Addressing the Maternal Mental Health Diagnosis Gap Through Screening Tools in Low- and Middle-Income Countries

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By: Teertha Arora, Candidate for Masters in Public Health (Global Health), Harvard T.H. Chan School of Public Health

World Maternal Mental Health Day, acknowledged by several global alliances on 2 May, seeks to raise awareness of mental health challenges that women may face before, during and after pregnancy. The prevalence of common perinatal mental disorders (CPMD) such as depression and anxiety in low- and middle-income countries (LMICs)—an estimated 16%—surpasses that of high-income countries. Research shows that CPMD can not only compromise a woman’s quality of life but can also lead to adverse effects on the child’s development. In LMICs, this is further intensified due to social and economic challenges that a child might face while growing up.

Diagnosis gap in LMICs

Despite contributing significantly to maternal deaths and unproductive life years, CPMD often go undetected among women in low-resource regions. This can mean that up to 80% of women remain untreated in such settings. Resource-constrained primary care centers, high patient volumes, lack of recognition by health workers as well as increased task shifting to semi-skilled health workers contribute to this treatment gap. In order to encourage timely identification of CPMD among mothers followed by referrals, antenatal care provision centers are a promising platform in LMICs due to the high level of touchpoints between expectant women and health systems. In South Africa, for example, a mother’s contact rate with any antenatal care facilities is quite high at approximately 91%.

After addressing ‘where’ to screen, the challenge remains ‘how’ to screen. There are numerous screening tools to identify CPMD, but they are designed for high-resource settings. There is a dearth of mental health screening tools validated for use in low-resource settings among pregnant women, specifically in Africa. To address this research gap, a study recently published in PLOS ONE by Heyningen et al. examined the reliability and feasibility of five screening tools to diagnose Major Depressive Episode and/or anxiety in a South African primary care antenatal clinic.

Leveraging screening tools in constrained settings

In LMICs—where the health workforce is often overburdened—it is essential that screening tools are simple and concise. Heyningen et al. found that the ultra-short “Whooley questions” tool is almost comparable to other screening questionnaires like the Edinburgh Postnatal Depression Scale (EPDS), Kessler 10 (K10) and Patient Health Questionnaire (PHQ9) in South Africa based on technical validity (table 1). They concluded that it is a feasible screening instrument for busy, non-specialist health workers in poor-resource settings. Further, the authors recommended that K6 screening tool might be the most “sensitive, feasible and acceptable” given the local constraints and scientific strength of the instrument. However, ultra-short screening instruments should be used with caution—follow-up with detailed clinical assessment can be useful to confirm the questionnaire results. It is critical to integrate screening for CPMD with antenatal primary care clinics along with development of care pathways for vulnerable mothers.

Table 1. Comparison of mental health screening tools for detecting antenatal depression and anxiety disorders in South African women

As the issues surrounding maternal mental health gain momentum, it is critical that stakeholders organize political will for universal screening to detect CPMD. The study in South Africa by Heyningen et al. supports the notion that easy-to-administer tools for depression and anxiety can be implemented successfully in antenatal care settings. Seizing the opportunity for early case detection and treatment is key to improving the quality of life for mothers in resource-constrained settings.

Lead author Thandi van Heyningen shares insight into progress and next steps for improving maternal mental health in low-resource settings:

“Where health system resources are scarce, one way of improving detection and improving access to treatment, is to integrate these services into existing, routine, primary health care services using a stepped care approach. Improving detection through routine antenatal screening may provide a vital first step, however there is a need to generate further evidence on the feasibility and acceptability of existing screening tools for use in such settings, and by non-specialist health care workers.”

Read the full paper “Comparison of mental health screening tools for detecting antenatal depression and anxiety disorders in South African women” in the MHTF-PLOS collection on NCDs and maternal health

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