By Thanya April
I work at the Perinatal Mental Health Project (PMHP) as Office Administrator. I am also a part-time student, completing my Psychology degree at the South African College of Applied Psychology. A requirement of this degree is a work-integrated learning component. In order to fulfil this, I started my first Mother-Baby support group in Hanover Park, which is also the clinical service site of the PMHP.
Before designing the programme for the group, I conducted a Needs Assessment with mother’s attending the postnatal clinic in the Hanover Park Community Health Centre. All participants reported that they had a good relationship with their baby and most of them were still breastfeeding. All participants felt that women would be interested in joining a Mother-Baby support group, but the consensus among most of the women was that an incentive was needed to motivate women to attend the support group. When asked about deterrents to attending the support group, the responses included lack of money, no transport and gang violence in the area.
When one participant suggested that women would only join a Mother-Baby support group if what they were getting out of it, was much more than what they had to give, I was disheartened. It seemed unlikely that I would be able to provide such an incentive, worthy enough for women to offer up their time.
Relevant research pertaining to postnatal support in low-income-settings, as well as interactions with various stakeholders, informed the programme design for the Mother-Baby support group.
Four women were recruited and joined the group. These women were clients who had received individual counselling from the PMHP, which meant that they had, on a previous occasion, screened positive for depression and/or anxiety during their pregnancy. The programme for session 1 included a discussion on gossip. Gossip in Hanover Park emerged as a central theme in the research of Rose Davidson, medical anthropology student who conducted her Master’s research with PMHP. Her dissertation was entitled “Gossip, Judgement and Trust: Contextualising Women’s Engagement With An Antenatal Mental Health Service in Cape Town, South Africa”. Rose’s findings were crucial to understanding the effects that gossip has in creating mistrust and in hindering access to support in vulnerable communities.
By discussing this topic, all women in the group became aware that they had similar fears about gossip. These women had isolated themselves because of these fears and all of them reported that they did not have friends because of this. When they shared their own experiences, it united them in a way they did not expect. Throughout the course of the 2-hour session, the women grew closer and were able to open up about their birthing experiences and found comfort in each other’s descriptions about what postnatal depression felt like.
I created a Whatsapp group to communicate about logistical issues. The women used this platform to keep in touch and when one mother could not afford the travelling fare to attend the second session, the women rallied together and offered to pay for her transport.
On the last session, when the women received their baby hampers and baby albums, they expressed great appreciation. However, I got the sense that the incentive they were most appreciative of was the support received and the friendships gained within the group.
The women were grateful for the group setting and easily started making plans with each other for the festive season. They were proud that they were the very first group and insisted on having one last session early next year. Under the PMHP, we hope to continue to conduct further groups next year to create support among postnatal women and foster friendships in a community that has many obstacles to this form of healthy social connection.
Disclaimer: Written consent has been obtained from all women participating in this group to use pictures of themselves and their babies.
In a recent report, the United Nations General Assembly has recognized the global phenomenon of mistreatment of women during childbirth as a human rights abuse and a form of gender-based violence.
This mistreatment, may take many forms including physical abuse (slapping, punching, conducting procedures without permission and restraining women in labour), psychological abuse (insults, humiliation, lack of privacy, threat of physical abuse, withdrawing care, accusation of blame for poor condition of the baby) and failure to meet professional standards of care. In some settings, women and their infants are detained in health facilities without adequate food until such time as they are able to pay the required fees.
In South Africa, obstetric violence has been documented in several reports and studies across the country. Numerous potential causes have been suggested. There is a lack of audit and systems of accountability for this abuse. Maternity care workers are overwhelmed, burned out, underappreciated, unsupported and are victims of various forms of abuse; in their personal lives and through the hierarchical and unsupportive health system. There is a lack of appropriate mentoring for compassionate care Abuse has become ‘routinized’ or habitual. Obstetric violence is a side-effect of the structural violence present in our South African history as well as in contemporary realities.
Illustration by Julia Kuo
What is the Perinatal Mental Health Project’s response?
We recognize the complexity of the problem and that multiple, mutually reinforcing approaches are needed to make a change. We have been involved, since the early 2000s, in addressing this complex problem in a variety of ways.
- We published an editorial in the South African Medical Journal.
- We contributed to the development and drafting development of the Western Cape Government Department of Health (DoH) Patient-Centred Maternity Care Code which outlines the rights and responsibilities of health providers and service users. We developed information brochures on the Code for staff and services users that were printed and distributed by DoH.
- As part of our training in empathic engagement for health and social service providers, we developed a participatory and theatrical training method called the “Secret History”.
In 2019, this method was published in an academic journal, Transcultural Psychiatry. It has been taken up by the National Department of Health training programme ESMOE (Essential Steps in the Management of Obstetric Emergencies) into a module we co-developed on Respectful Maternity Care.
- For others who want to use the Secret History Method in their training, we developed a film and facilitators’ guide for trainers. Our method has been adapted and used by others in Kenya and Germany.
- We developed a series of training courses on empathic engagement skills which have been taken up by the Department of Health and several non-governmental organisations (NGOs). To supplement this training, we developed an open-access short film and added a chapter to our Maternal Mental Health book published by Bettercare, available for free online.
- We developed an intervention for service providers called Nyamekela4Care (N4C). Nyamekela is an isiXhosa word which means “to treat or handle something with great care so that is lasts for a long time”.
N4C has been prototyped in several NGO settings and labour wards. It is currently being evaluated in a research project at two primary healthcare facilities and is being adapted for a pilot with Child Protection Teams.
- We were invited to contribute to the drafting of the new Maternity Case Records – the standard stationery used by the Department of Health to record all maternity care engagements, testing and outcomes for every pregnancy. We were delighted to note that all our insertions were accepted! These additions related to companionship in labour, reminders to staff to greet and explain as well as additions linked to social support, counselling and mental health screening and referral.
You can be a vital part of our system strengthening work which affects thousands of care providers, mothers and their families. Please donate here.
Associate Professor Simone Honikman, University of Cape Town’s (UCT), says more needs to be done for the treatment and prevention of postnatal depression.
Dr Honikman, who is also the Director of the Perinatal Mental Health Project (PMHP), says mothers who do not have a support system and those who live in poverty are more likely to suffer from postnatal depression.
In South Africa, studies have found that more than 30% of women living in adversity will experience a mental illness during or after pregnancy.
Life changes around pregnancy can make women more vulnerable to mental illness, therefor women are at higher risk of developing depression or anxiety during the perinatal period.
Perinatal period refers to the time from conception until the end of the first year after birth.
Dr Honikman highlights “that it is important to realise that depression is very common, not only during pregnancy but after in that first year […] People do get better from this illness, like from any other illness”. Furthermore, it is imperative to start “treatment early, so that we can prevent it from getting worse or prevent it in the first place.”
Listen to the full interview on SABC News here: https://iono.fm/e/728604
We have been busy advocating for maternal mental health during this year’s World Maternal Mental Health Day and at the Women Deliver conference. More updates in our latest newsletter
Or watch our Women Deliver session: Out of the Shadows – Addressing and Treating Maternal Mental Health on our YouTube channel now!
Food insecurity is an ongoing concern in Africa. According to the State of Food Security and Nutrition in the World report by FAO (Food and Agriculture Organization, 2018), the number of undernourished people has increased to nearly 821 million worldwide. Africa remains the continent with the highest prevalence of undernourishment, affecting over 250 million people.
Recent studies show that women with children make up a significant component of the households affected by food insecurity. In our Q&A we highlight this important topic and its connection to maternal mental health.
Read the full Food Security and Nutrition report here
What is food insecurity?
Food security is defined as having enough safe and nutritious food to sustain a healthy life. In contrast, food insecurity means that food is not sufficiently accessible or affordable, so households have difficulty securing adequate food.
What is maternal mental health?
Maternal Mental Health is a term that refers to the emotional state of women during and after pregnancy.
You can read more about perinatal mental health on our website
How is food insecurity linked to maternal mental health?
The relationship between food insecurity and poor maternal mental health is complex, with research showing that there are bi-directional associations between them. That means that suffering from food insecurity can have a negative impact on mental health and having mental health problems can negatively affect food security. The Perinatal Mental Health Project demonstrated these associations in a paper published in 2018.
How does food insecurity affect maternal mental health?
The negative physical health effects of poor maternal nutrition are well documented. Additionally, the emotional strain associated inadequate basic household resources, and how these resources are allocated substantially increases the overall household stress. Food insecurity can have persistent effects on the mental health of household members, especially those responsible for child care.
How can mental health problems during or after pregnancy affect food security?
In low-and-middle-income countries, maternal depression can is associated with an increased prevalence of food insecurity in the household by 50 to 80%. Mental health problems also impact the way food for the household is sourced. Mothers with depression or anxiety may find it more challenging to generate income, make contingency plans and draw on social networks for support. They are more likely to be in relationships characterised by abuse and control.
Breaking the cycle of food insecurity and poor maternal mental health!
Even though the link between the two highlighted issues is being explored worldwide, there is little evidence for interventions that successfully break this cycle.
Currently, many interventions target one or the other issue. While food banks and support grants are aimed at improving the nutrition of mothers and consequently alleviates household food insecurity – they do not address the mental health implications of food insecurity on households. Similarly, maternal mental health services do not typically poverty relief or similar interventions, which could reduce the negative impact food insecurity has on households.
Combined interventions need to be developed and tested for their dual impact on both the mother’s mental health and the food security of the household.
Photo by Annie Spratt, Unsplash
- Effects of maternal depression on family food insecurity by Noonan, K., Corman, H., & Reichman, N. E. (https://doi.org/10.1016/j.ehb.2016.04.004)
- Factors associated with household food insecurity and depression in pregnant South African women from a low socio-economic setting: a cross-sectional study by Abrahams, Z., Lund, C., Field, S., & Honikman, S. (https://doi.org/10.1007/s00127-018-1497-y)
- Food insecurity among adults residing in disadvantaged urban areas: potential health and dietary consequences by Ramsey, R., Giskes, K., Turrell, G., & Gallegos, D. (https://doi.org/10.1017/S1368980011001996)
- Food Insecurity and the Risks of Depression and Anxiety in Mothers and Behavior Problems in their Preschool-Aged Children by Whitaker, R. C., Phillips, S. M., Orzol, S.M. (https://doi.org/1542/peds.2006-0239)
- Food Insecurity/Food Insufficiency: An Empirical Examination of Alternative Measures of Food Problems in Impoverished U.S. Households by Scott, R. I.
- Food Insecurity and Mental Health among Females in High-Income Countries by Maynard, M., Andrade, L., Packull-McCormick, S., Perlman, C., Leos-Toro, C., & Kirkpatrick, S. (https://doi.org/10.3390/ijerph15071424)
“You are nothing” – that’s what Nosipho, a 19-year-old woman, was told by her mother on a regular basis. Nosipho’s stepfather was abusive and raped her over the course of four years. Eventually, she became pregnant and was diagnosed as HIV-positive. She told no-one about her story because she believed that no-one would care.
Sadly, many women in low-middle-income-settings have stories similar to that of Nosipho. The Perinatal Mental Health Project (PMHP) has a service site at the Hanover Park Midwife Obstetric Unit (MOU). When Nosipho attended the MOU for her first antenatal check-up she was also screened for depression, anxiety and suicidality. She was then referred to the PMHP counsellor, Liesl Hermanus.
Women living in disadvantaged communities, that are exposed to extreme hardship, multiple traumas and little social support, have a high chance of experiencing depression or anxiety around the time of pregnancy and childbirth. These mental health conditions can result in a higher chance of social exclusion, financial difficulties and vulnerability to experiencing violence. Women who are especially at high risk are those living with food insecurity, HIV/AIDS, intimate partner violence and insecure refugee status.
As a PMHP counsellor, Liesl provides support to women and girls who experience emotional distress during and after pregnancy. Since its inception in 2002, the PMHP is addressing the need for integrated mental health care for pregnant and postpartum women and girls in South Africa through research, advocacy and its clinical engagement with vulnerable women and their families.
Liesl can see the results of her efforts walking down the street, when former clients and their children approach her with gratitude, like this SMS one of the mothers sent “I finished my job application today. I want to say thanks for everything you did for me. You must continue to help other people, other people who are suffering, just like I was.”
About the PMHP
Based at the University of Cape Town, within the Alan J Flisher Centre for Public Mental Health, we provide mental health services for perinatal women (clinical services), train those who work with mothers in order to improve the quality of their care (training), form partnerships to promote the improvement of services and inform global interventions through robust research and advocacy.
How we operate
We envision mental health support for all mothers to promote their well-being and that of their children and communities. Our mission is to develop and advocate for accessible maternal mental health care that can be delivered effectively at scale, in low resource settings.
Overlapping programme activities targeting several goals simultaneously
Our four programmes
We provide screening for pregnant women and girls for psychological disorders (depression and anxiety) at their first antenatal visit at our service site in Hanover Park. For those who are at risk, we offer free on-site psychosocial counselling, follow-up and case management for up to one year after birth.
In 2018, the PMHP team screened 1860 clients, counselled 224 women and girls through 672 individual counselling sessions. At follow-up, 57% of the women who had received counselling stated that their problem was ‘much improved’ or ‘resolved’; 93% report successful bonding with their baby; 69% view their life as positive after counselling.
We provide training in the public health and social development sectors for all levels of staff in the community, social development and health care settings including the use of interactive methods, multi-media resources, distance-based learning opportunities and train-the-trainer courses. Our goal is to integrate maternal mental health into the routine practice of frontline providers in order to increase access to care for marginalised women. Our training aims also to shift negative attitudes, reduce stigma and eliminate client abuse.
We train between 700 and 1000 service providers annually in face-to-face seminars, workshops or courses. Our Training and Capacity Building programme works closely with our Research programme and partners with other academic and civil society organisations. Together we develop innovative, relevant and practical mental health training modules for use in urban and rural contexts.
We develop a range of open access multi-media resources to support our capacity building initiatives.
To determine the effectiveness and efficiency of all elements of the PMHP intervention package we conduct integrated, independent research. The research focusses on the distribution and determinants of several aspects of maternal mental health including depression, anxiety, suicidality, alcohol and substance abuse, food insecurity and domestic violence. We have recently developed and validated a brief mental health screening tool. We also partner with cutting-edge research initiatives that seek to address the knowledge gap for maternal mental health in resource-constrained settings. Our research work is coupled with uptake-strategies to ensure that the new knowledge produced is translated into policy and evidence-based practice.
We are currently involved in the evaluation, in distinct service contexts, of our Nyamekela4Care intervention which we have piloted and developed to embed in regular practice, care provider team knowledge generation, empathic skills practice, case sharing and self-care.
Our aim is to influence and change perceptions and awareness about maternal mental health. We translate the evidence-based research and experiences we gained in our clinical services and from others’ work in resource-constrained settings to engage with local and international change agents, including policy and programme makers and senior officials of governmental organisations.
Through several media platforms and public engagements, we focus on raising awareness among the general public, including mothers and families.
We actively support a range of government policy and implementation processes in health and social development.
Click here for an interview with our counsellor Liesl.
We are a non-profit entity and need funding to do our work. Your donation will help us build a more positive future for women, their children and the communities in which they live. If you want to support us, follow this link to donate here
The Relationships Between Domestic Violence and Perinatal Depression and Anxiety – A Global Perspective
According to the World Health Organisation (WHO), depression is the leading cause of disability worldwide and is a major contributor to the overall global burden of disease. Since women are twice as likely to experience depression in their lifetime than men, it is worthwhile to explore the many risk factors that make them more susceptible.
Although depression and anxiety can have devastating effects for any individual – women have an increased chance of being affected by these common mental disorders during the perinatal period, which can have long term consequences for both mother and child.
Domestic violence (DV) and intimate partner violence (IPV) are strongly linked to depression and anxiety in the perinatal period.
Zooming in on Domestic Violence as a risk factor
Domestic violence (DV) is defined as any physical, sexual, psychological or economic abuse that takes place between people who are sharing or have recently shared a home. Intimate partner violence (IPV) relates to violence committed by a current, ex- or would-be intimate relationship that causes physical, psychological or sexual harm to either partner.
The WHO has acknowledged that all forms of interpersonal violence leads to negative health outcomes and released a global plan of action to address interpersonal violence, particularly against women, girls and children. (More in this WHO report 2016)
In Africa, there is more violence against women than on any other continent. Compared to America, twice as many women In South Africa are killed by their partners.
Violence against women during pregnancy can have negative effects for both the mother and the child. Studies have shown that negative physical effects for mother and child can include fetal death by placental rupture, premature labour, low birth weight and haemorrhage after birth.
The negative psychological effects can include lowered self-esteem, depression, anxiety, substance or alcohol misuse. These effects, in turn, render women more vulnerable to experiencing domestic violence. Furthermore, abused women are more likely to delay getting pregnancy care and to attend fewer antenatal visits.
Research on IPV from four countries
Main findings from four countries show that there is a relationship between domestic and intimate partner violence.
A recent study from Australia found that out of the 4% of pregnant women who reported a history of IPV during a routine psychosocial assessment, more than 50% were immigrants. The highest number of women reporting abuse were born in Sudan and New Zealand, while women from China and India were least likely to report IPV. It is important to note that under-reporting is very likely in many communities and this may be due to a variety of reasons such as women’s experiences of shame, stigma and lack of appropriate responses or support from others.
Those women reporting IPV were more likely to report additional psychosocial concerns including depression, thoughts of self-harm and childhood abuse.
Another study conducted in Japan showed the association between verbal and physical abuse during pregnancy and linked it to postpartum depression. The study not only offers some insights into the significant influence of both verbal and physical abuse during pregnancy on postpartum depression, but also calls for regular screening for antenatal IPV by public health nurses who could identify those women who need further support, such as referral to centres for confidential advice and support.
Similar findings were reported from Malaysia, where the exposure to IPV was significantly associated with postnatal depression. The researchers of this study are also calling for training to healthcare professional to detect and manage both problems.
A recent South African study, conducted by the Perinatal Mental Health Project, showed 15% of nearly 400 pregnant women experienced IPV. We found a substantial proportion of women were additionally experiencing violence in the home at the hands of family members other than their partners, such as brothers, in-laws and grandparents. We found that abused pregnant women are more likely to be under 30 years of age, experience a range of mental health disorders, food insecurity and are more likely to be unemployed. They are more likely to have experienced abuse in the past and be unhappy with being pregnant.
‘The atmosphere was tense in the house’ a South African mother’s story.
Further research is needed to establish the best way to identify women at risk of domestic violence or intimate partner violence. A recent systematic review showed that there is promising evidence to indicate that mental health interventions for mothers may reduce their experiences of IPV. However, further research is required to determine the mechanisms and intensity of these interventions.
- Training and supervision
Trauma-informed care, empathy training, referral-making skills and safety planning should be embedded as an integral part of the training and supervision systems for all frontline workers who engage with mothers, across different sectors.
Clinical and policy guidelines provided by the World Health Organisation are available here.
- Systems strengthening
Political will, with the attendant resource allocation, is required to develop the structures able to protect and support survivors. These structures in health (physical and mental), justice, and the non-governmental sectors should operate in a co-ordinated and mutually enhancing way.
The World Health Organisation has produced an excellent manual for health managers for systems strengthening to respond to women subjected to IPV and sexual violence. This includes building awareness, advocating, analysing and planning as well as addressing leadership and governance factors.
The first 1000 days of a baby’s life (from conception to their second birthday) has been identified as a critical time in a child’s life. It has the potential to shape lifelong health and development. How does the mother’s wellbeing fit in with this? A healthy and emotionally well mother is better able to provide her child with the physical and emotional support and stimulation that they need for growth and development. Mothers need to be supported during this time.
There are many factors in a woman’s life that can put her at risk of experiencing mental distress during and after pregnancy. These include the lack of a supportive partner or family, an unintended pregnancy, poverty, food insecurity, HIV+ status and experience of domestic violence. Women who have experienced past trauma or who are refugees or migrants are also at higher risk.
About 1 in every 3 South African mothers suffers from common mental disorders – depression and anxiety – during pregnancy and in the first year after birth. This is approximately double the rates found in high-income countries.
In South Africa, there are many risk factors which may contribute to maternal mental disorders, especially among women living in poverty.
Maternal mental health has been getting more attention in the media, especially on social media. However, in South Africa and many other low-and-middle-income countries, mental illness is stigmatized and seen negatively. This means that many women do not want to admit to their feelings and will not seek help.
If left untreated, the risk of suicide is high in women experiencing maternal mental disorders. An article from the Economist highlights the case in Japan where suicide was the leading cause of death in pregnant and new mothers between 2015 and 2016. As a result, they have shifted their focus to be solely on the baby, to increased mental health care for mothers. “Japan is not alone in waking up to the inadequacy of care in early motherhood”
The Perinatal Mental Health Project was founded to address unmet mental health needs of pregnant women and new mothers in South Africa through research, advocacy and capacity building.
We believe maternal mental health needs to be routinely integrated into primary healthcare. The Mental Health Care Act (2002) and the National Mental Health Policy Framework and Strategic Plan (2013-2020) describe the need for mental health care to be integrated into general health services, in particular, services targeting vulnerable groups.
Pregnant women and new mothers are vulnerable and need mental health services that cater to their needs. This, in turn, will benefit their babies and children and the next generation.