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.
Recognition that pregnant and postpartum women living in resource-constrained low- and lower-middle income countries can experience mental health problems is growing. However, a double disparity remains.
- First, prevalence of mental health problems among women in resource-constrained countries is much higher than it is among women living in well-resourced countries, with the greatest burden among the poorest women with the least access to services.
- Second, while all high-income nations have substantial research evidence about the nature, prevalence and risks for perinatal common mental disorders, few resource-constrained countries have any evidence at all.
The evidence base in well-resourced settings allows for the development and implementation of training schemes for health care professionals, screening programs to identify women with clinically significant symptoms or at risk of developing them, referral pathways from primary to specialist care, evidence-informed psychological and pharmacological treatments and explicit public policies to support these. A lack of evidence in resource-constrained countries puts them at a deep disadvantage for developing mental health programming and services to serve the women who need them most.
Efforts to address this imbalance have been implemented in the last ten years with trials of structured programs to improve perinatal mental health problems. These have been conducted in China, India, Pakistan, South Africa, Chile, Jamaica, Mexico and Uganda, and were reviewed in 2013. The content of the programs and the place, time and method of implementing them varied. All the studies were informed by programs developed in high-income countries, but adapted for local cultures and circumstances, and most were implemented by community health workers who were trained, supported and supervised by specialists.
One group of programs addressed women’s depression directly. The Thinking Healthy Programme, for example, is a structured 16-session program using cognitive behaviour therapy methods to help women recognize unhelpful thinking styles—like fatalism, superstitious beliefs and somatization—and learn how to replace them with active problem solving. In rural Pakistan, Lady Health Workers implemented it during routine household visits to individual women from late pregnancy through the first nine postpartum months. It has since been adapted successfully for use with small groups of women, facilitated by female community leaders in Vietnam.
Another group of studies sought to assist adjustment to parenthood by providing additional antenatal classes. In one program in China for example, this involved using the social support of the group and structured learning tasks to teach participants how to take a solution-focused approach to managing conflict in family relationships.
In the third group of studies maternal mental health was not addressed directly, but rather parenting education was provided either by a supportive worker in individual home visits or in a facilitated community-based mother’s group with the intention that this would improve infant health and development, and thereby promote maternal confidence and well-being. In one of these, conducted in Jamaica, mothers were shown how to craft toys for their children out of affordable accessible materials and then how to use these in interactions with their babies so as to stimulate infant cognitive development.
In the studies that involved home visits, the relationship between the worker and the mother was considered to be an important mechanism of change. Health workers, who were members of the local community and understood their clients circumstances, were trained in essential counseling skills like active listening, being trustworthy and non-judgmental, maintaining privacy and offering affirmation and encouragement. Where women lived in multi-generation households, it was suggested that the worker engage other family members to adopt these positive behaviours towards the woman, often using the shared commitment to the healthy development of the baby as a focus.
All these studies included a comparison group and assessed outcomes at a point within the first twelve postpartum months. In a pooled analysis it was found that overall there was a benefit for women’s mental health, with significantly lower maternal depression among participants in the intervention than the comparison conditions. Where assessed, benefits to the baby included stronger relationship between mother and infant, improved cognitive development and growth, fewer diarrhoeal episodes and increased immunization rates.
Program content, number of sessions, theoretical rationale and amount of training provided to health workers varied, but overall the findings of the review indicate that structured programs offered by supervised local health workers are feasible, comprehensible, acceptable and effective in improving women’s mental health. The findings also suggest that the relationship between a woman’s mood and her baby’s health and development is reciprocal. Mothers who are taught how to interact sensitively with their babies, to play with and stimulate them and to be responsive and affectionate experience improved confidence and mood as well as a closer emotional relationship with the baby. Interventions that are directed at the woman’s mental health appear also to have benefits for the baby’s health, growth and development.
The first important lesson from the review is that programs which are culturally adapted and use well-established psycho-educational approaches like cognitive reframing, problem-solving, healthy assertiveness and life stage specific information about infant development and competent parental caregiving are effective in resource-constrained settings. The second is that community-based health workers or members of community organizations can implement these programs if they have received brief training, and, most importantly, have access to regular supportive supervision. Overall it provides promising guidance about ways in which the burden of perinatal mental health problems among women in resource-constrained settings can be addressed.
Photo: “New Mothers” © 2003 Kyle M Lease, used under a Creative Commons Attribution license: http://creativecommons.org/licenses/by/2.0/