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Available online at www.sciencedirect.com

www.elsevier.com/locate/semperi

Maternal mental health: The missing “m” in the global maternal and child health agenda Najia Atif, MSca, Karina Lovell, PhDb, and Atif Rahman, PhDc,n a

Human Development Research Foundation, Islamabad, Pakistan University of Manchester, Manchester, UK c Institute of Psychology, Health & Society, University of Liverpool, UK b

article info

abstra ct

Keywords:

While the physical health of women and children is emphasized, the mental aspects of

Maternal mental health

their health are often ignored by maternal and child health programs, especially in low-

Perinatal depression

and middle-income countries. We review the evidence of the magnitude, impact, and

Postnatal depression

interventions for common maternal mental health problems with a focus on depression,

Public mental health

the condition with the greatest public health impact. The mean prevalence of maternal

Low- and middle-income countries

depression ranges between 15.6% in the prenatal and 19.8% in the postnatal period. It is associated with preterm birth, low birth weight, and poor infant growth and cognitive development. There is emerging evidence for the effectiveness of interventions, especially those that can be delivered by non-specialists, including community health workers, in low-income settings. Strategies for integrating maternal mental health in the maternal and child health agenda are suggested. & 2015 Elsevier Inc. All rights reserved.

Introduction The World Health Organization (WHO) defines maternal mental health as “a state of well-being in which a mother realizes her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her community.”1 Globally, in women of childbearing age, depression accounts for the largest proportion of the burden associated with mental or neurological disorders.2,3 In addition to the economic and human costs of maternal depression, children of mothers who are depressed are at risk for poor health, developmental, and behavioral problems,4 thereby contributing to intergenerational disadvantage that accumulates throughout the life span. Addressing mental health could play an important

role in addressing the maternal and child health (MCH) agenda. However, mental health care remains conspicuous by its absence in large-scale global MCH programs. For more than a decade, the mental health community has recommended integration of mental health programmes into primary care.5 Despite the WHO recommendations and the mounting evidence indicating high prevalence of maternal mental health and its adverse impact on both mother and her infant, the maternal mental health agenda has not been incorporated into the primary health care system in most low- and middle-income countries (LMIC). The barriers to the provision of primary maternal mental health care in LMIC include the lack of human and financial resources6 and quite often the double burden of communicable and noncommunicable diseases, which relegate mental health to

n Corresponding author at: Child Mental Health Unit, Alder Hey Children’s NHS Foundation Trust, Mulberry House, Eaton Road, Liverpool L12 2AP, UK. E-mail address: [email protected] (A. Rahman).

http://dx.doi.org/10.1053/j.semperi.2015.06.007 0146-0005/& 2015 Elsevier Inc. All rights reserved.

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the margins of health care.7 Consequently the treatment gap for mental illness in LMICs is large, accounting for 76–85% patients with mental health problems not receiving intervention.8 Integrating maternal mental health into primary care MCH programmes has the potential to address the treatment gap through early detection, prevention, and treatment of maternal mental health problems such as depression.9 Such integration requires intersectoral collaboration and health system-wide approaches, focusing on prevention and treatment across the life course and employing evidence-based interventions.10 Studies conducted in LMIC show that psychosocial, educational, and supportive interventions are effective in improving maternal mental health, even when delivered through non-mental health specialists rather than specialists.11 Such non-specialist workers can play an integral role to provide primary mental health service to those who need it the most. As maternal depression is by far the mental disorder with the highest public health impact,4,12,13 we will focus on this condition. This article aims to review the prevalence and risk factors for maternal depression, its impact on the mother and the infant, evidence of effective use of non-specialists in the delivery of interventions for maternal depression, and recommendations for strategies to integrate maternal mental health into public health. The focus of the review is LMICs, where the vast majority of the women with mental health problems such as depression reside, and where the burden from untreated depression is the greatest.

Prevalence of maternal depression in LMIC Common mental health problems such as perinatal anxiety and depression are more prevalent in women from LMICs as compared to high-income countries (HIC). The weighted mean prevalence of these conditions was found to be 15.6% during the prenatal period and 19.8% during the postnatal period,14 which is higher than the rates reported in HICs, ranging from 6.5% to 12.9% during the perinatal period.15 A systematic review by Fisher et al.,14 included evidence available from nine countries on prenatal and 17 countries on postnatal depression. Most of the studies recruited participants from health care facilities such as primary care clinics, antenatal clinics, and maternity hospitals. The prevalence of prenatal depression recorded from these settings was 20.5% in Thailand,16 21.5% in Vietnam,17 and 41.6% in Nigeria.18 Postnatal depression prevalence was 23% in India,19 48% in Nigeria,20 and 22.4% in Indonesia.21 Prevalence rates in community-based samples were even higher—33% in Bangladesh,22 25% in Pakistan,23 and 59.5% in Ethiopia.24 It is important to note that the samples recruited from the community-based studies are more representative of country populations because many such settings have limited access to perinatal health facilities. Relatively low prevalence of postnatal depression was reported in Brazil (15.9%),25 China (15.5%),26 Mongolia (9.1%),27 and Uganda (6.1%).28 The pooled prevalence of perinatal depression ranges from 5.2% to 32.9% during pregnancy and 4.9–59.4%, after child birth.14 These studies varied in their settings, sample sizes,

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assessment tools, cutoff point used, timing of assessment, the quality of data collection and reporting, along with differences in cultural and socio-economic variables in the countries. In order to achieve reliable results globally, there is a need to establish standard cutoff scores, assessment tools, and timing of assessment.29

Risk factors for maternal depression in LMIC Several contributing factors related to maternal depression have been identified in women in LMIC. These contributory factors can broadly be classified as poor socio-economic conditions, interpersonal problems, and adverse life events. Women from LMIC are more likely to be exposed to poverty,26,30 lack of a permanent job,31 low literacy,25,32 lack of social support,14,31,30 and lack of empowerment33 compared to women in HICs. Likewise, evidence has also indicated a strong association with interpersonal relationship problems including poor marital relationship,23 domestic violence,33,34 perceived unsupportive partner,18 lack of intimate relationship,31 low spouse involvement in the perinatal period,26 abusive partner,35 and relationship problems with inlaws.36,30,22,37 Stressful life events such as health complications during and after pregnancy, having a previous history of stillbirth,18,22,33 unplanned or unwelcome pregnancy,31,28 financial difficulties, separation or divorce,18 and bereavement22 have been identified as risk factors for perinatal depression. In some cultures, gender preference of an offspring is also found associated with perinatal depression. In Pakistan, a mother with two daughters was found to be at a higher risk of perinatal depression,23 which is consistent with other cultures where there is a preference for male offspring such as India and Nigeria.19,28,30,36,38 Fisher et al.,14 in their systematic review covering 17 LMIC, quantified these key risks: socio-economic disadvantage [odds ratio (OR) range: 2.1–13.2]; unintended pregnancy (1.6–8.8); being younger (2.1– 5.4); being unmarried (3.4–5.8); lacking intimate partner empathy and support (2.0–9.4); having hostile in-laws (2.1– 4.4); experiencing intimate partner violence (2.11–6.75); having insufficient emotional and practical support (2.8–6.1); in some settings, giving birth to a female (1.8–2.6); and having a history of mental health problems (5.1–5.6). Protective factors were: having more education (relative risk ¼ 0.5; p ¼ 0.03); having a permanent job [OR ¼ 0.64; 95% confidence interval (CI): 0.4–1.0]; being of the ethnic majority (OR ¼ 0.2; 95% CI: 0.1–0.8), and having a kind, trustworthy intimate partner (OR ¼ 0.52; 95% CI: 0.3–0.9).

Impact of maternal depression on mothers Untreated maternal depression increases the risk of maternal morbidity and mortality.3 A global estimate of the maternal mortality ratio from suicide is 400 per 100,000 live births.39 The risk is significantly higher in LMIC region (1 in 2800) as compared to HIC (1 in 61). During the postpartum period, 20% of deaths are because of successful suicidal attempt.40 Maternal depression during pregnancy increases the risk of obstetric complications41,42 such as preterm birth43 and

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spontaneous abortion.44 Depressive symptoms in low-income pregnant mothers are found to be linked to unhealthy life styles such as increased rates of smoking, alcohol and cocaine abuse, poor self-care, and not seeking prenatal care.45 Maternal depression also impacts mother’s cognition resulting in impaired decision-making capacities, perception of decreased social support, increased life stresses,45,46 and low maternal self-esteem.47 Moreover, untreated prenatal depression and anxiety is a strong predictor of depression during the postnatal period48 causing significant functional and parenting disability, psychological distress,32 49 difficulties. Evidence has also indicated that a significant number of women continue to experience depressive symptoms for months or years after the birth of a child50 with 15% attempting suicide.51 These findings are consistent with the results obtained from studies conducted in LMIC indicating association between perinatal depression during and after pregnancy23,34,32 and a high risk of suicidal thoughts and attempts (5–14%)40 especially among women who experience gender-based violence.52 Poor maternal mental health is not only detrimental to the mother’s physical and psychological health, but also has adverse impact on her infant’s growth and development. Evidence from studies conducted in South Asia have linked maternal depression during pregnancy with preterm birth,53 infant’s low birth weight,54,55 and poor growth outcomes in infants during the first year of life.56 However, studies in other LMICs yielded varied findings with some indicating greater likelihood of stunting and underweight status of children of depressed mothers57,58 and others not indicating any significant association.59,60 The difference in findings could be attributed to sociological and cultural differences between countries and their complex interplay with childrearing practices. A meta-analysis of 17 studies including 13,923 mother and child pairs61 showed that globally, children of mothers with depression or depressive symptoms were more likely to be underweight (OR ¼ 1.5; 95% CI: 1.2–1.8) or stunted (OR ¼ 1.4; 95% CI: 1.2–1.7). The sub-analysis of three longitudinal studies showed a stronger effect: the OR for underweight was 2.2 (95% CI: 1.5–3.2) and for stunting was 2.0 (95% CI: 1.0–3.9). The meta-analysis indicated that 23–29% fewer children would be underweight or stunted if not exposed to maternal depression. The PAR for selected studies indicated that if the infant population were entirely unexposed to maternal depressive symptoms, 23–29% fewer children would be underweight or stunted. Evidence from LMICs has also indicated an association between perinatal depression and infant cognitive development. Six-month-old infants of depressed mothers showed significantly lower mental quotient sores in India62 and slower social and cognitive performance in Barbados.63 In Pakistan, postnatal depression was significantly associated with delay in child cognitive and motor development.64 Other impacts of maternal depression included higher rates of diarrheal episodes,65 early cessation of breastfeeding,4,66 lower rates of immunization,56 and increased childhood illnesses.67 Studies have indicated that such children are at a long-term increased risk of: poor mental health, social impairment, mortality from medical causes,68 and of

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exhibiting antisocial behavior, emotional problems, hyperactivity, and attention difficulties carried into adulthood.4

Interventions for maternal depression through non-mental health specialist workers The above evidence signifies the needs to implement policies and programmes to identify, treat, and prevent maternal depression effectively in order to ensure the healthy functioning of mothers and optimal growth and development of their children.61 Pharmacological treatments are not feasible or recommend in all settings, and are not indicated in pregnant or women who breastfeed.69 Psychological therapies such as cognitive behavior therapy, interpersonal therapy, and supportive therapy are recommended front-line treatments for depression.70 Systematic review from HICs have indicated that both psychosocial and psychological interventions are effective in reducing symptoms of depression when compared with usual postpartum care.71 In addition, the evidence for the effectiveness of non-mental health specialist-led interventions (e.g., involving nurses, health visitors, and midwives) in HICs has been building.72–74 In LMICs, there is a shortage of health specialists required to investigate the possibilities of using paraprofessionals and nonprofessional in the large-scale delivery of such interventions. A recently conducted meta-analysis of perinatal depression interventions in LMIC included 13 trials representing 20,092 participants. In all studies, supervised, nonspecialist health and community workers delivered the interventions, which proved more beneficial than routine care for both mothers and children.11 The pooled effect size of these interventions for maternal depression was 0.38 (95% CI: 0.56 to 0.21; I2 ¼ 79.9%). There was substantial heterogeneity of effect, and this could be attributed to their varied focus and approach; some addressed maternal depression directly and used active psychotherapeutic techniques to help mothers recognize and manage depression symptoms, adapt helpful ways of thinking, and implement useful behavior strategies.75–78 Others used more psycho-educational approaches aiming to enhance problem-solving skills and managing interpersonal conflicts.79–81 Studies that did not directly address maternal depression focused on neonatal and maternal morbidity,82 parenting education,83,84 and mother–child interaction to improve mother’s sensitivity and responsiveness.85–87 The findings highlighted the interdependent relationship between maternal mood and infant health and development, as interventions focusing on maternal depression reported positive outcomes on infant health and development and vice versa. Data also showed that community health workers (CHWs) under professional supervision can deliver mental health interventions; thus, implementing such findings could facilitate management of maternal mental disorders at primary level. Another recently conducted systematic review of psychological interventions for perinatal depression by nonspecialist mental health workers in LMIC identified nine studies.88 Four of the nine studies used CHWs such as community health monitors,89 community health aids,85

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and CHWs.75,83 The Table describes the key characteristics of these interventions and their delivery agents. As indicated in the Table, the interventions vary in their approach, level of training and supervision, and number of sessions offered to the participants. However, an element common in all the interventions was social support provided to the participants at home, which helped in improving symptoms of perinatal depression. This is consistent with the findings of meta-analyses, indicating the effectiveness of the use of CHWs to deliver interventions for perinatal mental disorders.11 The above studies have described characteristics of CHWs employed in primary health care: they were locally based women with no formal qualifications and had good understanding of the socio-cultural norms and local resources. They formed a trustworthy relationship with the study participants and were appreciated for their non-judgemental and empathic attitude.75,85 They encouraged family involvement75,85,89 and emphasized mother and child well-being.75 Such strategies ensured families’ endorsement and avoided stigmatization. Attempts have been made to integrate such interventions into routine maternal and child health programmes. For example, in Pakistan, a universal cognitive behavioral therapy-based intervention (the five-pillars approach) was adapted from a targeted intervention for perinatal depression75 and integrated into a child nutrition and development program.90 Following formative research with CHWs and families, CHWs were trained in1 empathic listening,2 family engagement,3 guided discovery using pictures,4 behavioral activation, and5 problem solving. A qualitative feasibility study in one rural area in Pakistan demonstrated that CHWs were able to apply these skills effectively to their work, and the approach was found to be useful by CHWs, mothers, and their families. The authors surmise that the success of the approach could be attributed to1 mothers being the central focus of the intervention,2 using local CHWs whom the mothers trust,3 simplified training and regular supervision, and4 an approach that facilitates, not adds, to the CHWs’ work. A recently published multisite formative study from Pakistan and India, indicated that peers from the same community were preferred as delivery agents of a community-based psychosocial intervention.91 Their preferred characteristics identified in the study were: being local, middle-aged, educated mothers with similar experiences to participants, good communication skills, and good character. Their characteristics have commonalities with the characteristics of CHWs, apart from the fact that CHWs were employed by the government health facilities and were already embedded in the health system. This study indicates that peers are a potential human resource to deliver perinatal mental health in countries where CHWs are lacking or overloaded with other tasks.

Discussion This article reviews the prevalence, risks, and impact of common mental health problems such as depression and highlights the evidence for interventions that can potentially be integrated into existing health systems to improve not only maternal depression but also immediate perinatal and long-term infant health and developmental outcomes. The priority now is to make policy makers, planners, and

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politicians aware of the missed opportunity of integrating these interventions into mainstream maternal and child health programs and to direct both research and implementation funds to meet the challenges of scaling up these promising approaches. Rahman et al.9,11 recommend the following steps for integration:

 

  

  



Enhance collaboration between MCH and mental health programs, re-searchers, and practitioners by encouraging more joint programs. Develop ways to integrate screening and core packages of mental health services into routine primary health care (e.g., antenatal visits) and establish effective referral mechanisms. Further develop effective treatments for use by nonspecialists, including lay health workers with minimal training. Address stigma related to mental illness that could impede the integration of mental health into MCH programs. Increase capacity in LMICs by creating regional centers for mental health research, education, training, and practice that incorporate the views and needs of local people. Develop sustainable models to train and increase the number of culturally and ethnically diverse lay and specialist providers to deliver evidence-based services. Strengthen the mental health component in the training of all health care personnel. Redesign health systems to integrate maternal depression with other chronic disease care, and create parity between mental and physical illness in terms of investment into research, training, treatment, and prevention. Incorporate a mental health component into international MCH aid and development programs.

Rahman et al.9,11 describe four key tasks needed to include maternal mental health as part of the MCH agenda. Firstly, gain recognition at the highest international and national policy forums that mental health and well-being is a critical component of MCH that does not compete with MCH programs but instead complements them. Secondly, enhance the training and supervision of MCH community and primary care personnel so that they can recognize and treat psychosocial distress and depression in women, enabling them to be more effective health workers. Thirdly, adapt effective interventions to local contexts and strengthen systems of supervision, referral, and continued training at the primary, secondary, and tertiary levels so that the community component is well supported. Finally, it is imperative to invest in research and implementation programs so that these approaches are refined and scaled up, leading to improved outcomes of all MCH programs. Efforts must also be made to address the risk factors that contribute to high rates of depression in LMIC. Our review indicates that the origins of depression in many women can be traced to the social circumstances of their lives.4,14 Over 2 decades ago, Desjarlais et al.92 noted:

Table – Role of community health workers in delivering psychosocial interventions for perinatal depression interventions. Sessions

Key findings

Aracena et al.,90 Santiago, Chile

Intervention program for first-time pregnant adolescents to improve physical health of mother and infant and maternal mental health

Community health monitors

Length of training not specified. Weekly supervision

Individual sessions (n ¼ 12)

BakerHenningham et al.,85 urban, Jamaica

Intervention programme for mothers of undernourished children to improve child development and maternal depression.

Community health aides

6-Week training and fortnightly supervision.

Individual sessions (n ¼ 50)

Cooper et al.,84 peri-urban, South Africa

Preventative intervention programme for mothers to improve quality of mother–infant interactions and maternal depression.

Community health workers

Paraprofessional, experience of healthrelated work, experience of raising children, recruited from the community, encourage participation of other family members. Paraprofessional, employed in government health centers, empathetic, friendly, supportive, good listener, encourage participation of other family members. No formal specialist qualification or training, locally based, strong community support, mothers, completed schooling.

4-month training and weekly supervision

Individual sessions (n ¼ 16)

Rahman et al.,76 Pakistan

CBT-based psychosocial intervention for mothers experiencing perinatal depression to improve infant weight and height and maternal depression

Community health workers

3-day training and monthly half day group supervision

Individual sessions (n ¼ 16)

Significantly higher scores for the intervention group on the mothers’ mental health (p ¼ 0.031) and nutritional state (p ¼ 0.055). No difference was found between the physical health and psychomotor development of the children in each group (p ¼ 0.15). Only those mothers who received Z25 visits in the intervention group reported a significant reduction in the frequency of depressive symptoms (CI ¼ 95%). Higher levels of maternal depression were associated with poorer development for boys only. Significant improvement in maternal depressed mood at 6 months (p ¼ 0.041) but the effects were not sustained at 12 months (p ¼ 0.813). Significant improvement in mother–infant relationship compared with control mothers. Mothers in the intervention group had significantly lower depression scores at 6 months (p ¼ 0.001); the effects were sustained at 12 months (p ¼ 0.001) as compared to mothers in the control group. The differences between the intervention and control groups in infant weight and height were not significant.

Locally based, completed secondary school, employed by the primary health care system to provide maternal and child health care and education in the community.

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“hopelessness, exhaustion, anger and fear grow out of hunger, overwork, violence and economic dependence. Understanding the sources of ill health for women means understanding how cultural and economic forces interact to undermine their social status. If the goal of improving women’s well-being from childhood through old age is to be achieved, healthy policies aimed at improving the social status of women are needed along with health policies targeting the entire spectrum of women’s health needs.” Unfortunately, the situation of women’s lives in most LMIC has not improved over this period. Attention to addressing risk factors for poor maternal mental health would provide additional impetus for creating healthy policies, from education to economic empowerment to legal and political mechanisms that enhance the status of women. The evidence presented in this article shows that many outcomes that contribute to maternal and child morbidity, such as under-nutrition, diarrheal disease, immunization, and breastfeeding uptake, have direct associations with maternal mental health. By fixating on mortality and morbidity targets and relegating maternal mental health to a peripheral goal, the MCH community is missing an important opportunity to holistically address the health needs of both mothers and their children. Urgent attention is required to remedy the situation.

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