Advertisement
Browse Subject Areas
?

Click through the PLOS taxonomy to find articles in your field.

For more information about PLOS Subject Areas, click here.

  • Loading metrics

Open Access

Study Protocol

Mental health problems in pregnant and postpartum women living with HIV in sub-Saharan Africa: Systematic review and meta-analysis protocol

  • Anthony Danso-Appiah ,

    Roles Conceptualization, Investigation, Methodology, Resources, Validation, Writing – original draft, Writing – review & editing

    adanso-appiah@ug.edu.gh, tdappiah@yahoo.co.uk

    Affiliations Centre for Evidence Synthesis and Policy, University of Ghana, Legon, Accra, Ghana, Department of Epidemiology and Disease Control, School of Public Health, University of Ghana, Legon, Accra, Ghana, Africa Communities of Evidence Synthesis and Translation (ACEST), Accra, Ghana

    ⨯
  • Kwadwo Owusu Akuffo,

    Roles Resources, Validation, Writing – review & editing

    Affiliation Department of Optometry and Visual Science, College of Science, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana

    ⨯
  • David Owiredu

    Roles Investigation, Resources, Validation, Writing – original draft, Writing – review & editing

    Affiliations Centre for Evidence Synthesis and Policy, University of Ghana, Legon, Accra, Ghana, Department of Epidemiology and Disease Control, School of Public Health, University of Ghana, Legon, Accra, Ghana

    ⨯

Abstract

Background

Existing evidence on the burden of mental health problems among pregnant and postpartum women living with HIV, a vulnerable population in sub-Saharan Africa (SSA), is limited and fragmented, affecting the development of context-sensitive and integrated interventions. This systematic review aims to provide an up-to-date and comprehensive synthesis of available evidence to estimate the burden and identify the determinants of mental health problems among pregnant and postpartum women living with HIV across countries in sub-Saharan Africa.

Methods

We will retrieve all relevant studies (published and unpublished) through searches in PubMed, Embase, PsycINFO, CINAHL, LILACS, Google Scholar, Scopus and Web of Science from inception to 30th June 2024, without language restriction. We will use the following search terms ‘mental health disorder’, ‘mental health problem’, ‘pregnant women’, ‘postpartum women’ and ‘HIV’ nested with all applicable alternate terms and the names of countries in SSA for running the searches. We will also search HINARI, African Index Medicus, African Journals Online, Academic Search Premier, medRxiv, ProQuest, EBSCO Open Dissertations, and reference lists of relevant studies. We will contact experts in the field for potentially relevant unpublished studies. All retrieved articles from the electronic databases and grey literature will be collated and deduplicated using Endnote and exported to Rayyan QCRI. Two reviewers will independently select studies using a pretested study selection flow chart developed from the pre-specified eligibility criteria. Two reviewers will extract data using a pretested data extraction form and assess the risk of bias in the included studies using the risk of bias tool for prevalence studies by Hoy et al. (2012). Any disagreements will be resolved through discussion between the reviewers. Binary outcomes (prevalence and incidence of mental health problems among pregnant and postpartum women living with HIV) will be evaluated using pooled proportions (for non-comparative studies) and odds ratio (OR) or risk ratio (RR) (for comparative studies), and mean difference for continuous outcomes, all will be reported with their 95% confidence intervals (CIs). Heterogeneity will be assessed graphically for overlapping CIs and statistically using the I2 statistic. If substantial heterogeneity is found, random-effects model meta-analysis will be performed; otherwise, fixed-effect meta-analysis will be employed. We will conduct subgroup analysis (to assess the impact of heterogeneity) and sensitivity analyses to test the robustness of the generated effect estimates to the quality domains. The overall level of evidence will be assessed using GRADE (Grading of Recommendations, Assessment, Development, and Evaluations).

Expected outcomes

The review is expected to produce an up-to-date and comprehensive synthesis of the available evidence, allowing for the generation of country-specific estimates of the burden of mental health problems among mothers living with HIV across SSA populations. Also, the review will attempt to identify the determinants of mental health problems among pregnant and postpartum women living with HIV, to shed light on the factors that contribute to the occurrence of mental health problems in this vulnerable population.

Systematic review registration

The systematic review protocol has been registered in the International Prospective Register for Systematic Reviews (PROSPERO), with registration ID CRD42023468537.

Citation: Danso-Appiah A, Akuffo KO, Owiredu D (2024) Mental health problems in pregnant and postpartum women living with HIV in sub-Saharan Africa: Systematic review and meta-analysis protocol. PLoS ONE 19(10): e0308810. https://doi.org/10.1371/journal.pone.0308810

Editor: Rogie Royce Carandang, University of Connecticut Health Center: UConn Health, UNITED STATES OF AMERICA

Received: February 23, 2024; Accepted: July 30, 2024; Published: October 3, 2024

Copyright: © 2024 Danso-Appiah et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: No datasets were generated or analysed during the current study. All relevant data from this study will be made available upon study completion.

Funding: The author(s) received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Background

Mental health problems in pregnant and postpartum women are increasingly gaining attention worldwide due to their impact on the well-being of the mother, foetus and infant, as well as families and communities [1, 2]. Globally, mental health disorders affect a high proportion of women during pregnancy and in the postpartum period [3–6]. Approximately, 10% of pregnant women and 13% of postpartum women experience one of the common mental disorders [1], primarily due to their physiological and hormonal changes [5, 7]. Human Immunodeficiency virus (HIV) infection disproportionately affects women [8–10], with pregnant and postpartum women being at a higher risk due to immune and hormonal alterations and shifts in the vaginal microbiome [11, 12].

Mental health problems among pregnant and postpartum women are responsible for increased morbidity and mortality among childbearing women worldwide, with stark disparities between high-income countries (HICs), low and middle-income countries (LMICs) and SSA [13–15]. For example, in the United States of America, the United Kingdom, and mainland Europe, approximately 1 in 5 (20%) of women reportedly experience a mental health problem during pregnancy and the postpartum period [16, 17]. Systematic reviews focusing on individual countries [18, 19] or regional [20, 21] and global contexts [22] have all consistently reported similar findings. The proportions of maternal mental health problems are higher for LMICs and SSA [14, 23–25], with some studies reporting rates as high as 39% for pregnant women [26] and 50% for postpartum women [27]. It has been suggested that limited access to healthcare services [23, 28, 29], poverty [30, 31], gender inequality [1, 31, 32], and conflicts [13, 14, 33, 34] are key factors affecting maternal mental health problems, whereas stigma [34, 35] and lack of awareness of mental health issues [6, 36] hinder proper care for mental health issues in SSA [37, 38]. Teenage pregnancy, which is associated with poor psychosocial support and an increased risk of depression if not detected early and treated, disproportionately affects teenage girls living in SSA [39, 40].

Globally, HIV continues to pose a significant public health threat, with women accounting for a high proportion of those affected [8]. Compared to other global sub-regions, SSA has the highest burden of HIV infections, accounting for over 66% of the global estimate in 2022 [8]. In that same year, 63% of all new HIV infections in the sub-region occurred in women and girls [8]. Similar to mental health problems, the high proportion of HIV cases in SSA has been attributed to poverty [41–43], gender inequality [8, 44], cultural practices [45, 46], low literacy levels, and inadequate access to healthcare services [43, 47], among others. Worryingly, an estimated 1.3 million women and young girls living with HIV become pregnant annually [9], further putting them at risk of a host of health problems, including those that affect their psychological well-being.

Mental health problems in pregnant and postpartum women living with HIV present complex challenges to the general well-being, care, and health outcomes of both the mother and baby [48–51]. The introduction of antiretroviral therapy (ART) has resulted in a reduction in viral load, HIV-related morbidities, and mortalities [52], and increasingly, more women living with HIV in childbearing age are seeking to become pregnant [53, 54]. However, pregnant and postpartum women living with HIV usually face a unique set of stressors and vulnerabilities [51], including heightened levels of anxiety [7], depression [55], and emotional distress [56] that may stem from their awareness of the risk of transmission of the infection to the foetus during pregnancy or the infant through breastfeeding [57]. HIV-associated stigmatisation may also further exacerbate the already compromised mental state of pregnant and postpartum women living with HIV [55–59]. On the other hand, the presence of maternal mental health problems may impact adherence to ART [60] and participation in prenatal and postnatal care [58, 61].

Rationale for this systematic review

Despite the reportedly high burden of mental health problems in pregnant and postpartum women living with HIV in SSA [1, 8, 14, 15], no systematic review has comprehensively generated robust country-specific estimates of the burden, risk factors, quality of life, interventions, and pregnancy outcomes related to mental health problems in this vulnerable population [14, 15, 62, 63]. This knowledge gap hinders the development of targeted and evidence-based interventions to address the mental health needs of this vulnerable population living with HIV. Existing systematic reviews of mental health problems usually focus on the general population and are often restricted to selected conditions, mainly depression and anxiety [64–67]. From comprehensive searches conducted as part of the preparation of this protocol, no systematic review of mental health problems among pregnant and postpartum women living with HIV in SSA exists. The only systematic review that sought to collate evidence on common mental health disorders among adolescents living with HIV in SSA [15] involved just one study [68] that met their inclusion criteria, suggesting a serious dearth of literature and evidence. Another systematic review investigating evidence on perinatal depression in HIV-infected African women conducted over a decade ago in 2014 [69], is not only outdated but concentrated on depression. A scoping review investigated the general experiences of adolescent mothers affected by HIV (not necessarily having HIV themselves) and their children but the focus was not mental health [70]. The present review seeks to provide an up-to-date and comprehensive synthesis of the available evidence, estimate country-specific burden and determinants of mental health problems among pregnant and postpartum women living with HIV, and assess the maternal and foetal birth outcomes among this vulnerable population across countries in SSA.

By collating evidence on mental health problems in this key population living with HIV, the review will contribute to promoting good health and wellbeing, a central objective of Sustainable Development Goal Three (SDG 3); by addressing sub-targets 3.1, 3.3, 3.4, and 3.5—to reduce maternal mortality and non-communicable diseases, and promote the general mental wellbeing. In addition, the review acknowledges the unique challenges faced by women living with HIV, highlighting the intersection of gender inequality and mental health. By targeting these issues, it lends to SDG 5- Gender equality and contributes to the promotion of gender equality and empowerment of women in the SSA region.

Methods

The current review protocol has been prepared following the Preferred Reporting Items for Systematic Review and Meta-Analysis extension for protocols (PRISMA-P) checklist [71] (S1 Table) and as the full review report will be guided by the PRISMA checklist [72]. We have also followed the guidance specified in the Cochrane Handbook [73] and methods reported in earlier works [74–83] and used the PECOS framework to describe the Population, Exposure, Comparator, Outcomes, and Study types. The databases and other sources searched, and the flow of studies will be reported using the PRISMA Flow Diagram [72] (S1 Fig).

Patient and public involvement

The review questions and outcomes to be assessed have been developed collaboratively with patients and public involvement, and informed by their priorities, experiences and preferences in line with GRIPP2 reporting checklists [84]. The review findings will be shared with relevant patient communities who will also be involved in the dissemination of the results.

Ethical considerations and dissemination

This is secondary research based on published studies or publicly available data. Therefore, no ethical approval is required. However, an eligible study with serious ethical issues will be excluded, and the reasons for exclusion documented. Study findings will be presented at conferences, and copies will be shared with relevant stakeholders, health authorities, and agencies involved in the mental health of mothers who are living with HIV. The final review report will be in the form of a scientific paper for submission for publication in a high-impact factor peer-reviewed journal.

Criteria for including studies for this review

Type of studies.

Any study (cohort, case-control, and cross-sectional design) conducted in a country in sub-Saharan Africa that assessed maternal mental health conditions in pregnant and postpartum women living with HIV will be eligible for inclusion. Randomized controlled trials (RCTs) reporting baseline prevalence of maternal mental health disorders in a well-defined sample of pregnant or postpartum women living with HIV will be considered for inclusion. Literature reviews, scoping reviews, and systematic reviews will not be included. However, the list of included/reviewed studies (especially from any retrieved global systematic review on the subject) will be perused for sub-Saharan African studies for inclusion in this review. Case studies, case series (are atypical and do not represent the source population), opinions, commentaries, and editorial letters will be excluded.

Population.

Pregnant and postpartum women living with a confirmed diagnosis of HIV and mental health conditions, including anxiety disorder, depression, psychosis, schizophrenia, suicidal ideation, paranoia, substance use disorder, Obsessive Compulsive Disorder, Posttraumatic Stress Disorder, Self-harm, etc., will be eligible for inclusion in the review. The tool or criteria used for diagnosing HIV (ELIZA, PCR, etc.) and/or mental health conditions such as the Diagnostic Statistical Manual of Mental Disorders (DSM-V) [85], the Depression, Anxiety and Stress Scale-21 Items (DASS-21) [86], the Edinburgh Postnatal Depression Scale (EPDS) [87] and Self Reporting Questionnaire-20 items (SRQ-20) [88] must be reported or documented. The tools for diagnosing the HIV infection as specified in the exposure should be documented. Pregnant or postpartum women living with HIV whose diagnosis of a mental health disorder could not be confirmed will be excluded. The study should involve participants resident in any of the sub-Saharan African countries to be eligible for inclusion. Studies involving sub-Saharan African nationals living outside SSA will be excluded.

Exposure.

A clinically confirmed (and documented) diagnosis of HIV using any standard testing algorithms, including initial screening with, for example, the enzyme-linked immunosorbent assay (ELISA) [89] and confirmed by polymerase chain reaction (PCR) [90]. All confirmed cases will be considered eligible participants (exposed) irrespective of the stage of HIV infection (whether acute or chronic HIV or acquired immunodeficiency syndrome (AIDS)).

Comparators.

This is not a comparative review, but where necessary, subgroup comparisons will be made.

Outcomes.

Primary outcomes.

  1. Prevalence and incidence of mental health disorders among pregnant and postpartum women living with HIV in SSA
  2. Birth outcomes (such as livebirths, stillbirths, preterm births, low birth weight, obstetric complications) of HIV-positive women with mental health disorders

Secondary outcomes.

  1. Sociodemographic determinants of mental health disorders in pregnant and postpartum women living with HIV in SSA
  2. Mental health predisposition of pregnant and postpartum women living with HIV
  3. Obstetric predisposition of pregnant and postpartum women living with HIV having mental health problems
  4. Medical predisposition of pregnant and postpartum women living with HIV to having mental health problems

Search methods for identification of studies

Electronic databases.

We will retrieve all relevant studies (published and unpublished) through searches in PubMed, Embase, PsycINFO, CINAHL, LILACS, Google Scholar, Scopus and Web of Science from inception to 30th June 2024, without language restriction. We will use the following search terms: ‘mental health disorder,’ ‘mental health problem’ ‘pregnant women,’ ‘postpartum women,’ and ‘HIV’ nested with all applicable alternate terms and the names of countries in SSA for running the searches (see Table 1 for further details) to give a comprehensive search strategy. The names of all the 48 countries in sub-Saharan Africa (according to the World Bank records) [91] will also be added as alternative search terms. The searches will be extended to HINARI, African Index Medicus, African Journals Online, Academic Search Premier, preprint databases (for example, medRxiv), grey literature sources (including conference proceedings) and dissertation/theses (ProQuest and EBSCO Open Dissertations), and specialised data repositories. A detailed search strategy developed for PubMed will be adapted for the searches in the other databases.

thumbnail
Download:
Table 1. Search strategy developed for PubMed, to be adapted for the other databases.

https://doi.org/10.1371/journal.pone.0308810.t001

Other sources.

The reference lists of all relevant studies (including systematic, scoping, and literature reviews) will be hand-searched to identify potentially relevant studies. For global systematic reviews where sub-Saharan Africa has been considered a subgroup, the included studies will be reviewed, and those missed by our searches will be retrieved for assessment and inclusion. Experts in the field will also be contacted via the most appropriate means (emails, WhatsApp, etc.) for any knowledge about potentially relevant publications missed by our searches and unpublished studies.

Screening and selection of studies

All the articles retrieved from the searches will be collated and deduplicated using EndNote. The deduplicated studies will then be exported to Rayyan (a web-based systematic review application) [92], where studies will be screened and selected. Two reviewers (DO and KOA) will independently screen studies using a study selection flow chart developed from the pre-specified eligibility criteria for considering studies for inclusion in the review (Fig 1), using a two-phase approach. First, the titles and abstracts of all retrieved studies will be screened to exclude apparent irrelevant studies using the pretested study selection flow chart. In the second phase, full texts of potentially relevant studies will be retrieved and subjected to further screening, and those that meet the inclusion criteria will be selected for inclusion in the review. Conflicts will be resolved through discussion between the reviewers. The study selection process and the respective decisions for inclusion and exclusion of studies will be summarised and presented using the PRISMA flow diagram (S1 Fig) [93]. All studies excluded at the full-text stage will be listed in a table, and the reason(s) for the exclusion provided.

thumbnail
Download:
Fig 1. Study selection flow chart developed from the pre-defined eligibility criteria.

https://doi.org/10.1371/journal.pone.0308810.g001

Data extraction and management

Relevant data from the included studies will be extracted independently by at least two reviewers (ADA, DO and KOA) and transferred to a Microsoft Excel [94] spreadsheet. The extraction process will be pretested using randomly selected studies to ensure consistency between data extractors. Study characteristics, such as the year of publication (for published studies), year study was conducted, the country where the study was conducted, study design, type of participants (pregnant and postpartum women), sample size; sociodemographic characteristics (age of participants, level of education, residence (rural or urban), occupation, occupation, employment status etc.); obstetric characteristics (parity, gravidity, age of first delivery, history of obstetric events such as miscarriage and stillbirth); and other clinical characteristics (such as HIV viral load counts, viral suppression status, ART enrolment status and the presence of other co-morbid conditions) will be extracted. Data on mental health conditions and diagnostic tools used will also be extracted from each included study. In studies where the primary estimates are not reported and do not have the minimum information to calculate the relevant estimates, the authors will be contacted directly via email, WhatsApp or phone call, where feasible, to provide the required information. In situations where it is not possible to obtain the missing data from the primary authors and the amount and reasons for the missing data will be reported. If the data from multinational studies have been lumped together, we will attempt to disaggregate the data by country. Where it is impossible to do disaggregate the data, such studies will be presented as one, accompanied with citations of the included countries. The extracted data will be verified independently, and any conflict will be resolved through discussion.

Assessment of quality of the included studies

The Risk of Bias Tool for Prevalence Studies [95] (S2 Table) will be used to evaluate the quality of the included observational studies for risk of bias on participant selection, non-response, and bias arising from measurement and data analysis methods. A determination of “low risk” of bias, “high risk” of bias, or “unclear” bias will be made for each bias domain accompanied by the assessor’s supporting information. The risk of bias assessment will be carried out by one reviewer (DO) and independently verified by ADA. Any disagreement will be resolved through discussions between the assessors.

Data analysis

The cleaned data will be analysed with Review Manager (RevMan)-Version 7.2.0) [96] for the data analysis, and where necessary, analyse some of the data in Stata-Version 15 [97]. Binary outcomes will be analysed and presented as odds ratio (OR) or risk ratio (RR), and for continuous data, we will employ mean difference (MD) or standardized mean difference (SMD) where different scales have been used. To compute the weighted average of the prevalence or incidence of maternal mental health disorders across studies, meta-analyses will be conducted to distil evidence at the highest possible level. The individual study’s OR, RR, and MD will be pooled and presented along with their corresponding 95% confidence intervals (CI). In instances of high heterogeneity among studies, we will adopt a random-effects model for the meta-analysis; otherwise, a fixed-effect model will be used. Additionally, descriptive statistics will be used to present proportions. Forest plots will be used to demonstrate the summary estimates with their CIs and weighted contributions to the pooled estimate. For trend-related outcomes, Bayesian analysis will be conducted through the use of meta-regression to summarize the effect estimates.

Assessment of heterogeneity and subgroup analyses

Heterogeneity will be assessed visually by inspecting overlaying CIs of the forest plots and outlying data and quantitatively using the I2 statistic. The variations in the studies included in the meta-analysis will be assessed by the I2-statistic, a measure of variation across studies due to heterogeneity rather than chance [98]. The I2 values will be classified as ≤ 25% (low), 50% (moderate), 75% (high), and ≥ 75% (significant) heterogeneity [99]. Where significant heterogeneity is detected, a subgroup analysis will be performed to detect the possible sources of variation, for example, study design, study setting, type of mental health disorder, parity, HIV viral suppression status, and geographic location (Central, Eastern, Southern and Western Africa).

Sensitivity analyses

Sensitivity analyses [100] will be performed to assess the impact of outliers in the included studies, particularly on the quality domains (for example, studies with large sample sizes, high prevalence or incidences, very precise confidence intervals, or very high risk of bias of any of the quality domains) on the resultant estimates. Meta-analyses will be performed, first with and then without such studies, to assess the robustness of the effect estimates. The impact of missing data and unpublished studies will also be adequately evaluated in sensitivity analysis to test the robustness of the pooled estimates.

Dealing with missing data

The pattern of missing data and the potential impact on the study findings and conclusions, as well as the reasons for the missing data will be explored. We will not employ imputation as a means of addressing missing data, but instead, we will contact primary study authors and ask for the missing data or, where possible, ask for the raw data to enable us to extract the missing information.

Assessing the certainty of evidence using GRADE

The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach [101] will be used to assess the overall quality or certainty of the evidence (how certain the authors are that the effect estimate represents the true effect) on the key outcomes provided by the included studies. Two reviewers (ADA and DO) will assess the certainty of evidence (quality of evidence or the confidence in the effect estimates) from the following five domains: risk of bias, inconsistency, indirectness, imprecision, or publication bias. The certainty of evidence will be graded as high, moderate, low, or very low. The certainty of evidence can be rated down by one or two levels when there are serious or very serious concerns, respectively, in any of the domains [101, 102]. The certainty of evidence upward for high-quality observational studies, although this is usually rarely done [102, 103]. An overall rating of the certainty of the evidence for each outcome will be presented in a summary of findings table together with the study types, the number of studies and participants, and the relative and absolute effects for each outcome [103].

Discussion

This systematic review and meta-analysis protocol is driven by the urgent need to address the notable gap in the literature regarding mental health problems among pregnant and postpartum women living with HIV in sub-Saharan Africa. Despite the increasing recognition of the intersection between mental health, HIV/AIDS, and maternal health, comprehensive evidence on the prevalence, determinants, interventions, and outcomes related to mental health issues in this vulnerable population remains deficient. This protocol aims to address this void by providing a detailed plan for synthesizing existing data and generating unbiased evidence regarding mental health problems among pregnant and postpartum women living with HIV in SSA.

In this systematic review and meta-analysis protocol, a detailed plan of all the steps of the review, including eligibility criteria, information sources, search strategy, study selection, data extraction, quality assessment, and data synthesis, has been described. This meticulous approach ensures errors and biases are minimised. By adhering to rigorous methodology and transparent reporting practices, we aim to provide reliable findings on the incidence, prevalence, determinants, and outcomes of mental health problems in this vulnerable population. Ultimately, the knowledge obtained from this review will serve as a valuable resource for clinicians, policymakers, and researchers working to improve the mental health and overall well-being of pregnant and postpartum women living with HIV in sub-Saharan Africa.

Strengths and limitations

This systematic review and meta-analysis will attempt to collate and distil empirical evidence at the highest level using explicit, transparent, and reproducible methods to answer the review question, ensuring strict adherence to evidence synthesis best practices. The process will involve a comprehensive search strategy operationalized on multiple databases and non-database sources to attempt to retrieve all potentially relevant studies. The selection of studies, data extraction, and assessment of quality of the included studies will be guided by validated or piloted instruments. It will be done in duplicates to minimize errors and biases. We will run updated searches until the final analyses start. A key limitation could be the inability to access complete data from some relevant studies, particularly very old studies, given that we have not placed any restrictions on the year was conducted or published. However, this is not expected to influence the magnitude and direction of the effect estimates since it is anticipated that the large number of studies will meet the inclusion criteria. Furthermore, completeness, validity, and reliability of the evidence generated are not expected to be severe issues given the rigorous methods and the review process itself employed, which will be guided by best practices.

Implications of the anticipated review findings

The findings of this review will support the development of targeted interventions and policies aimed at addressing the underlying drivers of poor mental health outcomes among pregnant and postpartum women living with HIV. Our study protocol anticipates highlighting the evidence on the impact of mental health problems on maternal and foetal outcomes among pregnant women living with HIV in sub-Saharan Africa. By synthesising data on outcomes such as maternal mortality, infant mortality, and perinatal complications among pregnant and postpartum women living with HIV, we aim to elucidate the downstream consequences of untreated mental health issues in this population. This understanding is essential for informing clinical practice and public health interventions aimed at improving maternal and foetal health outcomes in the context of HIV/AIDS.

Supporting information

S1 Fig. PRISMA 2020 flow diagram for new systematic reviews which included searches of databases, registers and other sources.

https://doi.org/10.1371/journal.pone.0308810.s001

(TIF)

S1 Table. PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) 2015 checklist: Recommended items to address in a systematic review protocol.

https://doi.org/10.1371/journal.pone.0308810.s002

(DOCX)

S2 Table. Quality assessment checklist for prevalence studies (adapted from Hoy et al. 2012).

https://doi.org/10.1371/journal.pone.0308810.s003

(DOCX)

Acknowledgments

This systematic review was prepared as part of the capacity-building initiative by the Centre for Evidence Synthesis and Policy (University of Ghana) and the Africa Communities of Evidence Synthesis and Translation (ACEST), Accra, that train promising scientists, health professionals, and policymakers in evidence-based medicine, evidence synthesis, and translation into evidence-based practice and policy for improving patient outcomes across Africa and other Low and Middle-Income Countries.

References

  1. 1. World Health Organization (WHO). Mental Health and Substance Use. https://www.who.int/teams/mental-health-and-substance-use/overview
    • 2. Fatin FN, Fitriana F, Hardianto G. Intervention for Reducing Maternal Mental Health Problems in The Golden Period: Systematic Review. PLACENTUM J Ilm Kesehat dan Apl. 2022;10: 196.
    • 3. Hazell Raine K, Nath S, Howard LM, Cockshaw W, Boyce P, Sawyer E, et al. Associations between prenatal maternal mental health indices and mother—infant relationship quality 6 to 18 months’ postpartum: A systematic review. Infant Ment Health J. 2020;41: 24–39. pmid:31524300
    • 4. Smith MS, Lawrence V, Sadler E, Easter A. Barriers to accessing mental health services for women with perinatal mental illness: Systematic review and meta-synthesis of qualitative studies in the UK. BMJ Open. 2019;9. pmid:30679296
    • 5. Chauhan A, Potdar J. Maternal Mental Health During Pregnancy: A Critical Review. Cureus. 2022. pmid:36426343
    • 6. Fatori D, Zuccolo PF, Polanczyk G V. A global challenge: maternal depression and offspring mental disorders. Eur Child Adolesc Psychiatry. 2020;29: 569–571. pmid:32385696
    • 7. Biaggi A, Conroy S, Pawlby S, Pariante CM. Identifying the women at risk of antenatal anxiety and depression: A systematic review. J Affect Disord. 2016;191: 62–77. pmid:26650969
    • 8. UNAIDS. Global HIV & AIDS statistics—Fact sheet | UNAIDS. 2023. https://www.unaids.org/en/resources/fact-sheet
      • 9. World Health Organization (WHO). Global HIV Programme. 2023.
        • 10. Ramjee G, Daniels B. Women and HIV in Sub-Saharan Africa. AIDS Res Ther. 2013;10. pmid:24330537
        • 11. Thomson KA, Hughes J, Baeten JM, John-Stewart G, Celum C, Cohen CR, et al. Increased Risk of HIV Acquisition among Women Throughout Pregnancy and during the Postpartum Period: A Prospective Per-Coital-Act Analysis among Women with HIV-Infected Partners. J Infect Dis. 2018;218: 16–25. pmid:29514254
        • 12. Machekano R, Tiam A, Kassaye S, Tukei V, Gill M, Mohai F, et al. HIV incidence among pregnant and postpartum women in a high prevalence setting. PLoS One. 2018;13. pmid:30592749
        • 13. Lasater ME, Beebe M, Gresh A, Blomberg K, Warren N. Addressing the Unmet Need for Maternal Mental Health Services in Low- and Middle-Income Countries: Integrating Mental Health Into Maternal Health Care. J Midwifery Women’s Heal. 2017;62: 657–660. pmid:29149521
        • 14. Mutahi J, Larsen A, Cuijpers P, Peterson SS, Unutzer J, McKay M, et al. Mental health problems and service gaps experienced by pregnant adolescents and young women in Sub-Saharan Africa: A systematic review. eClinicalMedicine. 2022;44: 101289. pmid:35198916
        • 15. Roberts KJ, Smith C, Cluver L, Toska E, Sherr L. Understanding Mental Health in the Context of Adolescent Pregnancy and HIV in Sub-Saharan Africa: A Systematic Review Identifying a Critical Evidence Gap. AIDS Behav. 2021;25: 2094–2107. pmid:33452658
        • 16. Royal College of Obstetricians & Gynaecologists. Maternal mental health—women’s voices. https://www.rcog.org.uk/for-the-public/rcog-engagement-listening-to-patients/maternal-mental-health-womens-voices/
          • 17. Brown CC, Adams CE, George KE, Moore JE. Mental Health Conditions Increase Severe Maternal Morbidity By 50 Percent And Cost $102 Million Yearly In The United States. Health Aff. 2021;40: 1575–1584. pmid:34606352
          • 18. Duko B, Wolde D, Alemayehu Y. The epidemiology of postnatal depression in Ethiopia: a systematic review and meta-analysis. Reprod Health. 2020;17. pmid:33213434
          • 19. Kalra H, Tran TD, Romero L, Chandra P, Fisher J. Prevalence and determinants of antenatal common mental disorders among women in India: a systematic review and meta-analysis. Arch Womens Ment Health. 2021;24: 29–53. pmid:32055988
          • 20. Prabhu S, George LS, Shyamala G, Noronha JA, Hebbar S. Prevalence and associated risk factors of postnatal depression in south asian region—a systematic review. Indian J Public Heal Res Dev. 2019;10: 329–333.
          • 21. Dadi AF, Wolde HF, Baraki AG, Akalu TY. Epidemiology of antenatal depression in Africa: a systematic review and meta-analysis. BMC Pregnancy Childbirth. 2020;20: 251. pmid:32345263
          • 22. Jha S, Salve HR, Goswami K, Sagar R, Kant S. Burden of common mental disorders among pregnant women: A systematic review. Asian J Psychiatr. 2018;36: 46–53. pmid:29966886
          • 23. Baron EC, Hanlon C, Mall S, Honikman S, Breuer E, Kathree T, et al. Maternal mental health in primary care in five low- and middle-income countries: a situational analysis. BMC Health Serv Res. 2016;16: 53. pmid:26880075
          • 24. Fellmeth G, Fazel M, Plugge E. Migration and perinatal mental health in women from low- and middle-income countries: a systematic review and meta-analysis. BJOG An Int J Obstet Gynaecol. 2017;124: 742–752. pmid:27320110
          • 25. Fisher J, de Mello MC, Patel V, Rahman A, Tran T, Holton S, et al. Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: A systematic review. Bull World Health Organ. 2012;90: 139–149. pmid:22423165
          • 26. Hartley M, Tomlinson M, Greco E, Comulada WS, Stewart J, le Roux I, et al. Depressed mood in pregnancy: prevalence and correlates in two Cape Town peri-urban settlements. Reprod Health. 2011;8: 9. pmid:21535876
          • 27. Stellenberg EL, Abrahams JM. Prevalence of and factors influencing postnatal depression in a rural community in South Africa. African J Prim Heal Care Fam Med. 2015;7: 1–8.
          • 28. Rathod S, Pinninti N, Irfan M, Gorczynski P, Rathod P, Gega L, et al. Mental Health Service Provision in Low- and Middle-Income Countries. Heal Serv Insights. 2017;10. pmid:28469456
          • 29. Manolova G, Waqas A, Chowdhary N, Salisbury TT, Dua T. Integrating perinatal mental healthcare into maternal and perinatal services in low and middle income countries. BMJ. 2023;381: e073343. pmid:37220917
          • 30. Hanlon C. Maternal depression in low- and middle-income countries. Int Health. 2013;5: 4–5. pmid:24029837
          • 31. World Health Organization. Maternal mental health and child health and development in low and middle income countries: Report of the meeting held in Geneva, Switzerland. World Heal Organ. 2008; 1–34.
            • 32. Raghavan A, Satyanarayana VA, Fisher J, Ganjekar S, Shrivastav M, Anand S, et al. Gender Transformative Interventions for Perinatal Mental Health in Low and Middle Income Countries—A Scoping Review. Int J Environ Res Public Health. 2022;19. pmid:36231655
            • 33. Tomlinson M, Chaudhery D, Ahmadzai H, Rodríguez Gómez S, Rodríguez Gómez C, van Heyningen T, et al. Identifying and treating maternal mental health difficulties in Afghanistan: A feasibility study. Int J Ment Health Syst. 2020;14. pmid:33133235
            • 34. McNab SE, Dryer SL, Fitzgerald L, Gomez P, Bhatti AM, Kenyi E, et al. The silent burden: a landscape analysis of common perinatal mental disorders in low- and middle-income countries. BMC Pregnancy Childbirth. 2022;22. pmid:35443652
            • 35. Pokharel A, Philip S, Khound M, El Hayek S, de Filippis R, Ransing R, et al. Mental illness stigma among perinatal women in low- and middle-income countries: early career psychiatrists’ perspective. Front Psychiatry. 2023;14. pmid:38116385
            • 36. McCauley M, Abigail B, Bernice O, Van Den Broek N. “i just wish it becomes part of routine care”: Healthcare providers’ knowledge, attitudes and perceptions of screening for maternal mental health during and after pregnancy: A qualitative study. BMC Psychiatry. 2019;19. pmid:31500606
            • 37. Govender D, Naidoo S, Taylor M. Antenatal and Postpartum Depression: Prevalence and Associated Risk Factors among Adolescents’ in KwaZulu-Natal, South Africa. Depress Res Treat. 2020;2020. pmid:32411457
            • 38. Nakku JEM, Okello ES, Kizza D, Honikman S, Ssebunnya J, Ndyanabangi S, et al. Perinatal mental health care in a rural African district, Uganda: A qualitative study of barriers, facilitators and needs. BMC Health Serv Res. 2016;16. pmid:27443346
            • 39. Gunawardena N, Fantaye AW, Yaya S. Predictors of pregnancy among young people in sub-Saharan Africa: A systematic review and narrative synthesis. BMJ Glob Heal. 2019;4. pmid:31263589
            • 40. Ahinkorah BO, Kang M, Perry L, Brooks F, Hayen A. Prevalence of first adolescent pregnancy and its associated factors in sub-Saharan Africa: A multi-country analysis. PLoS One. 2021;16. pmid:33539394
            • 41. Magadi MA. The disproportionate high risk of HIV infection among the urban poor in sub-Saharan Africa. AIDS Behav. 2013;17: 1645–1654. pmid:22660933
            • 42. Mbirimtengerenji ND. Is HIV/AIDS epidemic outcome of poverty in sub-Saharan Africa? Croat Med J. 2007;48: 605–617. pmid:17948947
            • 43. Kharsany ABM, Karim QA. HIV Infection and AIDS in Sub-Saharan Africa: Current Status, Challenges and Opportunities. Open AIDS J. 2016;10: 34–48. pmid:27347270
            • 44. Dwyer-Lindgren L, Cork MA, Sligar A, Steuben KM, Wilson KF, Provost NR, et al. Mapping HIV prevalence in sub-Saharan Africa between 2000 and 2017. Nature. 2019;570: 189–193. pmid:31092927
            • 45. Oramasionwu CU, Daniels KR, Labreche MJ, Frei CR. The environmental and social influences of HIV/AIDS in Sub-Saharan Africa: A focus on rural communities. Int J Environ Res Public Health. 2011;8: 2967–2979. pmid:21845169
            • 46. Tadele G, Amde W. Contextualizing HIV/AIDS in sub-saharan Africa: The link with tradition, religion, and culture. Vulnerabilities, Impacts, Responses to HIV/AIDS Sub-Saharan Africa. 2013; 25–45.
            • 47. Kim H, Musuka GN, Mukandavire Z, Branscum A, Cuadros DF. When distance matters: Mapping HIV health care underserved communities in sub-Saharan Africa. PLOS Glob Public Heal. 2021;1: e0000013. pmid:36962273
            • 48. Kaida A, Matthews LT, Ashaba S, Tsai AC, Kanters S, Robak M, et al. Depression during pregnancy and the postpartum among HIV-infected women on antiretroviral therapy in Uganda. J Acquir Immune Defic Syndr. 2014;67 Suppl 4: S179–87. pmid:25436816
            • 49. Moseholm E, Aho I, Mellgren Å, Pedersen G, Katzenstein TL, Johansen IS, et al. Psychosocial health in pregnancy and postpartum among women living with - and without HIV and non-pregnant women living with HIV living in the Nordic countries - Results from a longitudinal survey study. BMC Pregnancy Childbirth. 2022;22: 20. pmid:34996383
            • 50. Kapetanovic S, Dass-Brailsford P, Nora D, Talisman N. Mental health of HIV-seropositive women during pregnancy and postpartum period: A comprehensive literature review. AIDS Behav. 2014;18: 1152–1173. pmid:24584458
            • 51. Waldron EM, Burnett-Zeigler I, Wee V, Ng YW, Koenig LJ, Pederson AB, et al. Mental Health in Women Living With HIV: The Unique and Unmet Needs. J Int Assoc Provid AIDS Care. 2021;20. pmid:33472517
            • 52. Abdulai M, Owiredu D, Boadu I, Tabong PTN, Sarfo B, Bonful HA, et al. Psychosocial interventions and their effectiveness on quality of life among elderly persons living with HIV in Africa South of the Sahara: Systematic review and meta -analysis protocol. PLoS One. 2023;18. pmid:37729324
            • 53. Nattabi B, Li J, Thompson SC, Orach CG, Earnest J. A systematic review of factors influencing fertility desires and intentions among people living with HIV/AIDS: Implications for policy and service delivery. AIDS Behav. 2009;13: 949–968. pmid:19330443
            • 54. Feyissa TR, Harris ML, Melka AS, Loxton D. Unintended Pregnancy in Women Living with HIV in Sub-Saharan Africa: A Systematic Review and Meta-analysis. AIDS Behav. 2019;23: 1431–1451. pmid:30467712
            • 55. Falah-Hassani K, Shiri R, Dennis CL. Prevalence and risk factors for comorbid postpartum depressive symptomatology and anxiety. J Affect Disord. 2016;198: 142–147. pmid:27016657
            • 56. Ogueji IA. Experiences and predictors of psychological distress in pregnant women living with HIV. Br J Health Psychol. 2021;26: 882–901. pmid:33580626
            • 57. Pal M. A lead for integration of perinatal mental health in maternal and child health services. Int J Community Med Public Heal. 2023;10: 2637–2644.
            • 58. Tol WA, Ebrecht BO, Aiyo R, Murray SM, Nguyen AJ, Kohrt BA, et al. Maternal mental health priorities, help-seeking behaviors, and resources in post-conflict settings: A qualitative study in eastern Uganda. BMC Psychiatry. 2018;18: 39. pmid:29415710
            • 59. Lingen-Stallard A, Furber C, Lavender T. Testing HIV positive in pregnancy: A phenomenological study of women’s experiences. Midwifery. 2016;35: 31–38. pmid:27060398
            • 60. Tamuzi J, Okwundu C. Mobile Phone Communication for Improving Uptake of Antiretroviral Therapy in HIV-infected Pregnant Women: Review. Int Ann Med. 2017;1.
            • 61. Fonseca A, Canavarro MC. Women’s intentions of informal and formal help-seeking for mental health problems during the perinatal period: The role of perceived encouragement from the partner. Midwifery. 2017;50: 78–85. pmid:28395200
            • 62. Parcesepe AM, Cordoba E, Gallis JA, Headley J, Tchatchou B, Hembling J, et al. Common mental disorders and intimate partner violence against pregnant women living with HIV in Cameroon: a cross-sectional analysis. BMC Pregnancy Childbirth. 2021;21: 178. pmid:33663428
            • 63. Poku OB, West NS, Eschliman EL, Dangerfield DT, Bass J, Kennedy CE, et al. Mental Health Problems Across the HIV Care Continuum for Adolescents Living with HIV in Sub-Saharan Africa: A Scoping Review. AIDS Behav. 2023;27: 2548–2565. pmid:36650389
            • 64. Dlamini LP, Amelia VL, Shongwe MC, Chang PC, Chung MH. Antenatal depression across trimesters as a risk for postpartum depression and estimation of the fraction of postpartum depression attributable to antenatal depression: A systematic review and meta-analysis of cohort studies. Gen Hosp Psychiatry. 2023;85: 35–42. pmid:37742599
            • 65. Pillai L, Srivastava S, Ajin A, Rana SS, Mathkor DM, Haque S, et al. Etiology and incidence of postpartum depression among birthing women in the scenario of pandemics, geopolitical conflicts and natural disasters: a systematic review. J Psychosom Obstet Gynaecol. 2023;44: 2278016. pmid:38050938
            • 66. Nakamura A, van der Waerden J, Melchior M, Bolze C, El-Khoury F, Pryor L. Physical activity during pregnancy and postpartum depression: Systematic review and meta-analysis. J Affect Disord. 2019;246: 29–41. pmid:30576955
            • 67. Zhu QY, Huang DS, Lv J Da, Guan P, Bai XH. Prevalence of perinatal depression among HIV-positive women: a systematic review and meta-analysis. BMC Psychiatry. 2019;19: 330. pmid:31666033
            • 68. Osok J, Kigamwa P, Stoep A Vander, Huang KY, Kumar M. Depression and its psychosocial risk factors in pregnant Kenyan adolescents: A cross-sectional study in a community health Centre of Nairobi. BMC Psychiatry. 2018;18. pmid:29776353
            • 69. Sowa NA, Cholera R, Pence BW, Gaynes BN. Perinatal depression in HIV-infected African women: a systematic review. J Clin Psychiatry. 2015;76: 1385–1396. pmid:26528645
            • 70. Toska E, Laurenzi CA, Roberts KJ, Cluver L, Sherr L. Adolescent mothers affected by HIV and their children: A scoping review of evidence and experiences from sub-Saharan Africa. Glob Public Health. 2020;15: 1655–1673. pmid:32507031
            • 71. Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Rev Esp Nutr Humana y Diet. 2016;20: 148–160. pmid:25554246
            • 72. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Syst Rev. 2021;10. pmid:33781348
            • 73. Higgins J, Thomas J, Chandler J, Cumpston M, Li T, Page M, et al. Cochrane Handbook for Systematic Reviews of Interventions version 6.4 updated August 2023). Cochrane Handb Syst Rev Interv version 64. 2023;1.
              • 74. Danso-Appiah A, Owiredu D, Akuffo KO. Praziquantel-related visual disorders among recipients in mass drug administration campaigns in schistosomiasis endemic settings: Systematic review and meta-analysis protocol. Coulibaly J, editor. PLoS One. 2024;19: e0300384. pmid:38758736
              • 75. Abdulai M, Owiredu D, Boadu I, Tabong PT-N, Sarfo B, Bonful HA, et al. Psychosocial interventions and their effectiveness on quality of life among elderly persons living with HIV in Africa South of the Sahara: Systematic review and meta -analysis protocol. Bongomin F, editor. PLoS One. 2023;18: e0291781. pmid:37729324
              • 76. Awini E, Agyepong IA, Owiredu D, Gyimah L, Ashinyo ME, Yevoo LL, et al. Burden of mental health problems among pregnant and postpartum women in sub-Saharan Africa: systematic review and meta-analysis protocol. BMJ Open. 2023;13: e069545. pmid:37286328
              • 77. Ohene-Adjei K, Asante KP, Akuffo KO, Tounaikok N, Asiamah M, Owiredu D, et al. Malaria vaccine-related adverse events among children under 5 in sub-Saharan Africa: systematic review and meta-analysis protocol. BMJ Open. 2023;13: e076985. pmid:37793915
              • 78. Danso-Appiah A, Eusebi P, Lo NC, Orso M, Akuffo KO, Fleming FM, et al. Optimal Prevalence Threshold For Guiding The Implementation Of Preventive Chemotherapy In Countries Endemic For Schistosomiasis: Synthesis Of Evidence From Mass Drug Administration Programmes For Developing This Tool. medRxiv. 2022; 2021.05.10.21256643. http://medrxiv.org/content/early/2022/02/01/2021.05.10.21256643.abstract
                • 79. Danso-Appiah A, Minton J, Boamah D, Otchere J, Asmah RH, Rodgers M, et al. Accuracy of point-of-care testing for circulatory cathodic antigen in the detection of schistosome infection: systematic review and meta-analysis. Bull World Health Organ. 2016;94: 522–533A. pmid:27429491
                • 80. Danso-Appiah A, Olliaro PL, Donegan S, Sinclair D, Utzinger J. Drugs for treating Schistosoma mansoni infection. Cochrane Database Syst Rev. 2013. pmid:23450530
                • 81. Ganle JK, Baatiema L, Quansah R, Danso-Appiah A. Barriers facing persons with disability in accessing sexual and reproductive health services in sub-Saharan Africa: A systematic review. Amo-Adjei J, editor. PLoS One. 2020;15: e0238585. pmid:33044966
                • 82. Mirzoev T, Koduah A, Cronin de Chavez A, Baatiema L, Danso-Appiah A, Ensor T, et al. Implementation of medicines pricing policies in sub-Saharan Africa: protocol for a systematic review. BMJ Open. 2021;11: e044293. pmid:33622951
                • 83. Danso-Appiah A, Owiredu D, Asiamah M, Akuffo K, Eusebi P, Jiangang G, et al. Safety of praziquantel in persons with and without schistosomiasis: systematic review and meta-analysis. medRxiv. 2022; 2022.03.09.22270839. http://medrxiv.org/content/early/2022/03/12/2022.03.09.22270839.abstract
                  • 84. Staniszewska S, Brett J, Simera I, Seers K, Mockford C, Goodlad S, et al. GRIPP2 reporting checklists: Tools to improve reporting of patient and public involvement in research. Res Involv Engagem. 2017;3. pmid:29062538
                  • 85. American Psychiatric Association D, Association AP. Diagnostic and statistical manual of mental disorders: DSM-5. American psychiatric association Washington, DC; 2013.
                    • 86. Lovibond SH, Lovibond PF. Depression anxiety stress scales. Psychol Assess. 1995;3: 118–120.
                    • 87. Vincenti GE. Edinburgh Post-natal Depression Scale. Br J Psychiatry. 1987;151: 865. pmid:3502820
                    • 88. Beusenberg M, Orley JH, World Health Organization. Division of Mental Health. A User’s guide to the self reporting questionnaire (SRQ / compiled by M. Beusenberg and J. Orley. 1994.
                      • 89. Alhajj M, Zubair M, Farhana A. Enzyme linked immunosorbent assay. StatPearls. 2023. https://www.statpearls.com/point-of-care/21178
                        • 90. Joshi M, Deshpande JD. Polymerase Chain Reaction: Methods, Principles and Application. Int J Biomed Res. 2011;2.
                        • 91. The World Bank. Data. https://data.worldbank.org/country/ZG
                          • 92. Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan—a web and mobile app for systematic reviews. Syst Rev. 2016;5: 210. pmid:27919275
                          • 93. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol. 2009;62: 1006–1012. pmid:19631508
                          • 94. Corporation M. Microsoft Excel. 2019. https://office.microsoft.com/excel
                            • 95. Hoy D, Brooks P, Woolf A, Blyth F, March L, Bain C, et al. Assessing risk of bias in prevalence studies: Modification of an existing tool and evidence of interrater agreement. J Clin Epidemiol. 2012;65: 934–939. pmid:22742910
                            • 96. The Cochrane Collaboration. Review Manager (RevMan) Computer program. Version 7.2.0. 2024.
                              • 97. StataCorp. Stata Statistical Software: Release 15. College Station, TX: StataCorp LLC; 2017.
                                • 98. Thorlund K, Imberger G, Johnston BC, Walsh M, Awad T, Thabane L, et al. Evolution of Heterogeneity (I2) Estimates and Their 95% Confidence Intervals in Large Meta-Analyses. Emmert-Streib F, editor. PLoS One. 2012;7: e39471. pmid:22848355
                                • 99. Higgins JPT, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002;21: 1539–1558. pmid:12111919
                                • 100. Mowbray FI, Manlongat D, Shukla M. Sensitivity Analysis: A Method to Promote Certainty and Transparency in Nursing and Health Research. Can J Nurs Res. 2022;54: 371–376. pmid:35702010
                                • 101. Schünemann H, Brożek J, Guyatt G, Oxman A. GRADE handbook for grading quality of evidence and strength of recommendations. GRADE Work Gr. 2013.
                                  • 102. Balshem H, Helfand M, Schünemann HJ, Oxman AD, Kunz R, Brozek J, et al. GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol. 2011. pmid:21208779
                                  • 103. Guyatt G, Oxman AD, Akl EA, Kunz R, Vist G, Brozek J, et al. GRADE guidelines: 1. Introduction—GRADE evidence profiles and summary of findings tables. J Clin Epidemiol. 2011;64: 383–394. pmid:21195583