This post is part of “Mental Health: The Missing Piece in Maternal Health,” a blog series co-hosted by the MHTF, the Mental Health Innovation Network at the London School of Hygiene and Tropical Medicine and Dr. Jane Fisher of Monash University.
Across most settings, and particularly in low- and middle-income countries (LMICs), antenatal care (ANC) is a critically missed opportunity to identify and support women with common mental health problems.
ANC has proven itself a promising and cost-effective platform to address a multitude of health and social issues for expectant mothers and their children. In recent years, successful initiatives have addressed issues such as HIV, syphilis and other sexually transmitted infections; screening for nutritional deficiencies and anaemia; malaria in pregnancy; and, in some contexts, screening, referral and support for women experiencing intimate partner violence.
ANC attendance in many LMICs is high and increasing with 90% of women visiting a skilled provider for at least one ANC visit (75% in Africa and 76% in Southeast Asia). ANC is one of the few junctures in a woman’s life where accessing health services is likely and may also be the first time she connects to the formal health system. This provides a unique opportunity to engage with her at a critical point in her own life and her family’s life. Additionally, ANC potentially provides a connection between her and additional health and social services that may support her well after her baby is born.
Though more evidence on non-psychotic common perinatal mental disorders is needed from LMICs, we know that depression affects a substantial proportion of women: one in six pregnant and one in five postpartum women – almost double that found in high-income countries. Although screening for postnatal depression has been introduced in some LMIC safe motherhood programmes, it is insufficient since poor antenatal mental health holds consequences for pregnancy and early childhood outcomes and is a predictor of postnatal depression. At the extreme, suicide has become a leading cause of pregnancy-related death in multiple contexts, with many of these deaths occurring during pregnancy.
From a practical perspective, introducing mental health screening and psychosocial interventions through ANC would allow more women to receive the screening, diagnosis and treatment they need, since postpartum care reaches only half the number of women that ANC does and global experts are increasingly calling for integrated services. Also, failing to integrate services such as HIV and malaria testing and treatment into ANC has a high social, health and economic cost, which is likely also true for failing to integrate mental health services.
Integrating mental health into ANC is not without its challenges though, and further research is needed in LMICs to better understand and ultimately shape interventions with the following characteristics:
- Perinatal mental health services are context specific and sensitive
- Tools are feasible and valid and can be applied in pregnancy by non-mental health specialists
- Efforts reduce stigma and increase acceptability of mental health interventions, particularly in contexts where partners or other significant others may be present during ANC visits
- Psychosocial interventions are realistic and may be offered in even the most resource-strapped settings
Investment is needed to enable overworked and basically trained service providers to deliver mental health screening and care, but worthwhile results are possible.
Delivering better mental health outcomes through ANC for non-psychotic common perinatal mental disorders is less about the medical model of care and more about psychosocial support, and may be less affected by matters of supply chain, stock outs, facilities and infrastructure. It is first and foremost about offering an empathetic ear in a safe space in which women can explore options for healthier and happier motherhood alongside their families and service providers. Let’s work together to ensure the antenatal platform is an effective and pragmatic channel that can support these much needed efforts.
Enjoyed this post about maternal mental health? Read more posts in the Mental Health: The Missing Piece in Maternal Health blog series.
Photo Credit: A pregnant woman Ruman Khanom has a general check up from a BRAC community nurse © 2012 DFAT, used under a Creative Commons Attribution license: https://creativecommons.org/licenses/by-sa/2.0/