PMNCH Knowledge Summary #31 Maternal mental health: Why it matters and what countries with limited resources can do
Publisher: The Partnership for Maternal, Newborn and Child Health
Publication date: 2014
Language: English only
Despite being a basic right for every woman and important for the psychosocial well being of women and their children, recognition of maternal mental health has not been a priority on health agendas for many low- and middle-income countries. Mental health and non-communicable diseases have emerged as a central focus for public health experts globally, in discussions about the post-2015 agenda. A paradigm shift towards integrated approaches ensures a responsive health system with strategies in place not only for treatment and care, but also for the promotion of maternal mental health and prevention of mental health problems through broader, cross-sector linkages.
Why maternal mental health matters
Common perinatal mental disorders (CPMDs), essentially comprising depression, anxiety and somatic disorders, are one of the major causes of disability during and after pregnancy, affecting the quality of life of both mother and child.1 Depressive disorders in pregnant women have been shown to be associated with the use of tobacco, alcohol and other harmful substances, necessitating the need for intervention.2 According to a recent review, almost one in every five women experiences one or more CPMDs during pregnancy or after child birth in low- and middle-income countries (LMIC).3
Maternal mental health problems primarily including CPMDs, alcohol use and psychosis are a key cause of pregnancy related morbidity and mortality.
Psychosis, although rare - affecting only one to two women in every 1 000 giving birth can lead to detrimental consequences like suicide and harm to the baby. This makes it vital for health-care providers to identify the symptoms at an early stage for timely intervention.4
Adolescent mothers are not only at higher risk of pregnancy-related complications, e.g. miscarriage and stillbirth, but also face challenging social circumstances including forced marriage, poverty and stigma, making them more vulnerable to mental health problems like depression.5 According to World Health Organization (WHO) statistics, 95% of adolescent pregnancies occur in LMICs.6
Long-term studies have shown that depressive disorders in mothers adversely affect the psychosocial well-being of their children.7 Evidence makes clear how maternal depression can translate into the intergenerational transmission of health and socio-economic disadvantages.8,9 Interventions for improving maternal mental health lead to better mother-infant interaction, improved cognitive development and growth, reduced diarrhoeal episodes and increased immunization rates.10
How are countries responding to this need?
Currently, there are no formal integrated systems for addressing maternal mental health needs in LMIC, yet mental health problems are detectable at primary care level,3 and there are examples in which non-specialists have delivered acceptable, feasible and affordable interventions with encouraging outcomes in terms of early detection and timely and effective treatment.12
A major problem is the difficulty of detecting CPMDs in resource-constrained health systems. During regular antenatal and postnatal visits, primary symptoms of these disorders - like poor sleep, fatigue and low appetite - can go easily unnoticed by health professionals who have no training in mental health screening.13,14,15
A lack of trained health workers, along with insufficient resource allocation for primary care and weak health systems further contributes to the problem.16
Comprehensive and integrated primary mental health care is a concept that takes into account the complexity of the interaction of physiological, social and psychological factors for mental health care provision at primary and community level.17,18 As such, it offers a solution for addressing maternal mental health. It can be achieved by taking into account WHO's building blocks for health systems, i.e. appropriate and timely service delivery, a trained health workforce at primary care level, improved health information systems, equitable access to essential medicines and enhanced financing, and effective leadership/governance at national, local, health facility and community levels.19
WHO's Mental Health Gap Action Programme (mhGAP) stipulates evidence-based guidelines for an integrated system to treat maternal depression, psychosis and alcohol abuse at primary and community health care levels through a non-specialised health workforce in LMIC.20 The mhGAP intervention guide provides simple and locally applicable tools, that can be integrated within the health system for comprehensive planning, education and training of health care providers, and delivery of services at primary level to manage mental health problems.21
Such services need to be incorporated into routine antenatal and postnatal care services to reach a greater proportion of women at a minimal cost. Recent analysis indicates improvements in maternal mental health in a few LIMC through psychological and health promotion interventions given during the antenatal and postnatal periods.22 These have been effective in reducing the symptoms of CPMDs through non-pharmacological interventions provided by trained and supervised non-specialist health professionals.
Agenda for action
An integrated system involving identification of mental health problems through the application of context appropriate assessment methods during routine antenatal and postnatal visits, followed by provision of psychosocial support and appropriate referrals as needed, can improve both maternal and child health outcomes.
Simultaneously, innovative preventive programmes targeted at promoting maternal psychosocial well-being and raising awareness among women and their partners of the danger signs, along with social support through participatory women's groups and/or health visitors, may also be beneficial. However, careful evaluation is required to see how these interventions work.
This would be facilitated through fund-raising for mental health and redirecting available resources towards primary health care and community-based services to integrate mental health services into existing sexual health, reproductive, maternal and child health, and youth and adolescent health services.18,25 The process will initially require a situation analysis of the current burden of CPMDs in any given country, followed by a gap analysis of available and required resources. For these steps, WHO's Assessment Instrument for Mental Health Systems (WHO-AIMS) provides improved tools to collect information on mental health systems at country level.26
In addition, cross-sector collaboration to improve access to education and employment, and the formulation and implementation of laws for social protection and to prevent violence against women, are essential to maternal mental health.
Innovations to address this need
There are a number of examples where effective interventions for mental health have been integrated within maternal and child health care package.11 Two such examples are:
Case study 1
A cluster-randomised control trial aimed at testing the efficacy of a cognitive behaviour therapy-based intervention for mothers with depression in two rural areas in Pakistan, have shown a remarkable decrease in the percentage of women with depression over a 6- to 12-month period. The intervention is designed to be integrated into the routine work of Lady Health Workers. The advantage of this approach is that it reaches women who are most in need, with the added benefit of improvements in infant health outcomes.14 The approach has also been adapted for integration into large scale maternal and child health programmes.23
Case study 2
The Perinatal Mental Health Project (PMHP), began in 2002 in South Africa. It is a stepped care intervention approach applied within a facility-based maternal and child health programme. The main focus is to integrate mental health care for pregnant women at primary level. PMHP has proved successful in increasing maternal mental health screening (with an average of 91% coverage), uptake of counselling (with 2 394 women receiving individual counselling) and improved maternal well-being at the four obstetric sites where it is currently running.24
Maternal mental health is fundamental to achieving global health targets relating to women and children because of its direct and potentially long-term impact on their general well-being and social and economic participation. It also influences women’s care-giving capabilities, which in turn impacts children’s health and development. Addressing maternal mental health requires comprehensive and holistic models of care in which psychosocial assessment and treatment can be provided through integrated primary health care. Access to simple, reliable and affordable means of identification and management of mental health problems is a basic human right.
Box 1: Maternal mental health care provision - a moral case
Disparity in the provision of mental health services, poses a moral and ethical dilemma.27 The risk of depression for women is more than one and a half times greater than for men, which is thought be mainly due to historically and culturally rooted social and economic inequalities, and also to gender-based violence, which increases women’s vulnerability and reduces their ability to access timely care.16,28 The Comprehensive Mental Health Action Plan, endorsed by the 66th World Health Assembly in 2013, highlights the need to integrate mental health services into maternal health programmes.17 As a part of the WHO’s Quality Rights initiative, the recently launched MiNDbank programme is directed at promoting human rights.13
Box 2: Key terminologies
CPMDs: Common mental disorders are defined as depressive, anxiety, and somatic disorders, causing disability among women during the perinatal period. Postnatal depression: A mental illness that occurs within the weeks or months after childbirth characterised by unhappy feelings, irritability, tiredness, sleeplessness, loss of appetite and hopelessness. Somatic disorders: Mental illness causing bodily symptoms including pain and gastrointestinal and neurological symptoms, without any organic/physical cause. Psychosis: Psychosis (puerperal) is a mental illness, which comes on after childbirth. The symptoms are usually severe depression or mania, often with psychotic features including false beliefs, hallucinations (seeing things or hearing voices that do not exist), muffled thinking, bizarre behaviour, etc. Abortion: Termination of a pregnancy after, accompanied by, resulting in, or closely followed by the death of the fetus. It could either be a spontaneous expulsion during the first 12 weeks of gestation or an induced expulsion of the foetus. Miscarriage: Spontaneous expulsion of a foetus before it is viable and especially between the 12th and 28th weeks of gestation. Stillbirth: A baby born with no signs of life at, or after 28 weeks gestation.
1.World Health Organization. Maternal mental health and child health and development in low and middle-income countries. Geneva, WHO, 2008. 2.Zuckerman B, Amaro H, Bauchner H, Cabral H. Depressive symptoms during pregnancy: relationship to poor health behaviours. Am J Obstet Gynaecol 1989; 160: 1107–11. 3.Fisher J, Mello CD, Patel V, Rahman A, Tran T, et al. Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review. Bulletin of the World Health Organization 2012; 90: 139–149. 4.WHO. Suicide prevention and special programmes. Maternal mental health & child health and development. http://www.who.int/mental_health/prevention/suicide/MaternalMH/en Accessed (Accessed 12 March, 2014) 5.WHO. Maternal, new-born, child and adolescent health: Adolescent pregnancy http://www.who.int/maternal_child_adolescent/topics/maternal/adolescent_pregnancy/en (Accessed 12 March, 2014) 6.WHO. Adolescent pregnancy: Fact sheet. http://www.who.int/mediacentre/factsheets/fs364/en (Accessed 20 March, 2014) 7.Walker SP, Wachs TD, Gardner JM, Lozoff B, Wasserman GA, et al. (2007) Child development: risk factors for adverse outcomes in developing countries. Lancet 2007; 13(369): 145–157. doi: 10.1016/S0140-6736(07)60076-2. 8.Weissman MM, Wickramaratne P, Nomura Y, Warner V, Pilowsky D, Verdeli H. (2006) Offspring of depressed parents: 20 years later. American Journal of Psychiatry 163: 1001–1008. doi: 10.1176/appi.ajp.163.6.1001. 9.Surkan PJ, Kennedy CE, Hurley KM, Black MM. (2011). Maternal depression and early childhood growth in developing countries: systematic review and meta-analysis. Bulletin of the World Health Organization 2011; 89:608-615E. doi: 10.2471/BLT.11.088187 10.Rahman A, Fisher J, Bower P, Luchters S, Tran T, Yasamy MT, et al. Interventions for common perinatal mental disorders in women in low- and middle-income countries: a systematic review and meta-analysis. Bulletin of the World Health Organization. 2013; 91:593–601. 11.Prince, M. et al. No health without mental health. Lancet 2007; 370: 859–77. doi:10.1016/S0140- 6736(07)61238-0. 12.Patel V, Kirkwood B. Perinatal depression treated by community health workers. Lancet 2008; 372:868–9. doi: http://dx.doi.org/10.1016/S0140- 6736(08)61374-4 PMID:18790294. 13.WHO MiNDbank. http://www.mindbank.info (Accessed 20 March, 2014) 14.Rahman, A. et al. Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial. Lancet. 2008 September 13; 372(9642): 902–909. 15.Chowdhary N, Sikander S, Atif N, Singh N, Fuhr D, Rahman A, etal. The content and delivery of psychological interventions for perinatal depression by non-specialist health workers in low and middle-income countries: A systematic review. Best Practice & Research Clinical Obstetrics and Gynaecology 2014; 28: 113–133. 16.Mirza I, Jenkins R. Risk factors, prevalence, and treatment of anxiety and depressive disorders in Pakistan: systematic review. BMJ 2004; 328: 794. 17.WHO (2013). Mental Health Action Plan 2013-2020. ISBN: 9789241506021. 18.Petersen I (2000) Comprehensive integrated primary mental health care for South Africa. Pipedream or Possibility. Social Science and Medicine, 51:321-334. 19.WHO (2007), Strengthening health systems to improve health outcomes: WHO’s framework for action. ISBN: 9789241596077. 20.WHO (2014). WHO Mental Health Gap Action Programme (mhGAP). http://www.who.int/mental_health/mhgap/en/index.html 21.WHO (2010). mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings. ISBN: 9789241548069. Available at: http://www.who.int/mental_health/publications/mhGAP_intervention_guide/en/index.html 22.Clarke K, King M, Prost A. (2013) Psychosocial Interventions for Perinatal Common Mental Disorders Delivered by Providers Who Are Not Mental Health Specialists in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis. PLOS Medicine 10 (10). doi: e1001541. 23.Zafar S, Sikander S, Haq Z, Hill Z, Lingam R, Skordis-Worrell J, Kirkwood B, Rahman A. Integrating maternal psychosocial well-being into a child-development intervention: the five-pillars approach. Ann N Y Acad Sci. 2014; 1308:107–117. 24.Perinatal Mental Health Project. Mid-Year Report Jan-June 2013. Available at: http://www.pmhp.za.org/about/reports 25.Rahman A, Surkan PJ, Claudina E. Cayetano CE, Rwagatare P, Dickson KE. Grand Challenges: Integrating Maternal Mental Health into Maternal and Child Health Programmes. PLoS Med. 2013; 10(5):e1001442. 26.World Health Organization Assessment Instrument for Mental Health Systems (WHO-AIMS). http://www.who.int/mental_health/evidence/WHO-AIMS/en (Accessed 28 April, 2014) 27.Patel V, Saraceno B, Kleinman A. Beyond evidence: the moral case for international mental health. Am J Psychiatry 2006; 163: 1312–15. 28.Ferrari AJ, Charlson FJ, Norman RE, Patten SB, Freedman G, Murray CJL. et al. Burden of Depressive Disorders by Country, Sex, Age, and Year: Findings from the Global Burden of Disease Study 2010. PLoS Med 2013; 10(11): e1001547. Doi: 10.1371/journal.pmed.1001547.
Scientific writer: Iram Ejaz Hashmi. Contributors for development and review: Jane Fisher, Charlotte Hanlon, Joy Lawn, Natalie Likhite, Olayinka Olusola Omigbodun, Vikram Patel, Atif Rahman, Jennifer Requejo, Joanna Schellenberg, Kadi Toure, Mohammad Taghi Yasamy. Coordinating team: Bilal Avan, Agnes Becker, Shirine Voller, Deepthi Wickremasinghe, at the London School of Hygiene and Tropical Medicine, and Vaibhav Gupta, Shyama Kuruvilla, Rachael Hinton, at the Partnership for Maternal, Newborn and Child Health. Design by: Roberta Annovi.