Electronic searches using PubMed yielded five journal articles. A total of 25 articles were identified using PubMed Central, 6 articles were found using African Journals Online (AJOL), 4 (1 journal article and 3 dissertations) were found on the UZIR and 1240 articles were identified through Google Scholar. After screening the articles by title where we excluded all non-Zimbabwean studies, 5 remained from PubMed, 7 from PubMed Central, 3 from Google Scholar, one from UZIR and none from AJOL. A description of the resultant 9 reviewed studies published between 1998 and 2017 is provided in Table 1.

As previously discussed, the primary care setting offers a good opportunity for women to be screened for depression in Zimbabwe. As there is good ANC coverage, the health care system could take advantage of the high numbers of women who attend ANC services and offer screening. Health care workers could sensitise women on perinatal depression during health promotion sessions in primary care settings when women present for ANC or for other primary care services. Targeting women for potential screening when they attend for ANC may however not be feasible for sections of society that have lower odds of utilisation of health services such as Apostolics.¹⁷ Previous studies from Zimbabwe reported that Apostolics consider the church as an alternative health care system.^18,19 This indicates that community-based screening programmes involving both village health workers and religious healers may improve coverage. The cost of using lay health workers to screen for perinatal depression in communities is relatively low as compared to using nurses.^20,21 Periodic supportive supervision will however be required to ensure that the assessments are conducted in a standardised manner.

The postnatal period can also be used to screen for those women who may have missed screening or screened negative at the ANC stage. However, challenges would exist in effectively reaching most women following childbirth as most provinces within Zimbabwe reported postnatal care (PNC) coverage of less than 80% with 4 out of the 10 provinces reporting less than 50% (see Table 2). In light of these PNC coverage levels, using community-based screening in addition to health-facility-based screening would potentially yield better results.

Another important yet often neglected entry point involves using traditional or religious health care practitioners. Pregnant women in Zimbabwe have been reported to also seek help from non-medical practitioners.²² This provides an opportunity for integrating activities of traditional medical practitioners with their biomedical counterparts.^18,23 Such integration would contribute towards increasing awareness of mental health problems that women may suffer during the perinatal period so that appropriate interventions can be instituted. Furthermore, to optimise benefits to women who engage in medical pluralism, especially in resource-limited settings such as Zimbabwe, there is need to address structural and cultural realities of screening for perinatal depression. Thus, more studies exploring these cultural antecedents are warranted. There is also need to establish proper referral patterns for women identified to be at higher risk for depression. Thus, future studies could potentially explore whether traditional medical practitioners would be willing to refer women they identify as having depression to biomedical practitioners and vice versa.

Based on lessons learnt from HIV programmes where provider-initiated counselling and testing has yielded positive results,²⁴ a similar approach may also be instituted regarding mental health screening. Thus, use of multi-component health programmes has the potential to yield maximum health benefits for primary care attenders. However, multi-component interventions would require appropriate training, more financial support and provision of locally developed and culturally relevant screening tools such as the Shona Symptom Questionnaire (SSQ) for mental health problems. Furthermore, the success of such approaches hinges heavily on their incorporation into existing policy and legislative frameworks. To minimise the amount of time taken when screening for depression, health care workers in Zimbabwe can adopt shorter versions of screening instruments such as the two-item Patient Health Questionnaire (PHQ-2) which is administered as an initial brief screening for depression. The PHQ-2 has been found to have a high sensitivity of 91% when it was validated in a community with high HIV prevalence in Zimbabwe.²⁵ Additionally, the existence of the SSQ which is an indigenous measure of CMD also presents an ideal opportunity to screen women during the perinatal period using emic criteria. Previous studies have utilised this screening measure to estimate the prevalence of CMDs in prenatal and postnatal women.²⁶

The health care sector in Zimbabwe has, in recent years, suffered as a result of the economic downturn that is being experienced in the country. There has been an increase in outmigration of health workers, particularly nurses,²⁷ and that has resulted in depleted clinical staff levels.²⁸

To compound the problem of depleted clinical staff, the few primary care nurses currently do not have adequate training in screening for mental health problems.²⁸ It is therefore imperative to train primary health care workers to identify and manage CMDs among women.²⁵ Because of staff shortages and heavy workloads, nurses may not have sufficient time to check for mental health problems at primary care facilities. Closely related to this, most patients who present at primary care facilities report somatic complaints and may not highlight the psychological distress they may be suffering.¹⁴ Most primary care facilities may also lack privacy and as such clients may be less inclined to highlight the mental health distress they may be suffering from. In addition, stigma around mental illness still exists in Zimbabwe,²⁹ and this may result in patients not consulting or disclosing that they have psychological distress. The increased burden of caring for a mentally ill relative may also hinder health seeking as family may experience both psychological and economic strain which is likely to result in them seeking spiritual or traditional support rather than biomedical care.²⁹

Referral systems for those suffering from depression in Zimbabwe are in most cases poor and unreliable.²⁸ This means that only the most severe cases of mental illnesses reach qualified mental health practitioners. There are currently no existing policies in relation to mental health screening among women during the perinatal period, which may make it difficult to institute appropriate interventions. Furthermore, there is need for adequate provision of interventions for those women who need support.

Validation of screening tools for perinatal depression in Zimbabwe has been done mainly for Shona-speaking women who are resident in urban settings.^9,25 Data are currently unavailable for rural women and those who are not Shona speakers. Thus, there is need for more validation studies on screening tools such as the locally developed SSQ, the EPDS and the PHQ among rural women and other ethnic groupings within the country. Additionally, there is need to develop more locally relevant depression screening tools that will take into account other local languages spoken in Zimbabwe.

Women’s own beliefs and previous experiences regarding mental illness may contribute to challenges surrounding screening for depression.¹⁴ This is especially so where depressive symptoms may be viewed as normal in pregnancy and following childbirth. Consequently, depression may be overlooked during the perinatal period because its symptoms are often similar to bodily experiences that are associated with pregnancy.³⁰ In the absence of reliable data on the acceptability of women to undergo universal perinatal screening for CMDs in Zimbabwe, there is need to carry out large-scale studies so as to inform policy regarding maternal mental health.

Because of the limited studies we found on screening for perinatal depression within Zimbabwe, we did not perform quality assessment of the studies retrieved as we aimed at including as many papers as possible in this narrative review. Furthermore, our results may be biased because of limited published studies on screening for depression within Zimbabwe as there could be some grey literature which was not included in this review. The review also did not include expert opinion from health authorities and focused only on Zimbabwe which limits generalisability of results to other LMICs. Although the search terms included ‘common mental disorders’, the review only focused on perinatal depression and did not include studies on anxiety or other psychological morbidity. However, important lessons learnt from such studies can also be relevant to women with perinatal depression.