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 2. Nature of interventions for common perinatal mental disorders in low- and middle-income countries and acceptability to consumers and providers

Study Nature of intervention Recipient and provider perceptions
Cooper et al., 200228 Adaptation of the Health Visitor Intervention Programme by incorporating principles of WHO’s Improving the Psychosocial Development of Children programme to:
– enhance emotional support for the mother
– promote sensitivity in interacting with infant
– use items from the NBAS to sensitize mother to infant’s abilities
– provide specific practical advice about management of infant sleep, crying and feeding.
Home visits to mothers were made twice antenatally, twice weekly during first month after birth; weekly for next 8 weeks; fortnightly for next month and monthly for next 2 months (a total of 20 visits).
Recipients: moderate to strong agreement among recipients on four-point fixed choice questionnaire items:
– 94% said provider “made me feel supported”; “‘was on my side”; “I could trust and talk openly to her”
– 90% said provider “really understood how I felt”
– 100% said provider “‘made me appreciate the things my baby can do”’
– 90% said provider “‘helped me to solve problems I was having with my baby”; “helped me understand my child’s needs”; “showed me how to respond to what my child was doing”.
Baker-Henningham et al., 200522 Weekly home visits lasting half an hour to:
– improve mothers’ knowledge of child-rearing practices and parenting self-esteem
– use homemade toys, books and household items to demonstrate age-appropriate activities for the child by involving mother and child in play
– provide experiences of mastery and success for mother and child;
– emphasize the importance of praise, responsiveness, nutrition, appropriate discipline and play and learning;
– friendly, empathic approach, but no specific focus on problem solving or on addressing maternal concerns
– standard health and nutrition care offered at clinics.
No data about recipient or provider perceptions reported.
Rojas et al., 200723 A multi-component intervention that included:
– eight weekly structured psycho-educational groups to convey information about symptoms and treatments and to teach problem solving and behavioural activation strategies and cognitive techniques using examples illustrative of the postnatal period
– structured cost-free pharmacotherapy protocol of fluoxetine (20–40 mg per day) or sertraline (50–100 mg per day) for women who did not respond to fluoxetine or were lactating
– medical appointments at weeks two and four and thereafter monthly for 6 months to monitor clinical progress and treatment compliance.
No data about recipient or provider perceptions reported.
Rahman et al., 200825 Thinking Healthy Programme (THP), a manualized intervention incorporating cognitive and behavioural techniques of active listening and collaboration with family; non-threatening enquiry into the family’s health beliefs, a challenging of wrong beliefs, and substitution of these with alternative information when required; and inter-session practice activities. It is designed to be integrated into existing maternal and child health education home visits.
Intervention group received: one THP session per week for the last month of pregnancy, three sessions in the first postpartum month and one session per month for the subsequent nine months (a total of 16 sessions).
Providers: LHWs trained in THP reported that the intervention was relevant to their work and did not constitute an extra workload.
Rahman et al., 200924 Learning Through Play (LTP) programme, developed for use by lay home visitors in Canada and adapted for use in low-income countries. It includes images demonstrating infant development, parent–child play activities and skilled parenting practices conducive to normal cognitive, social and emotional development in the child. The images are accompanied by simple text for groups with low literacy and are presented together as a calendar demonstrating developmental progress. A training manual for providers with additional information about child development is used as a supplement, together with group sessions or one-to-one sessions with parents.
Intervention group received a half-day session on LTP in late pregnancy, with a calendar for home use. Mothers were subsequently visited for 15–20 minutes once a fortnight to discuss their infants’ development, using the calendar as a reference point, until infants turned 12 weeks old. Participants were encouraged to meet informally in groups to apply the techniques in the calendar and provide mutual support to each other.
LHW (n = 24) feedback on the LTP training showed that:
– 87.5% agreed fully or partially that the intervention was relevant to their work
– 84% said that it was easy to integrate into their routine tasks
– 100% felt that the concepts were understandable
– 84% felt they could communicate the concepts to mothers in their care.
Cooper et al., 200926 Same adaptation of the Health Visitor Intervention Programme incorporating principles of WHO’s Improving the Psychosocial Development of Children programme, as used in Cooper et al. (2002)28 to:
– enhance maternal sensitivity and responsiveness towards infants and mother–infant interaction
– use items from the NBAS to sensitize mothers to their infants’ abilities and needs
– hour-long home visits to mothers made twice antenatally, weekly for the first 8 weeks after birth, fortnightly for the next 2 months and monthly for another 2 months (a total of 16 visits, finishing at infant age of 5 months)
– standard health care, which included a fortnightly home visit from a community health worker who assessed maternal and infant health and encouraged mothers to attend the local clinic for infant immunization and weight checks.
Strong support from the local community for the health workers and the project.
Low dropout rates, suggesting that the assessments were acceptable to participants.
Ho et al., 200933 The education programme included a printed three-page booklet containing the incidence, symptoms, causes and management information about the postpartum depression. Women in the experimental group received the booklet and discussed it with primary care nurses on the second day after delivery. No data about recipient or provider perceptions reported.
Gao et al., 201029 & 201230 Intervention embedded in the antenatal childbirth psycho-education programme. In addition to routine antenatal care (two 90-minute classes), the intervention group received two “interpersonal psychotherapy-oriented” classes lasting two hours each and a postpartum follow-up telephone call to reinforce principles. Classes included information-giving, clarification, role playing and brainstorming about new roles and strategies to manage relationships with husbands and mothers-in-law, supplemented by written material. Women in the study group completed the classes with an attendance rate of 95.8%.
Tripathy et al., 201034 Monthly intervention consisting of facilitated women’s group meetings in intervention clusters. The groups involved a participatory action cycle with a focus on maternal and neonatal health: clean births and care seeking. Contextually appropriate case studies used to identify and prioritize perinatal health problems, select strategies to address them (including prevention, home-care support and consultations), implement the strategies and assess results. Maternal depression not a direct focus of the intervention but potentially improved by social support of the group and acquisition of problem-solving skills. No data about recipient or provider perceptions reported.
Lara et al., 201031 Eight weekly sessions lasting 2 hours each and with no more than 15 participants per group. Intervention programme that included: (i) information about the “normal” perinatal period and risk factors for postpartum depression; (ii) a psychological component, aimed at reducing depression through various strategies (e.g. increasing positive thinking and pleasant activities, improving self-esteem and self-care), and (iii) a group component designed to create an atmosphere of trust and support.
Control participants received the usual care provided by their institutions, and both groups received copies of a self-help book on depression especially designed for women with limited reading abilities. The book included a directory of community mental health services in the area.
High proportion of participants reported the impact of the intervention on their depression as having been moderate (60%) or major (23%).
Mao et al., 201232 Emotional Self-Management Group Training (ESMGT) programme comprising 4 weekly group sessions and one individual counselling session. Each group session lasted for 90 minutes. Group session topics included self-management, effective problem solving, positive communication, relaxation, cognitive restructuring and improving self-confidence. On completion of group training, one individual counselling session was arranged to address personal problems.
Control group received standard antenatal education at the study venue. This consisted of four 90-minute sessions conducted by obstetrics nurses. The content of the programme focused on preparation for childbirth.
All participants completed the 4-week ESMGT programme.
Hughes, 200927 Home visits lasting 45 minutes made twice antenatally and three times postnatally (at 4, 7 and 10 weeks, for a total of 5 visits). Visits involved supportive, empathic listening and education intended to:
– provide information within a relationship of trust
– focus on gender determination to help women overcome the notion that infant sex is maternally determined
– conduct client-centred postpartum discussions, including demonstrations of infant massage.
No data about recipient or provider perceptions reported.
Morris et al., 201235 The intervention, derived from the LTP Play programme, was in addition to intensive feeding and included:
– culturally appropriate psycho-education about early childhood development
– given in mother–infant group sessions, which also provided opportunities to share experiences and discuss the new information
– supplemented by home visits
– there were six mother–infant groups at weekly intervals, with an unspecified number of home visits.
No data about recipient or provider perceptions reported. However, nine women who had received the intervention initiated groups spontaneously in their own locations to assist other mothers, which suggests that they experienced the intervention as being worthwhile.

LHW, lay health worker; NBAS, Neonatal Behavioural Assessment Scale; THP, Thinking Health Programme; WHO, World Health Organization.