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.
This blog post starts in Goa. Not at the white beaches, but in the antenatal clinic at Asilo hospital in Mapusa where women in all stages of pregnancy are queuing up for antenatal check-ups. It is one of the busy days at the hospital, with women sometimes needing to stand for hours before they are seen by a doctor. At least 15% of women in this queue suffer from perinatal depression and this figure can increase to up to 30% after the baby has been born – this is what we know from our research. In a country like India, where human resources are low, health-systems ill-equipped and mental disorders heavily stigmatized, these women will always be silent sufferers and will only in rare cases get the help and care they need to overcome their condition.
Our vision: To overcome the shortage of human resources by training peer workers in the treatment of maternal depression.
It is in the antenatal clinic where our study “The Thinking Healthy Programme for Peer Delivery” starts and where pregnant women are screened for maternal depression and invited to participate in our study. A very high proportion of women in Goa keep their antenatal bookings which provides us with the opportunity to screen a large cohort of pregnant women. But what do we do and where do we refer these women when there is only one psychiatrist in the whole hospital and other mental health clinicians are scarce or already overburdened? Basically, we were in search of a community-based resource to address the burden of maternal depression in an acceptable, feasible and cost-effective way.
The answer was quickly found: Peers who have the potential to deliver maternal psychosocial interventions in low-income settings and who can help relieve the scarcity of human capital through task sharing. This is supported by evidence from low- and middle-income countries in which peers have shown to be effective providers in other areas of health care, facilitating mother and child programmes or care for non-communicable diseases and HIV/AIDS.
Who are the peers, and what do they need to be good peer workers?
Before starting our study, we conducted formative research and investigated the preferred characteristics of peers among women with maternal depression and health professionals. Women emphasized the importance of having a peer who has undergone similar experiences and stressful motherhood.
Someone like us… a mother who has undergone similar situations and has overcome them. She will know how to overcome these situations and she can explain that to a mother who is experiencing the same things in her life.
In addition, preferred characteristics included being a local woman who has good communication skills and is trustworthy. There was a preference for educated, middle- to older-aged women. All stakeholders preferred peers over community health workers.
What is the intervention?
For our study, we have adapted the “Thinking Healthy Programme”, an already existing cognitive behavioral intervention to be delivered by peers. The Thinking Healthy Programme was originally evaluated in Pakistan and delivered by community health care workers.
Large effects on depressed mothers and their babies were found: The intervention more than halved the rate of depression in perinatally depressed women compared to mothers in the control group. The intervention had also a big impact on babies. Babies whose mothers received the intervention had less diarrhoea and were more likely to have completed their scheduled immunisations. The Thinking Healthy Programme was so successful that it was recently adopted by the WHO for field testing as an intervention for management of perinatal depression. However, efforts to integrate the Thinking Healthy Programme in the daily routines of community health care workers in Pakistan were compromised due to the multiple roles and tasks community health workers have to play. This will pose long-term problems for scaling up of effective solutions creating a need to explore other human resources like peers delivering this effective intervention.
We are evaluating the Thinking Healthy Programme for Peer-Delivery through an individual randomized control trial in Goa, India, and a cluster randomized control trial in Rawalpindi Pakistan. We have finalized our pilot study, and started the main trials in spring 2015. Research reported in this blog post is supported by the National Institute of Mental Health of the National Institutes of Health under award number 1U19MH095687-01. For more information about peers and specific information about our intervention please read our papers cited below, and view our website, South Asian Hub for Advocacy, Research and Education on Mental Health (SHARE).
Photo: “India 3 Gender 3” © 2007 Justin Kernoghan/Trocaire, used under a Creative Commons Attribution license: http://creativecommons.org/licenses/by/2.0/