalence ratio and case-fatality ratio for maternal near misses ranged from 1.1%–10.1% and 3.1%–37.4%, respectively 
. In our study sites, the general percentage of women undergoing Caesarean sections was around 25% in both hospitals (S.B. Nguah, personal communication). Thus, the number of complications during previous pregnancies in our sample appears to reflect collective norm. Somewhat unexpected, there was no association between physical health factors (e.g., weight, blood pressure, hemoglobin level) and CMD or disability in our subjects. Pregnancy complications not leading to study exclusion and Caesarean sections in previous pregnancies were also not associated with disability. The strongest predictor of disability was depression.
We conclude that CMD, primarily depression, strongly impact on disability during pregnancy in our study population. This finding is worrying as are the high prevalences of antepartum CMD. CMD during pregnancy predicts maternal CMD throughout the first year postpartum 
, which in turn may impact on duration of breastfeeding, infant growth, morbidity, and child cognitive and behavioural development 
. CMD not only affect the woman, but also her unborn child. Various studies report negative effects of maternal depression and anxiety on the course of pregnancy and birth outcome due to poor antenatal care, complication of labour, preterm delivery, fetal growth restriction, and low Apgar scores 
, which are more pronounced among deprived social groups and in poor countries 
. Consequences for the course of pregnancy, birth outcome and maternal and child health in our cohort have yet to be investigated.
Strengths and limitations
This is the first study to examine depression, anxiety, disability and their correlates using screening instruments in a large sample of Ghanaian and Ivorian pregnant women. The cross-sectional nature of the study does not allow for causal inference. The sample was systematically recruited, refusal rates were low, and the instruments were applied by local mental health professionals. Yet, information bias may occur when using imperfect tests like the PHQ-9 and the GAD-7. Our main outcome the WHO-DAS 2.0, however, is self-reported. The structure of the samples, being pregnant women who attended hospital prenatal care, raises the possibility of selection bias. Our sample also appears to be rather homogeneous with regard to SES.
A difficulty faced when measuring antenatal depression or anxiety is that somatic symptoms related to pregnancy itself may lead to misclassification. Yet, our sample was restricted to women without severe pregnancy complications. The GAD-7 explicitly removes somatic symptoms, while the PHQ-9 emphasizes on emotional and cognitive symptoms, but assesses functional somatic symptoms, which have been found typical presentations of depression in African people 
Established measures to screen for anxiety in antepartum populations do not exist 
. Because anxiety is probably common but rarely investigated in Africa 
, we decided to use the GAD-7, which proved suitable in primary care settings. The effect of the armed conflict in Côte d'Ivoire during the study period is difficult to assess. Post-conflict mean raw sores for the PHQ-9, GAD-7, and WHODAS 2.0 were slightly lower as compared to pre-conflict scores. Possibly, societal conflicts that precede armed conflicts affect a population long-term and this is reflected by our measures of depression, anxiety and disability.
Implications for further research
Intensive research and clinical efforts need to be directed towards recognizing and understanding antepartum mental distress and disability. Paving the way to develop effective interventions that are suitable for integration into primary healthcare in LMICs is paramount.