Interpersonal factors associated with depression symptom severity among PrEP-naïve pregnant women in South Africa: a mixed-methods analysis

Depression during pregnancy is linked to reduced use and adherence to pre-exposure prophylaxis (PrEP), increasing HIV risk. However, few studies explore how interpersonal factors shape depressive symptoms in pregnant women. We surveyed 110 pregnant women in Cape Town, South Africa, assessing depression and three interpersonal constructs: reproductive autonomy, dyadic trust, and relationship power. Participants had a mean age of 25.7 years and a mean gestational age of 29.3 weeks. In the multivariable model, decreased reproductive autonomy in decision-making remained a significant predictor of increased depression symptom severity (<i>β</i> = -1.21, 95% CI [-2.05, -0.37], <i>p</i> < .05). A subset of 17 women with likely depression participated in qualitative interviews analyzed using thematic analysis. These narratives revealed four pathways linking reduced reproductive autonomy to worsened depression: (1) loss of control over reproductive events, (2) gendered power imbalances, (3) fear of retaliation for asserting autonomy, and (4) emotional strain in efforts to regain agency. These findings suggest that addressing interpersonal dynamics, especially by involving male partners in communication and shared decision-making may enhance the effectiveness of mental health and HIV prevention interventions for pregnant women in South Africa.