Bulletin of the World Health Organization

Interventions for common perinatal mental disorders in women in low- and middle-income countries: a systematic review and meta-analysis

Atif Rahman, Jane Fisher, Peter Bower, Stanley Luchters, Thach Tran, M Taghi Yasamy, Shekhar Saxena & Waquas Waheed

Volume 91, Number 8, August 2013, 593-601I

Table 1. Design, methods and main findings of 13 trials of interventions for common perinatal mental disorders in women in low- and middle-income countries

Study Location Design Inclusion/exclusion criteria, recruitment and retention Baseline assessment and outcome measures Main findings
Cooper et al., 200228 Khayelitsha, a periurban settlement outside Cape Town, South Africa Pilot investigation to inform a controlled trial, with comparison between two non-systematically recruited groups consisting of mother–infant pairs Inclusion criteria: intervention group, 40 women-infant pairs; comparison group, 32 mother–infant pairs, group-matched with survey participants in an adjacent area on at least two of maternal age, parity and marital status;
Recruitment: strategy not specified;
Retention: 32 of 40 (80%) mothers in intervention group followed up to the end of the project. No attrition in control group was reported.
Baseline: No assessment.
Outcomes (assessed at 6 months postpartum):
– maternal mood – SCID-I for major depression in mothers;
– mother–infant interaction – coded ratings of 5–10 minute video recordings of mother and infant during free play and feeding;
– infant growth – infant weight, length and head circumference.
Maternal mood:
– major depression 19% (6/32) in intervention group; 28% (9/32) in comparison group;
Mother-infant interaction:
– after controlling for age and education, mothers in the intervention group were more sensitive in play (P = 0.02) and tended to show more positive affect during feeding (P = 0.08).
Infant growth – infants in the intervention group were heavier (P = 0.01) and taller (P = 0.02), but no differences in head circumference or weight-to-height ratio were noted.
Baker-Henningham et al., 200522 Nutrition clinics in Jamaica Comparison between mother–infant pairs recruited from government clinics. Clinics were stratified by size of client population and randomly assigned to intervention (11) and control (7) arms Inclusion criteria: singleton infants aged 9 to 30 months; weight-for-age Z-score ≤ –1.5 at time of assessment and ≤ –2 in 3 most recent months; birth weight > 1.8 kg; absence of chronic disease or disability;
Exclusion criteria: none stated;
Recruitment: 70 of 76 (92%) eligible mother–infant pairs recruited for intervention arm; 69 of 70 (99%) eligible pairs recruited for control arm;
Retention: 64 of 70 (91%) mother–infant pairs in intervention group and 61 of 69 (88%) pairs in control group were followed up to the end of the study.
Baseline: parental sociodemographic characteristics, housing quality, maternal vocabulary on PPVT-R.
Outcomes (assessed 1 year after recruitment):
maternal mood – culturally modified version of the CES-D to assess maternal depression;
child development – subscales of the Griffiths Mental Development Scale assessing: locomotor development, hearing and speech, hand–eye coordination and performance development to give a global developmental quotient (DQ);
child anthropometry – height-for-age, weight-for-height, and weight-for-age Z-scores of the NCHS growth reference.
Maternal mood:
– decline in depressive symptoms seen in intervention group but not in control group (β = –0.98; 95% CI: –1.53 to –0.41);
mothers receiving 40–50 home visits had greatest decline in depressive symptoms (β = −1.84; 95% CI: –2.97 to –0.72);
mothers receiving 25–39 home visits had lesser decline in depressive symptoms (β = −1.06; 95% CI: –2.02 to –0.11);
mothers receiving 0–24 home visits did not differ from control group (β = −0.09; 95% CI: –1.11 to 1.13).
Child development – final maternal depression and final DQ correlated in boys (P < 0.05) but not in girls.
Rojas et al., 200723 Primary care clinics in Santiago, Chile Comparison between participants randomized to multi-component intervention or to regular primary health care Inclusion criteria: having a child aged ≤ 1 year old; being enrolled in one of the clinics; EPDS score ≥ 10 on two occasions 2 weeks apart; MINI diagnosis of major depression;
Exclusion criteria: any treatment for depression since giving birth; pregnancy; psychotic symptoms; suicidal behaviour; history of mania or alcohol or substance abuse;
Recruitment: of 313, 67 met at least one exclusion criterion and 16 refused; 230 of 246 (93%) recruited;
Retention: in intervention group, 101 of 114 (89%) at 3 months and 106 of 114 (93%) at 6 months; in control group, 108 of 116 (93%) at 3 months and 102 of 116 (88%) at 6 months.
Baseline: maternal age, marital status, occupation, parity, interval since giving birth and history of depression (EPDS, SF-36, MINI).
Outcomes (assessed blindly 3 and 6 months after the intervention):
maternal mood primary outcome: EPDS score; secondary outcomes: mental health, emotional role, social functioning and vitality dimensions of the SF-36 and clinical improvement.
Maternal mood:
EPDS scores improved in multi-component intervention at 3 months (–4.5 difference in mean scores between groups [95% CI: –6.3 to –2.7; P < 0.0001]);
EPDS scores were at least 3 points lower (95% CI: 3–29) at 6 months than at baseline in 73% of the intervention group and 57% of the usual care group.
Rahman et al., 200825 Union Council clusters in two sub-districts: Gujar Khan and Kallar Syedan in rural Pakistan Comparison between women living in 40 union councils that had been randomized independently to intervention (20) and control (20) groups Inclusion criteria: being married; being 16 to 45 years old; being, in the third trimester of pregnancy; meeting SCID-I criteria for major depressive episode;
Exclusion criteria: serious medical condition or pregnancy-related illness; significant learning or intellectual disability; postpartum or other psychosis;
Recruitment: inclusion criteria were met by 463 of 1787 (26%) women in intervention councils and by 440 of 1731 (25%) women in control councils;
Retention: in intervention group, 418 of 463 (90%) mothers at 6 months and 412 of 463 (89%) at 12 months; in control group, 400 of 412 (91%) mothers at 6 months and 386 of 412 (88%) at 12 months; in intervention group, 368 (79%) infants at 6 months and 360 (78%) at 12 months; in control group, 359 (82%) at 6 months and 345 (78%) at 12 months.
Baseline: maternal age, education, family structure, parity, socioeconomic status and financial empowerment; HDRS, Brief Disability Questionnaire, Global Assessment of Functioning, self-assessment of adequacy of social support.
Outcomes (assessed blindly):
maternal mood psychiatrist-administered HDRS and SCID-I at 6 and 12 months postpartum to assess maternal depression;
infant health and development – infant weight and length; number of diarrhoeal episodes in previous fortnight and infant immunization status;
– family health and functioning – maternal reports of exclusive breastfeeding, use of contraception and time dedicated to infant play.
Maternal mood after adjusting for covariates women in the intervention group:
– were less likely to be depressed at 6 months postpartum (23% vs 53%; aOR: 0.22; 95% CI: 0.14–0.36; P < 0.0001);
– were less likely to be depressed at 12 months postpartum (27% vs 59%; aOR 0.23; 95% CI: 0.15–0.36; P < 0.0001);
– were less disabled at 6 months (aMD: −1.80; 95% CI –2.48 to –1.12; P < 0.0001) and at 12 months (aMD: –2.88; 95% CI –3.66 to –2.10; P < 0.0001);
– had better global functioning at 6 months (aMD: 6.85; 95% CI: 4.73–8.96; P < 0.0001) and at 12 months (aMD: 8.27; 95% CI: 6.23–10.31; P < 0.0001);
– had better perceived social support at 6 months (aMD: 6.71; 95% CI: 3.93–9.48; P < 0.0001) and at 12 months (aMD: 7.85; 95% CI: 5.43–10.27; P < 0.0001).
Infant health and development:
– no difference between groups in infant stunting or malnutrition;
– infants of intervention group mothers had fewer episodes of diarrhoea at 12 months (aOR: 0.6; 95% CI: 0.39–0.98; P = 0.04) and were more likely to be fully immunized (aOR: 2.5; 95% CI: 1.47–4.72; P = 0.001).
Family health and functioning:
– intervention group more likely to be using contraception at 12 months (aOR: 1.6; 95% CI: 1.20–2.27; P = 0.002);
– both parents dedicated time to playing with the infant (aOR for mothers: 2.4; 95% CI: 2.07–4.01; P < 0.0001; aOR for fathers: 1.9; 95% CI: 1.59–4.15; P = 0.0001).
Rahman et al., 200924 Kallar Syedan, a Union Council district of 60 villages in a rural area south-east of Rawalpindi, Pakistan 48 of 60 villages accessible by road. Comparison between mothers and infants living in villages randomly assigned to the intervention (24) or to usual care (24) Inclusion criteria: being married; being 17–40 years old; being in the third trimester of pregnancy; being registered with a lay health worker;
Exclusion criteria: serious medical condition or complication of pregnancy;
Recruitment: of 367 women, 334 met inclusion criteria and agreed to participate: 177 of 194 (91%) in intervention villages and 157 of 173 (90%) in control villages;
Retention: 163 of 177 (92%) women in intervention group and 146 of 157 (93%) women in control group.
Baseline:
– maternal age, education and parity and family income and structure;
– maternal knowledge and attitudes about infant development in the first 8 weeks of life using an original infant development questionnaire;
– maternal emotional distress using the SRQ-20, locally field-tested and validated.
Outcomes (assessed blindly at 3 months postpartum):
– maternal knowledge about infant development;
– infant development questionnaire;
– maternal emotional distress SRQ-20.
Maternal knowledge about infant development – intervention group had significantly higher increase in questionnaire scores than control group at 3 months postpartum (aOR: 4.28; 95% CI: 3.68–4.89; P < 0.0001);
Maternal emotional distress – no difference in SRQ-20 scores between intervention and control groups.
Cooper et al., 200926 Khayelitsha, South Africa Comparison between women, identified systematically during pregnancy via home visits and randomly assigned to intervention or standard care using minimization procedures to control for antenatal depression and unintended pregnancy Inclusion criteria: living in one of the two study areas; being in the third trimester of pregnancy;
Exclusion criteria: none;
Recruitment: 449 of 452 eligible women recruited: 220 assigned to intervention group and 229 to control group;
Retention: 354 of 449 (78.8%) at 6 months; 346 of 449 (77%) at 12 months and 342 of 449 (76%) at 18 months. Retention lower among younger women than among older women (P < 0.05).
Baseline: No assessment.
Outcomes (assessed in a purposely-built accessible facility with a one-way mirror and video-recorders):
– mother–infant interaction – at infant age of 6 months, video tapes of 10 minutes of free play independently scored to assess maternal sensitivity and intrusiveness; at infant age of 1 year, observations of maternal ability to facilitate play;
– infant attachment – at infant age of 18 months, the Strange Situation Procedure;
– maternal depression – at 6 months postpartum, SCID-I interviews, which incorporated the EPDS, administered in Xhosa by a trained research worker, taped and then scored with a clinical psychologist.
Mother-infant interaction – intervention group significantly more sensitive and less intrusive in interactions with infants at both 6 and 12 months (all P < 0.05);
Infant attachment:
– more securely attached infants in intervention group than in control group (OR: 1.70; P < 0.029);
– higher rates of anxious–avoidant attachment in control than intervention group.
Maternal depression:
– lower prevalence of depression in intervention than control group at 6 and 12 months postpartum, but differences not significant;
– EPDS scores lower in intervention than control group at both assessment points, but difference only significant (P = 0.04) at 6 months;
– depression ratings unrelated to maternal sensitivity or intrusiveness.
Ho et al., 200933 Taipei and Taiwan, China Comparison between primiparous women assigned alternatively on day one postpartum to intervention or control group. Women in shared wards were assigned as a group Inclusion criteria: being married; being primiparous; being 20–25 years old; having had a spontaneous vaginal delivery; having had a singleton, at-term infant weighing ≥ 2500 g and with an APGAR score > 8;
Exclusion criteria: postnatal complications or psychiatric history;
Recruitment: numbers meeting eligibility criteria not reported. Of 240 invited, 200 were recruited and 100 were assigned to each arm;
Retention: 83 of 100 (83%) women in intervention group and 80 of 100 (80%) women in control group were followed up to the end of the project.
Baseline: no baseline assessment; sociodemographic characteristics assessed at 6 weeks.
Outcomes:
– maternal mood – EPDS score and “experience of postnatal depression” assessed at 6 and 12 weeks postpartum.
Maternal mood:
– no differences between groups in sociodemographic factors or “postnatal experiences”;
– no difference between groups in EPDS score > 9 at 6 weeks (21% intervention versus 30% control, P = 0.2) or at 3 months (11% intervention versus 16% control, P = 0.3) postpartum;
– both groups experienced improvement in mood over time.
Gao et al., 201029 & 201230 A regional teaching hospital in southern mainland China Comparison between groups randomly assigned to intervention and control arms Inclusion criteria: being married; being nulliparous; being < 36 years old; being > 28 weeks pregnant;
Exclusion criteria: having a complicated pregnancy or a psychiatric history;
Recruitment: 194 of 262 (74%) eligible women recruited: 96 assigned to intervention group and 98 to control group;
Retention: 87 of 96 (90%) women in intervention group and 88 of 98 (89%) women in control group.
Baseline:
Sociodemographic characteristics, EPDS, GHQ-12, SWIRS.
Outcomes (assessed at 6 and 12 weeks postpartum):
maternal mood – EPDS, GHQ-12, and SWIRS completed at obstetric clinic visits.
Maternal mood:
– intervention group significantly lower EPDS (95% CI: –3.48 to –1.09); GHQ-12 (95% CI: –1.29 to 0.33) and SWIRS mean scores (95% CI: 0.31–1.25) than control group at 6 weeks postpartum;
– difference in proportion with EPDS scores > 12 in intervention (9.38%) and control (17.35%) not significant (P = 0.1) at 6 weeks postpartum;
– intervention group significantly lower mean scores on EPDS (5.61 vs 6.87; P < 0.01) and GHQ-12 (1.44 vs 1.71; P < 0.01) at 3 months postpartum.
Tripathy et al., 201034 Saraikela Kharswan, West Singhbhum and Keonjjhar districts in Jharkand and Orissa states, India Comparison between women living in control and intervention communities from July 2005 to July 2008. Clusters stratified by whether or not women’s groups were available, then allocated to intervention and control groups by a transparent number-drawing process on site Inclusion criteria: being 15–49 years old; being pregnant and giving birth during the study period; being a resident of a study district;
Exclusion criteria: none, but data from women who migrated out of the study area were excluded from intention-to-treat analyses.
Baseline: no assessment of individual women.
Outcomes:
– neonatal mortality rate – maternal and neonatal deaths assessed by key informant (usually a traditional birth attendant) surveillance system and verbal autopsies;
– maternal mood – structured interviews about sociodemographic characteristics, antepartum, intrapartum and postpartum health and health care and the K10 in 2nd and 3rd years of the study.
Neonatal mortality ratio 55.6, 37.1 and 36.3 per 1000 births in intervention clusters vs 53.4, 59.6 and 64.3 in control clusters in the 3 years of the study. Overall, 32% lower in intervention than in control clusters (aOR: 0.68; 95% CI: 0.59–0.78); 45% lower in years 2 and 3 (aOR: 0.55; 95% CI: 0.46–0.66);
Maternal mood – no significant differences between groups overall, but moderate depression (K10: 16–30) 5% in intervention and 10% in control group in year 3 of the study (aOR 0.43; 95% CI: 0.23–0.80);
Infant care – clean birth care practices and rates of exclusive breastfeeding at 6 weeks higher in intervention than control groups.
Lara et al., 201031 Mexico City, Mexico Comparison of depression rates at 3 and 6 weeks and at 4 to 6 months postpartum in women randomly assigned to intervention and to regular antenatal care Inclusion criteria: ≥ 18 years old; ≤ 26 weeks pregnant; completed primary school;
Exclusion criteria: substance abuse or bipolar conditions; reported suicide attempts during the last six months;
Recruitment: from the waiting rooms of: (i) a hospital providing intensive care for women with high-risk pregnancies; (ii) a women's clinic for partners and/or wives of men in the armed forces; and (iii) a community health-care centre. Intervention group: 117 pregnant women; comparison group: 250 pregnant women;
Recruitment rate: 70.2%;
Retention: 27.2% women in intervention group and 53.6% in control group.
Baseline: demographic and obstetric data; SCID-I; BDI-II, SCL-90-R.
Outcomes:
– maternal mood;
– major depression: SCID-I interviews for DSM-IV diagnoses of major depression in mothers;
– depressive symptoms: BDI-II, cut-off point of 14;
– anxiety symptoms: SCL-90-R, cut-off point of 18.
Maternal mood:
– cumulative incidence of major depression over three time periods was 10.7% in intervention and 25% in control group (P < 0.05);
– significant reduction of BDI-II score in both groups, but no significant treatment effect;
– most participants who completed the intervention reported that it had a moderate to large influence on their well-being, mood, ability to cope with problems, role as mothers and relationship with their infants.
Mao et al., 201232 First Hospital of Hangzhou, Zhejiang, China Comparison of depression rates at 6 weeks postpartum in pregnant women randomly assigned to an emotional self-management training programme or to standard antenatal care Inclusion criteria: being healthy and nulliparous; having a single pregnancy;
Exclusion criteria: “puerpera of old age” (age not specified); pregnancy complications; personal or family history of psychiatric disorder;
Recruitment: 240 of 532 (45.1%) eligible women recruited and randomized to intervention (120) and control (120) groups;
Retention: 113 of 120 (94%) women in intervention group and 108 of 120 (90%) women in control group.
Baseline: socio-demographic characteristics, PHQ-9.
Outcomes:
– maternal mood – depression: PHQ-9 score ≥ 10, EPDS, SCID-I, interviewed by the first author who was blind to group allocation.
Maternal mood:
– at 6 weeks postpartum, intervention group had significantly lower mean PHQ-9 (P < 0.01) and EPDS scores (P = 0.04) than control group;
– fewer in intervention group with SCID-I diagnosis of major depression (OR = 0.29; 95% CI: 0.21–1.01).
Hughes, 200927 Goa, India Pregnant women identified through 138 anganwadi centres and randomly assigned to intervention or standard care arms Inclusion criteria: being in the third trimester of pregnancy; being able to speak English or Konkani; scoring ≥ 5 on GHQ-12, or having an unplanned pregnancy, or having a “male child fixation”;
Exclusion criteria: having a severe health condition; intending to leave area during study period; having frequent thoughts of harming self;
Recruitment: of 1320 pregnant women, 62 were ineligible and 76 did not attend the screening interview. Of the 1173 women screened, 565 (48.1%) met inclusion criteria, 142 (25.1%) met at least one exclusion criterion and 1 declined. Remaining 422 women at “high risk of postnatal depression” randomly assigned to intervention group (212) or standard care (210);
Retention: 187 of 212 (88.2%) women in intervention group and 181 of 210 (86.2%) women in control group.
Baseline:
– socioeconomic factors; parity, gestational age; feelings about the pregnancy and past psychiatric history;
– maternal mood assessed by locally validated EPDS and CIS-R.
Outcomes (assessed blindly):
– maternal mood – EPDS score and meeting CIS-R assessed ICD diagnostic criteria for depression at 3 months postpartum;
– infant development DAS-II mental development quotient ; maternal report of infant birth weight; infant weight at 12 and 26 weeks postpartum.
Maternal mood (with control for between-group differences in sociodemographic factors) – no difference between groups in EPDS score > 12 (7.7% vs 7.8%; uOR: 1.01; 95% CI: 0.51–2.01).
Infant development – no difference between groups in DQ < 85 (12.1% vs 10.0%; uRR: 0.82; 95% CI: 0.45–1.49); no differences in mean infant weight between intervention and control groups.
Morris et al., 201235 Camps for internally displaced people in Kitgum district, Northern Uganda Comparison between women attending three Kitgum emergency feeding centres (intervention group) and women attending two other centres (control group) Inclusion criteria: having a moderately or severely malnourished infant aged 6 to 30 months; being enrolled in a feeding centre;
Exclusion criterion: infant requiring inpatient care;
Recruitment: all 132 eligible women agreed to participate in the intervention; 105 were in control group;
Retention: 106 of 132 (80.3%) women in intervention group and 52 of 105 (49.5%) in control group.
Baseline: sociodemographic characteristics and years in camp.
Outcomes:
– maternal knowledge of child development – 10-item Knowledge, Attitudes and Practice test;
– mother–infant relationship – Acholi adaptation of the HOME Inventory to assess maternal involvement, variety, punishment, play materials, emotional and verbal responsiveness, acceptance and organization;
– maternal mood –study-specific, culturally appropriate Kitgum Maternal Mood Scale developed through multiple methods to assess sadness, irritability and somatic complaints.
Maternal knowledge about child development – no effect of the intervention and the measure found to have poor internal consistency.
Mother–infant relationship – mothers in intervention group more emotionally responsive (OR: 2.97; 95% CI: 0.71–5.23) and used more play materials (OR: 2.16; 95% CI: 1.22–3.10) than those in the control group.
Maternal mood – no differences between groups when interview location controlled.

aMD, adjusted mean difference; aOR, adjusted odds ratio; BDI-II, Beck Depression Inventory II; CES-D, Center for Epidemiologic Studies Depression Scale; CI, confidence interval; CIS-R, Revised Clinical Interview Schedule; DASII, Development Assessment Scales for Indian Infants; DQ, developmental quotient; EPDS, Edinburgh Postnatal Depression Scale; GHQ-12, 12-item General Health Questionnaire; HDRS, Hamilton Depression Rating Scale; HOME, Home Observation and Measurement of the Environment; ICD, International Classification of Diseases; K10, 10-item Kessler Psychological Distress Scale; MINI, Mini International Neuropsychiatric Interview; NCHS, National Center for Health Statistics; OR, odds ratio; PHQ-9, nine-item Patient Health Questionnaire; PPVT-R, Peabody Picture Vocabulary Test – revised; SCID-I, Structured Clinical Interview for DSM-IV Diagnoses; SCL-90-R, Symptom Checklist-90-R; SF-36, Short Form (36) Health Survey; SRQ-20, 20-item Self-Reporting Questionnaire; SWIRS, Satisfaction with Interpersonal Relationships Scale; uOR, unadjusted odds ratio; uRR, unadjusted relative risk.