Exploring the effects of mental health on bonding and caregiving among pregnant and postpartum persons with likely depression and/or PTSD in South Africa: a qualitative analysis

Probably not a substantial claim: may not pass S3 (load-bearing).

A qualitative study conducted in Johannesburg, SA found when participants received informational support in health settings, they were more likely to think positively of their pregnancy.

“A qualitative study conducted in Johannesburg, SA found when participants received informational support in health settings, they were more likely to think positively of their pregnancy [53].”

• cites [53] Rivi V, Petrilli G, Blom JMC. Mind the Mother When Considering Breastfeeding. Front Glob Womens Health. 2020;1:3. sourceCould not verify

  The Recommendations sections discuss screening during pregnancy check-ups and individualized support for maternal mental health, but do not report a qualitative study in Johannesburg or link informational support in health settings to more positive feelings about pregnancy. Searches for Johannesburg and that reported finding found no passage addressing it in our copy. (LLM, conf=0.75)

  Experimental — accuracy not yet measured

Probably not a substantial claim: may not pass S3 (load-bearing).

Given current understanding of developmental psychology and the negative impact of adverse childhood events on adult outcomes, these emotional and behavioral challenges can have lifelong impacts.

“Given current understanding of developmental psychology and the negative impact of adverse childhood events on adult outcomes [22], these emotional and behavioral challenges can have lifelong impacts [23], especially in contexts with limited resources and significant public health challenges.”

• cites [22] Nurius PS, Green S, Logan-Greene P, Borja S. Life course pathways of adverse childhood experiences toward adult psychological well-being: A stress process analysis. Child Abuse Negl. 2015;45:143–53. sourceSupported
• cites [23] Bell J, Norris S, Shand A, Lain S, Hall B et al. Healthy mothers and babies - a lifecourse approach: an Evidence Check rapid review brokered by the Sax Institute for the NSW Ministry of Health. 2018 . Available from: https://www.saxinstitute.org.au/wp-content/uploads/2019_Healthy-mothers-and-babies-a-life-course-approach.pdf. [Cited 2024 May 31].Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

A separate SA-based study found no significant associations between poor breastfeeding outcomes and mental health.

“though a separate SA-based study found no significant associations between poor breastfeeding outcomes and mental health [45].”

• cites [45] McNamara J, Townsend ML, Herbert JS. A systemic review of maternal wellbeing and its relationship with maternal fetal attachment and early postpartum bonding. Hill B, editor. PLoS ONE. 2019;14(7):e0220032. sourceCould not verify

  The Results (Statistical analyses) discuss associations between maternal mental health and postpartum bonding, not breastfeeding outcomes. A search for breastfeeding found only a reference about breastfeeding and mother–infant sleep proximity; our copy does not report the claimed finding from a South African study. (LLM, conf=0.76)

  Experimental — accuracy not yet measured

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Maternal sensitivity impacts secure attachment, and both are associated with positive developmental outcomes.

“Bigelow and colleagues have discussed how maternal sensitivity (i.e., appropriately responding to cues from the child) impacts secure attachment, both of which are associated with positive developmental outcomes [37].”

• cites [37] Qu F, Wu Y, Zhu YH, Barry J, Ding T, Baio G, et al. The association between psychological stress and miscarriage: A systematic review and meta-analysis. Sci Rep. 2017;7(1):1731. sourceCould not verify

  The Results (Effect size analysis; page unavailable) address psychological stress and miscarriage, not maternal sensitivity or secure attachment. Searches for maternal sensitivity, secure attachment, child cues, developmental outcomes, and Bigelow found no passage in our copy addressing the attributed claim. (LLM, conf=0.75)

  Experimental — accuracy not yet measured

May combine two claims.

Despite the strong need for interventions to improve peripartum mental health and associated HIV-outcomes, there are still many barriers to routine mental health screening, psychoeducation, and efficient treatment referral pathways in South African antenatal clinics.

“Despite the strong need for interventions to improve peripartum mental health and associated HIV-outcomes [57], there are still many barriers to routine mental health screening, psychoeducation, and efficient treatment referral pathways in South African antenatal clinics [58].”

• cites [57] Republic of South Africa, Department of Health. National mental health policy framework and strategic plan 2023–2030. 2023. https://www.health.gov.za/wp-content/uploads/2024/02/National-Mental-Health-Policy-framework-and-strategic-Plan-2023-2030.pdf.Not checked yet

  Not checked in the free run.

• cites [58] Cornick R, Picken S, Wattrus C, Awotiwon A, Carkeek E, Hannington J, et al. The Practical Approach to Care Kit (PACK) guide: developing a clinical decision support tool to simplify, standardise and strengthen primary healthcare delivery. BMJ Glob Health. 2018;3(Suppl 5):e000962. sourceCould not verify

  Split into 2 atoms — 0 confirmed, 0 partially supported, 0 disputed, 0 misattributed, 2 unverifiable. Expand the claim to see per-atom verdicts.

  Experimental — accuracy not yet measured

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Breastfeeding has a complex relationship with maternal mental health, and has been shown to have a protective effect against mental health symptoms, primarily through the release of oxytocin.

“Breastfeeding, which has a complex relationship with maternal mental health, has also been shown to have a protective effect against mental health symptoms, primarily through the release of oxytocin [46–48].”

• cites [46] Stelson EA, Kulkacek L, Frasso R, Hall M, Guevara JP. Perspectives on Breastfeeding from Mothers with Postpartum Depression Symptoms: A Qualitative Assessment of Antecedents, Barriers, Facilitators, and Intervention Suggestions. Breastfeed Med. 2021;16(10):790–8. sourceNot checked — no full text of the source
• cites [47] Thomas E, Kuo C, Cohen S, Hoare J, Koen N, Barnett W, et al. Mental health predictors of breastfeeding initiation and continuation among HIV infected and uninfected women in a South African birth cohort study. Prev Med. 2017;102:100–11. sourcePartly supported

  The Introduction and Discussion describe a complex relationship between maternal mental health and breastfeeding, including mixed findings about whether depression predicts breastfeeding behaviour. They do not say that breastfeeding protects against mental health symptoms or that oxytocin is the primary mechanism. The paper studies mental health as a possible predictor of breastfeeding, rather than that proposed protective effect. (LLM, conf=0.88)

  Experimental — accuracy not yet measured
• cites [48] Anoop S, Saravanan B, Joseph A, Cherian A, Jacob K. Maternal depression and low maternal intelligence as risk factors for malnutrition in children: a community based case-control study from South India. Arch Dis Child. 2004;89(4):325–9. sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

One study in Ethiopia found that maternal depression, long walking distances, and late initial engagement in antenatal care predicted inadequate service utilization among antenatal patients.

“One study in Ethiopia found that maternal depression, long walking distances, and late initial engagement in antenatal care predicted inadequate service utilization among antenatal patients [12].”

• cites [12] Beyene GM, Azale T, Gelaye KA, Ayele TA. Effect of antenatal depression on ANC service utilization in northwest Ethiopia. Sci Rep. 2023;13:14443. sourcePartly supported

  The Results section reports that antenatal depression, late initiation of ANC visits, and long travel time to ANC were associated with increased odds of inadequate visits. The Methods section defines the travel measure by time (at least 30 minutes), not walking distance; the source does not establish that patients walked or measure distance. (LLM, conf=0.86)

  Experimental — accuracy not yet measured

Probably not a substantial claim: may not pass S3 (load-bearing).

The Practical Approach to Care Kit (PACK) was developed to support clinical decision making and standardize care, including mental health care, in low- and middle-income primary care settings.

“Recently, the Practical Approach to Care Kit (PACK), a tool kit from the University of Cape Town, was developed to support clinical decision making and standardize care, including mental health care, in low- and middle-income primary care settings [56].”

• cites [56] Stanton AM, O’Cleirigh C, Knight L, Davey DLJ, Myer L, Joska JA et al. The importance of assessing and addressing mental health barriers to PrEP use during pregnancy and postpartum in sub-Saharan Africa: state of the science and research priorities. J Int AIDS Soc. 2022 Oct;25(10). Available from: https://onlinelibrary.wiley.com/doi/https://doi.org/10.1002/jia2.26026[Cited 2022 Nov 8]. sourceCould not verify

  The Discussion section on research priorities addresses mental health screening and counselling in sub-Saharan Africa, but does not describe the Practical Approach to Care Kit (PACK). Searches for PACK and for clinical decision-making and standardized primary care found no passage in our copy addressing the tool or its development. (LLM, conf=0.75)

  Experimental — accuracy not yet measured

Probably not a substantial claim: may not pass S3 (load-bearing).

The South African National Mental Health Policy Framework and Strategic Plan 2023-2030 states that action is required to develop mental health promotion/mental illness prevention programs, particularly at key developmental life stages including pregnancy, early childhood, adolescence, and old age.

“For example, the South African National Mental Health Policy Framework and Strategic Plan 2023–2030 states that action is required to develop mental health promotion/mental illness prevention programs, particularly at key developmental life stages including pregnancy, early childhood, adolescence, and old age [55].”

• cites [55] Mabetha K, Soepnel LM, Klingberg S, Mabena G, Motlhatlhedi M, Norris SA et al. Young women’s social support networks during pregnancy in Soweto, South Africa. African Journal of Primary Health Care & Family Medicine. 2024 Apr 29;16(1). Available from: http://www.phcfm.org/index.php/PHCFM/article/view/4146. [Cited 2024 Aug 14]. sourceCould not verify

  The Introduction discusses mental health risks during pregnancy, and the Discussion recommends support for expectant mothers, but neither passage describes the South African National Mental Health Policy Framework and Strategic Plan 2023–2030. Searches for the policy title and for its claimed life-stage priorities found no passage addressing what the policy states. (LLM, conf=0.77)

  Experimental — accuracy not yet measured

May combine two claims.

A strong support network is critical for the wellbeing of pregnant and postpartum persons, and those who have this support are more likely to embrace their pregnancy.

“A strong support network is critical for the wellbeing of pregnant and postpartum persons, and those who have this support are more likely to embrace their pregnancy [53].”

• cites [53] Rivi V, Petrilli G, Blom JMC. Mind the Mother When Considering Breastfeeding. Front Glob Womens Health. 2020;1:3. sourcePartly supported

  The section “Operating ‘With the Mother in the Mind’” identifies social support as a factor in the perception of motherhood and says family involvement in feeding decisions could benefit maternal mental health. It does not say that people with strong support networks are more likely to embrace their pregnancy. (LLM, conf=0.85)

  Experimental — accuracy not yet measured

Probably not a substantial claim: may not pass S3 (load-bearing).

In a South African cohort, maternal PTSD was found to be associated with impaired neurodevelopment in the infant.

“In a South African cohort, maternal PTSD was found to be associated with impaired neurodevelopment in the infant [16].”

• cites [16] Koen N, Brittain K, Donald KA, Barnett W, Koopowitz S, Maré K, et al. Maternal posttraumatic stress disorder and infant developmental outcomes in a South African birth cohort study. Psychol Trauma: Theory Res Pract Policy. 2017;9(3):292–300. sourceSupported

May combine two claims.

While most expected their mental health symptoms to compromise their ability to caregive, some expressed a sense of resilience to overcome and/or de-prioritize their mental health symptoms for the sake of their babies and in defiance of established generational patterns.

“While most expected their mental health symptoms to compromise their ability to caregive, some expressed a sense of resilience to overcome and/or de-prioritize their mental health symptoms for the sake of their babies and in defiance of established generational patterns.”

May combine two claims.

Mental health symptoms will inhibit milk production and reduce attentiveness to their baby's needs.

“Not only will mental health symptoms inhibit milk production, but symptoms will also reduce attentiveness to their baby’s needs (i.e., providing nourishment).”

Probably not a substantial claim: may not pass S3 (load-bearing).

Other participants indicated that their stress was reduced at the clinic due to the support of nurses and staff.

“Other participants indicated that their stress was reduced at the clinic due to the support of nurses and staff.”

May combine two claims. The quote only partly states this claim.

Some participants found unanticipated sources of social support in other mothers at the clinic, and interactions while bringing their baby to the clinic improved their own mental status.

“In some cases, the sense of personal obligation or sacrifice required to parent led to the discovery of unanticipated sources of social support in other mothers.”

• Also stated in: § Characteristics of sample · plain

  “Her interactions while bringing her baby to the clinic improved her own mental status.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Participants were told that sadness or stress could transfer to their baby when breastfeeding postpartum.

“Participants were also told that their sadness or stress could transfer to their baby when breastfeeding postpartum.”

May combine two claims.

Participants discussed connecting with other patients at the clinic and how clinic staff relieved their stress over health concerns for their baby.

“Participants discussed connecting with other patients at the clinic and how clinic staff relieved their stress over health concerns for their baby.”

May combine two claims.

Some participants experienced increased anger due to life stressors and current mental health symptoms, which either led to predictions that bonding might be negatively affected or negatively impacted bonding postpartum.

“Some particpants experienced increased anger due to life stressors and current mental health symptoms, which either led to predictions that bonding might be negatively affected or negatively impacted bonding postpartum.”

May combine two claims.

Three main themes emerged: (1) a strong perceived connection between maternal mental health and baby's wellbeing; (2) perceived strains on bonding with the baby; and (3) negative impact of mental health on likelihood of completing parenting tasks.

“Three main themes emerged: a strong perceived connection between maternal mental health and baby’s wellbeing; (2) perceived strains on bonding with the baby; and (3) negative impact of mental health on likelihood of completing parenting tasks.”

May combine two claims.

Participants discussed two specific ways in which mental health contributed to strains on emotional bonding: via increased anger and/or through a lack of emotional connection.

“Participants discussed two specific ways in which mental health contributed to strains on emotional bonding, both during pregnancy and postpartum: (2a) via increased anger and/or (2b) through a lack of emotional connection.”

May combine two claims.

Collectively, participants were highly aware of potential negative impacts of their mental health symptoms on their baby's wellbeing, and they highlighted the importance of ensuring that their babies were protected, even if it was challenging to do so.

“Collectively, participants were highly aware of potential negative impacts of their mental health symptoms on their baby’s wellbeing, and they highlighted the importance of ensuring that their babies were protected, even if it was challenging to do so.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Most mental health disorders have their origins in childhood and adolescence.

“It is also now known that most mental health disorders have their origins in childhood and adolescence, which reinforces the importance of maintaining a healthy environment for child development [43].”

• cites [43] van Veen T, Wardenaar KJ, Carlier IVE, Spinhoven P, Penninx BWJH, Zitman FG. Are childhood and adult life adversities differentially associated with specific symptom dimensions of depression and anxiety? Testing the tripartite model. J Affect Disord. 2013;146(2):238–45. sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

Exclusive breastfeeding is recommended for the first six months for persons with and without HIV by the WHO.

“Exclusive breastfeeding is recommended for the first six months for persons with and without HIV by the WHO”

• cites [49] Rahman A, Harrington R, Bunn J. Can maternal depression increase infant risk of illness and growth impairment in developing countries? Child. 2002;28(1):51–6. sourceNot checked — no full text of the source
• cites [50] Tomlinson M, Rabie S, Skeen S, Hunt X, Murray L, Cooper PJ. Improving mother–infant interaction during infant feeding: A randomised controlled trial in a low-income community in South Africa. Infant Mental Health J. 2020;41(6):850–8. sourceNot checked — no full text of the source
• cites [51] WHO. Infant feeding for the prevention of mother-to-child transmission of HIV. 2023. Available from: https://www.who.int/tools/elena/interventions/hiv-infant-feeding. [Cited 2024 Aug 13].Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The coding process included double coding of transcripts and resolution of discrepancies in code definitions and coding conventions.

“Then four transcripts were double coded (by LRG, MF, JL, KK) using the Dedoose software [32]. Team members met to discuss and resolve any discrepancies in code definitions and coding conventions, and if discrepancies were not resolved by the coders, they were discussed with the PI (AMS) and the South Africa-based team (JNG, LG).”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Qualitative analyses followed the principles of thematic analysis and were informed by grounded theory.

“Qualitative analyses followed the principles of thematic analysis [30] and were informed by grounded theory [31].”

• cites [30] Braun V, Clarke V. Thematic analysis. In: Cooper H, Camic PM, Long DL, Panter AT, Rindskopf D, Sher KJ, editors. APA handbook of research methods in psychology, Vol 2: Research designs: Quantitative, qualitative, neuropsychological, and biological [Internet]. Washington: American Psychological Association; 2012 . pp. 57–71. Available from: http://content.apa.org/books/13620-004.[Cited 2023 Aug 7]. sourceNot checked — no full text of the source
• cites [31] Glaser BG, Strauss AL. The discovery of grounded theory: strategies for qualitative research. London New York: Routledge; 2017. p. 271. sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S2 (checkable).

Our findings support the need for improved access to mental health screening and treatment in the antenatal care setting.

“Our findings support the need for improved access to mental health screening and treatment in the antenatal care setting”

Probably not a substantial claim: may not pass S3 (load-bearing).

Rigor in data collection was ensured by co-creating the semi-structured guide with the SA-based team and iteratively refining the guide.

“We ensured rigor in our data collection by co-creating the semi-structured guide with our SA-based team and iteratively refining the guide to meet the study aims and to provide rich data.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The study used Tracy's eight criteria to ensure high quality in the analysis process.

“We used the eight criteria (worthy topic, rich rigor, sincerity, credibility, resonance, significant contribution, ethical, meaningful coherence) established by Tracy to ensure high quality in our analysis process [33].”

• cites [33] Tracy SJ. Qualitative Quality: Eight Big-Tent Criteria for Excellent Qualitative Research. Qualitative Inq. 2010;16(10):837–51. sourceNot checked — no full text of the source

May combine two claims.

Our study offers perspectives on how women perceive their poor mental health to negatively impact the wellbeing of their baby in utero and while breastfeeding, and how through cognitively avoiding their depression or stress, they hope to protect their baby.

“For this reason, our study meaningfully offers perspectives on how women perceive their poor mental health to negatively impact the wellbeing of their baby in utero and while breastfeeding, and how through cognitively avoiding their depression or stress, they hope to protect their baby.”

• AssumptionRests on an assumption: There is a lack of published literature, particularly qualitative perspectives, from women on the impact their mental health has on their baby’s wellbeing.

Probably not a substantial claim: may not pass S3 (load-bearing).

Maternal psychological stress is associated with an increased risk of miscarriage.

“There is also evidence that maternal psychological stress is associated with an increased risk of miscarriage [36].”

• cites [36] Raina J, El-Messidi A, Badeghiesh A, Tulandi T, Nguyen TV, Suarthana E. Pregnancy hypertension and its association with maternal anxiety and mood disorders: A population-based study of 9 million pregnancies. J Affect Disord. 2021;281:533–8. sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S2 (checkable).

Our findings may be well placed to inform future mental health interventions for peripartum persons in SA, especially given the potential for inter-generational effects and for negative, HIV-related public health impacts.

“and may be well placed to inform future mental health interventions for peripartum persons in SA, especially given the potential for inter-generational effects and for negative, HIV-related public health impacts.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Interviews were conducted by trained, bilingual (English and isiXhosa) research assistants.

“Interviews were conducted by trained, bilingual (English and isiXhosa) research assistants at the clinic or over the phone depending on participants’ preferences.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Women who face physical challenges or pain when trying to exclusively breastfeed may be more likely to experience depression.

“For example, women who face physical challenges or pain when trying to exclusively breastfeed may be more likely to experience depression [52].”

• cites [52] CDC. Breastfeeding Recommendations and Benefits. Centers for Disease Control and Prevention. 2022. Available from: https://www.cdc.gov/nutrition/infantandtoddlernutrition/breastfeeding/recommendations-benefits.html. [Cited 2024 Aug 13].Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

There is a strong association between maternal stress and the development of hypertensive disorders during pregnancy, including pre-eclampsia and eclampsia.

“For example, there is a strong association between maternal stress and the development of hypertensive disorders during pregnancy, including pre-eclampsia and eclampsia [35].”

• cites [35] Patton MQ. Qualitative Research & Evaluation Methods: Integrating Theory and Practice. Fourth edition. Saint Paul, MN: Sage Publications; 2014 . Available from: https://us.sagepub.com/en-us/nam/qualitative-research-evaluation-methods/book232962. [Cited 2023 Feb 9].Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

One study conducted in Japan found that, in the context of parental psychopathology, feelings of anger, lack of affection, and rejection towards infants led to childhood emotional and behavioral problems.

“One study conducted in Japan found that, in the context of parental psychopathology, feelings of anger, lack of affection, and rejection towards infants, led to childhood emotional and behavioral problems [21].”

• cites [21] Murakami K, Ishikuro M, Obara T, Noda A, Ueno F, Onuma T, et al. Maternal postnatal bonding disorder and emotional/behavioral problems in preschool children: The Tohoku Medical Megabank Project Birth and Three-Generation Cohort Study. J Affect Disord. 2023;325:582–7. sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Credibility was reached through detailed descriptions of the findings and triangulating conclusions with multiple study team coders.

“Credibility was reached through detailed descriptions of the findings and triangulating conclusions with multiple study team coders.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The semi-structured interview guides were approved by the Human Research Ethics Committee of the Faculty of Health Sciences at the University of Cape Town.

“The semi-structured interview guides (Additional file 1), developed based on the principles of Huberman and Miles [29], were approved by the Human Research Ethics Committee of the Faculty of Health Sciences at the University of Cape Town, South Africa [HREC REF Number: 231/2021].”

Probably not a substantial claim: may not pass S3 (load-bearing).

Sample size for the qualitative analysis was based on the richness of data captured and the analytic abilities of the research team, rather than relying on thematic saturation.

“In alignment with Patton’s approach, we based our sample size for the qualitative analysis on the richness of data captured and the analytic abilities of the research team, rather than relying on the principles of thematic saturation [34].”

• cites [34] Wutich A, Beresford M, Bernard HR. Sample Sizes for 10 Types of Qualitative Data Analysis: An Integrative Review, Empirical Guidance, and Next Steps. Int J Qualitative Methods. 2024;23:16094069241296206. sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

Anhedonia has been linked with emotional neglect of a child.

“and in more severe cases, anhedonia has been linked with emotional neglect of a child [42].”

• cites [42] Tester-Jones M, Karl A, Watkins E, O’Mahen H. Rumination in dysphoric mothers negatively affects mother–infant interactions. Child Psychol Psychiatry. 2017;58(1):38–45. sourceNot checked — no full text of the source

May combine two claims.

A parent's ability to attend clinic appointments, nourish their baby, and engage in HIV prevention behaviors, such as taking pre-exposure prophylaxis consistently during the peripartum period, may well reduce the risk of HIV acquisition and transmission as well as support the wellbeing of the infant.

“A parent’s ability to attend clinic appointments, nourish their baby, and engage in HIV prevention behaviors, such as taking pre-exposure prophylasis consistently during the peripartum period, may well reduce the risk of HIV acquisition and transmission as well as support the wellbeing of the infant.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The study shares limitations common among secondary analyses of qualitative data; the interview guide was already written and the interview data were collected when the analysis began; therefore, the guide was not developed to specifically address the main question of these analyses, and we were unable to probe around topics like the perceived impact of mental health on bonding.

“This study also shares limitations that are common among secondary analyses of qualitative data; the interview guide was already written and the interview data were collected when the analysis began; therefore, the guide was not developed to specifically address the main question of these analyses, and we were unable to probe around topics like the perceived impact of mental health on bonding.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

We worked closely with our isiXhosa-speaking team-members to reduce the likelihood of losing key information and cultural context during the analysis and interpretation phases, but it is possible that some cultural nuances may have been missed or misinterpreted.

“We worked closely with our isiXhosa-speaking team-members to reduce the likelihood of losing key information and cultural context during the analysis and interpretation phases, but it is possible that some cultural nuances may have been missed or misinterpreted.”

May combine two claims.

We could not formally assess differences in perceived impacts of mental health on caregiving and bonding between pregnancy and postpartum, though some participants who were interviewed only postpartum did reflect on differences.

“Therefore, we could not formally assess differences in perceived impacts of mental health on caregiving and bonding between pregnancy and postpartum, though some participants who were interviewed only postpartum did reflect on differences.”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

These women were therefore already exhibiting resilience with respect to their mental health symptoms.

“These women were therefore already exhibiting resilience with respect to their mental health symptoms.”

May combine two claims.

The parent study was designed to explore psychological barriers to PrEP uptake during pregnancy and after delivery, but only seven of the 23 participants completed two interviews (one during pregnancy and one postpartum).

“The parent study was designed to explore psychological barriers to PrEP uptake during pregnancy and after delivery, but only seven of the 23 participants completed two interviews (one during preganancy and one postpartum).”

Probably not a substantial claim: may not pass S3 (load-bearing).

Some meaning and cultural nuances may have been lost in translation, as most interviews were conducted in isiXhosa and then analyzed in English after transcription and translation.

“Finally, some meaning and cultural nuances may have been lost in translation, as most interviews were conducted in isiXhosa and then analyzed in English after transcription and translation.”