Overall statement or summary

This study aimed to determine the prevalence of antenatal depression and associated factors among pregnant women in Addis Ababa, Ethiopia. A cross-sectional study was conducted in 6 Public Health facilities. results showed that prevalence of antenatal depression was 24.94%. Factors associated with it were an unplanned pregnancy, the absence of partner support and a personnal history of depression. Hence the recommendations to reinforce family planning programs, and include an assessment of these factors associated with antenatal depression among pregnant women in Ethiopia.

First, further research could be built upon this first study in Ethiopia. Then, there could be no health without mental health according to the WHO definition of health. Indicators of good antenatal care services provision only relates to the number of visits the pregnant woman has done. The Lancet Maternal Health Series have concluded that the true engine of change in maternal health will not only be the formal clinical guidelines, but mostly the determination of people at the frontlines of health systems, starting with patients. This study raises awareness on the high prevalence of depression in pregnant women in Ethiopia. It could be a starting point to explore ANC services uptake based on the mental health status of the pregnant women. It provokes reflections such as if these women are not determined to seek care, maybe it is also related to antenatal depression. So, no matter what quality improvement of ANC services, if care providers are not able to assess the patients' readiness through the lens of mental health issues, there could be no true engine for change on the long run.

Strengths

Abstract, title and references The Abstract is strong enough and engaging. The aim, the methods and findings are clear for a start. Furthermore, the title informative and relevant. References are relevant, recent and referenced correctly. Absolutely appropriate key studies were included to support the statements, especially in the Introduction section.

Introduction The Introduction is really well-structured and puts the readers into the context of the topic. Ti is clear what is already known about this topic: from the general to the specific case of Ethiopia, frequencies of antenatal depression and its severity, the validity of the tool which is going to be used (Edinburgh Postnatal Depression Scale), all with appropriate references. In total, the research question is justified given what is already known about the topic.

Methods Study design was appropriate to answer the aim in general.

Results The data is presented in an appropriate way, tables and figures relevant and clearly presented with appropriate units, rounding, and number of decimals. Titles, columns, and rows are labelled correctly and clearly. Categories are grouped appropriately. The text in the results is not repetitive. It is also clear what a statistically significant result is and what a practically meaningful result is.

Discussion and conclusions The results are not overinterpreted, and conclusions do answer the aims of the study. Conclusions are supported by results. The limitations of the study are opportunities to inform future research.

Ethical considerations: All information related to funding transparency, disclose of conflicts of interest were given by the authors in the paper.

Overall, the article is consistent within itself.

Weaknesses

I have concerns mainly with the Methods section. The authors have not included enough information for the readers to understand the choice of the study settings and to ensure the reproducibility of the study.

Major points

Methods: 1. Study setting :
- inclusion criteria: there is not enough information on the features of the selected public health centers. For instance, might location, offering of specific services, intensity of antenatal care services uptake have an impact on the selection? - can the authors further explain how the fact that services are free of charge play with study settings selection? what does that information bring to the selection of the facilities? or also why not paying services such as clinics where women with antenatal depression could also be screened - for the sake of representation-?

1. Sample size and sampling procedure :
   - Can the authors provide a reference for the 50% assumption of the prevalence of pregnant women with antenatal depression? Because when one refers to what has been said in the Introduction, the prevalences in the cited African countries were all between 20 to 30%. - when the authors say "randomly" on Page 2 : do all the 26 public health centers in Addis Abbaba have the same size, same activity volume etc.? I am uncomfortable with the representation and the external validity of the study if the authors do not explain why they have chosen such sampling method. - 422 participants were selected for 6 Public Health centers : did the authors recruit an equal number of participants per facility? - Inclusion criteria of participants : any specific criteria such as age, urban residence (not rural women who occasionnally came to the facility at the moment the study was conducted???). - Can the authors explain why they have chosen to explore all terms instead of mid and late terms (which is well defended in the Introduction section and might lead readers to think there should be no room for early term pregnancies then). - "Any apparently healthy pregnant woman": who assessed that (investigators or the participants themselves?). And which criteria were used to attribute such characteristic to a participant?

Minor points

1. Introduction : The factors associated with antenatal depression already outlined in existing litterature prior to the study should have been highlighted in the Introduction -maybe in relationship with Figure 1. This way, readers might be acquainted first with the factors and understand why the authors have chosen specific variables to study instead of exploring a whole lot of other variables.

2. Figure 1: Can the authors add up the source/reference/permission to the figure?

3. Results : Table 2 : what is the definition of "chronic illness"? It should have been given in the Methods section.

4. Discussion and conclusions :

5. The results are not really discussed from multiple angles, but only as compared to similar studies. The future research which could flow from this study for instance were not mentionned, like what further research is required based on these results to bridge the gap between actual situation and the recommendations for implementation the authors have provided.

6. When the authors suggest strengthening of referral systems, which results does it relate to and why?

7. Ethical considerations It could be interesting to find out how they could access the data for data-sharing purposes when appropriate.