Community Health Intervention through Musical Engagement (CHIME) to reduce anxiety and depression symptoms in pregnant women in South Africa.
It has been a busy three months for the CHIME-SA team. This blog reports on two highlights.
‘Music and Medicine’ for UCT medical students
On 28 August, PMHP research consultant Lele Sigwebela, musicians and ethnomusicologists, Dr Bronwen Clacherty and Prof. Dizu Plaatjies were invited to present their work to 2nd year medicine students participating in the “Music and Medicine” module at the Primary Health Care department at UCT Health Sciences. The course is facilitated by Prof. Steve Reid and is focused on the intersection of music and medicine. Lele presented on the CHIME project and reflected her experiences facilitating and co-developing a musical engagement intervention with community health workers. The session was a discussion with students encouraging them to include their clients in the delivery and performance of music as a part of their healing or recovery processes.
Eastern Cape research and celebration
In the last week of September, visiting researcher Dr Bonnie McConnell, Lele Sigwebela and CHIME research assistant Ncumisa Waluwalu spent a week in Mankosi, Eastern Cape. The team conducted follow-up focus group discussions with One to One management as well as the seven Mentor Mothers who participated in last year’s co-design workshop and who had composed 14 songs related to maternal mental health.
From left to right: Lele Sigwebela, Ncumisa Waluwalu, Tumeka Tyabulwa, Thandi Matinkinca, Chwayita Mhlanganyelwa and Bonnie McConnell.
During the discussions, participants shared that the music has been used by other Mentor Mothers in the organisation, as well as by women served by the organisation. They thought the messages in the music resonated with listeners and that the CHIME participatory, collaborative approach, was refreshing and respectful of the knowledge and skills of the mentor mothers. The management team also shared that some of the other programmes at One to One Children’s Fund would benefit from the CHIME project. The CHIME team shared copies of the physical album with the musicians, which was met with much excitement and relief! They also shared and recorded four new songs which will soon be available on the CHIME website.
From left to right: Ncumisa Waluwalu, Cwayita Mhlanganyelwa, Lele Sigwebela, and Bonnie McConnell
Finally, the mentor mothers and researchers held a CHIME celebration event at the Mankosi clinic on 26 September. The event aimed to share the CHIME-SA co-development process with their clients, community, and organisation. The event was a success despite the stormy weather. Clients and mentor mothers shared their testimonials about the effect music has had on their wellbeing and expressed gratitude for the mentor mothers’ high spirits and dedication to their community. Overall, it was an incredible afternoon, with music, tears, and laughter.
Reckoning: The Intergenerational Burden
Written by Tyla Prinsloo, PMHP Mental Health Counsellor
“The story of the traumatic event surfaces not as a verbal narrative but as a symptom.” This is a statement by Judith Herman, a psychiatrist who focuses on trauma. I am saddened by this point because it means that broad societal issues that need widescale intervention end up being an individual ‘problem.’ The symptoms of post-traumatic stress, anxiety and depression become a client’s burden rather than the causes of those symptoms being addressed with more urgency.
Cognitive dissonance brews
There is a National Mental Health Conference set to take place in Johannesburg in April this year. I was invited to submit an abstract that describes how counsellors working at our Maternal Support Service at Hanover Park Midwife Obstetric Unit intervene with psychological problems as well as the social/external issues contributing to their psychological wellbeing. This needed to be done in a 300-word abstract. How do I portray the realities of intergenerational trauma present in South African society, today and do it justice? How do I package the impact of Apartheid’s legacies in a 300-word abstract? Many unanswerable questions bothered me because the problems that clients face often feel like mountains that are too tall to climb. How do I, with so few words, communicate the experiences of a community cast aside, especially when I see people who look like me carry a burden that is too painful to put into words.
Now, all I can do is try.
Pictures taken by Bev Meldrum: Hanover Park, Cape Town.
The legacy of Apartheid
We seem to forget that Apartheid has ruined the fabric of society and that issues like unemployment, poor housing infrastructure, overcrowding in homes, food insecurity, gun violence, gangsterism, and abuse, aren’t just newspaper headlines and political agenda items but they are chronic, long-standing stressors that are deeply traumatizing for real people. If we aren’t directly experiencing these issues, we have the freedom to shake our heads in disbelief and feel sympathy. But, we get to turn away from these realities and retreat into our places of safety, comfort, and rest, where all our basic needs are met, and we don’t need to think twice about it. Many pregnant women walking through the doors of the Hanover Park Midwife Obstetric Unit don’t have this privilege.
A trauma-centered approach to counselling
This leads me to consider the first sentence of this blog – ‘the story of the traumatic event surfaces not as a verbal narrative but as a symptom.’ The word – ‘symptom’ broadly means that there is evidence of some kind of problem in the body. In the health system, there is a huge focus on what is happening in the body of pregnant women – mostly around the development of the fetus as the pregnancy progresses and the tasks that women are given to fulfill to care for their bodies during this time. But what requires great attention here is the immense impact of external trauma. The stories of trauma remain in the body and women are carrying these traumas with them, as they carry their pregnancies. What does this mean for the development of these pregnancies?
This makes me think about the style of intervention that is needed. For the story to be released from the body, we must help women feel safe, both physically and psychologically. This is a wonderful formula reading it on paper but when yourself and the woman you’re counselling work together to decipher whether a sound outside was a gunshot or a car backfiring, the nature of safety takes on a completely different meaning because of how unsafe one truly is. One thing that can be done here is to think ‘can we live within our ribcages?’ breathing plays a crucial role in trauma and panic, it’s also a tool that becomes deeply personal for women, it helps women trust their bodies.
Work outside the counselling room
What else can be done? I believe the saying should be it takes a “village” to support a pregnant woman. Being a counsellor at the Hanover Park MOU means that I form part of that village. Given the landscape of an immensely under-resourced area, much of the work includes sourcing and building relationships with additional avenues of support for the woman to draw on, like child protection agencies, community health center services, and community-based organisations, so that the “village” expands. To be honest, this is a tremendously difficult undertaking, in general, because these resources are supposed to be available in all areas but it’s often not the case. Working with a woman in counselling means shifting the focus to the smallest of victories. What might these victories look like? If there is a pregnant teenager without sufficient support to raise her baby, is there a Social Worker that can conduct a home visit and assess her level of need, intervene, and provide meaningful feedback? If a woman hasn’t had a meal in the last 24 hours, is there a food-support programme available? If a woman has no clothing for her baby and barely any toiletries for herself, is there an organisation to call on? If a woman is experiencing intense symptoms of depression or anxiety with no relief after we have spent time together exploring strategies in counselling, is there additional mental health support available?
Agency and dignity open possibilities
Sometimes the answer is no, and this is the heartbreaking part, but when the answer is yes, there is a realm of possibility. For a woman to be able to access agency and restore her own dignity is groundbreaking. It does not sound like much, but if a client can begin to carry hope in their bodies in response to the trauma, her baby might be born into a maternal world that is empowered.
The picture is not this promising at many facilities nationwide because these additional resources are hard to come by, or they aren’t available. In essence, many people’s basic needs are barely being met. Mental health care is not far removed from basic needs, it’s embedded within them. The work is far from over and hopefully, the causes of the symptoms can be addressed as well, but there are possibilities that exist when you search for them and when you actually want to see change happen. But that means, you cannot retreat into your comfort, you must do the work. That work exists in community, we have to do the work in community. It is very easy to feel weighed down, but we must try.
Tyla graduated with her Bachelor’s degree in Psychology, in 2020. She is originally from Johannesburg, but relocated to Cape Town to pursue her studies. She has a keen interest in working with intergenerational trauma and community psychology. Mental health care provision in underserved communities is a passion of hers as well as advocating for social change. For the past two years, she has worked with the Perinatal Mental Health Project to empower the family system of the women we serve.
Reflection on the need, development, and usefulness of the birth preparation pamphlet
Why Labour Needs a New Narrative
For many pregnant women, especially first-time mothers, labour is a looming question mark. Fear of the unknown, or even dread because of a past experience, can overshadow the excitement of welcoming a baby.
Traditionally, childbirth is portrayed as a long, painful ordeal. This narrative can be incredibly anxiety-provoking, making a natural process even more challenging.
Sometimes, in cases of unintended or teen pregnancies there is a “punishing approach” adopted by those around the client – “you chose this, now you’re going to feel it.”
Our aim is to be responsive to the needs of pregnant women – and this is where our new birth preparation pamphlet comes in. The PMHP team wanted to create a resource that empowers women to approach labour with confidence.
The Development of the Birth Preparation Pamphlet
“I wasn’t prepared for my first birth. And during my second pregnancy, amid a pandemic, I was determined to have a different experience. Hypnobirthing empowered me, and the second time, birth felt powerful. Knowledge may not erase fear entirely, but it arms you – and that’s what I would like for every woman on their birthing journey.” Thanya April, Operations Manager
We decided to develop a psychoeducational resource that helps women prepare for their labour process. Hypnobirthing uses relaxation techniques like visualisation, affirmations, and mindful breathing to manage pain and promote a positive birth experience. With this framework, we consulted senior lecturers in obstetrics and gynecology, and advanced midwives to work with us to formulate a pamphlet that explained the physical and psychological components of labour.
When developing the pamphlet, we prioritised creating a resource that aligned with the realities of birthing in a public facility setting. This meant focusing on information that would be most relevant and applicable to our clients and their specific experiences.
We wanted to ensure that women who accessed the pamphlet had the opportunity to shift their view of birth from a ‘pain-centered’ narrative to an ‘empowered’ narrative where the woman has an active role. While there are some things you can’t control during labour, the pamphlet reframes the process as a collaboration between mother and baby – not just something that happens to a woman. It has a biopsychosocial framework that allows women to understand the physiological process of the womb contracting and its rhythmic elements. This allows for an informed understanding of the role that breathing plays for the body and the relationship it has with the mind.
Before finalising the pamphlet, drafts were reviewed by experts and piloted with clients for sense-checking and understanding.
The Power of Birth Preparation
Clients have been very receptive to the pamphlet and have reported a greater understanding of the mechanisms of labour. They have said that this has made the process feel less daunting – simply understanding what a contraction means has helped women approach their labour with greater insight.
The physical understanding of the feedback mechanism of oxygen and contractions has enlightened women about the inner workings of their wombs and muscles and has fostered a greater appreciation for their physical capacity.
In addition, the breathwork exercises have been anchoring. These have helped to alleviate some of the discomfort and have strengthened women’s capacity to cope as they welcome their babies into the world.
Moreover, it seems the pamphlet has contributed to equipping women with useful strategies and insights for their labour. We hope this will ensure more birth processes are affirming experiences for the women we serve.
PMHP internship
Written by: Nina de Jong and Marisa Dawson, final year medical students at the University of Amsterdam in The Netherlands.
For our public health internship, we spent three weeks with the inspiring and caring women who run the Perinatal Mental Health Project. We never imagined we would learn so many valuable lessons in such a short amount of time.
We were welcomed warmly and were immediately invited to participate in all team events such as the annual Research Day, the PMHP board meeting, the Spring Walk and an Acceptance and Commitment Therapy training. By week two we were deemed “part of the furniture”.
Our internships so far have mostly been in large Dutch hospitals. It was completely new for us to experience community work, and see medical care being provided in a small local clinic. Instead of being incorporated into a vast group of many medical professionals, we experienced very personal contact with and guidance from the team at the PMHP. There was a strong focus on interpersonal relationships between the PMHP and sister organisations, as well as it being an important aspect of the care that was being delivered. We were impressed by the amount and variety of work that was being done by such a small team: the research they undertake, the informative literature they create, and the valuable counseling sessions they offer women attending the Midwife Obstetric Unit (MOU).
The PMHP building at the Hanover Park clinic feels like a calm safe haven for women attending the busy MOU. During the time we spent at Hanover Park we were able to observe how the clinic operates and how the PMHP is integrated into the obstetric care provided there. The work being done at Hanover Park showcases the importance and feasibility of integrating mental healthcare as a standard component of perinatal care. Women attending the MOU face many challenges that are more prevalent in this area compared to other parts of the world such as HIV, intimate partner violence and teen pregnancy. This higher prevalence is connected to the history of the neighborhood. Hanover Park was brought into existence as part of the Group Areas Act of 1950, with many families being displaced from their homes and jobs as part of the Apartheid regime. This resulted in trauma and economic hardship for Hanover Park’s new inhabitants, which impacts the neighborhood to this day. Intergenerational trauma and poverty have an effect on the mothers living in this community, and in turn, their children can also be impacted by this, continuing the cycle. This means that, in order to fully provide help to individual mothers as well as the community as a whole, you need to break through a cycle that has been going on for generations. The PMHP is tackling this challenge with the work that they do at the MOU.
In The Netherlands, the obstetric wards we worked on during our internships were not located in disadvantaged areas. However, mothers there were also facing mental health challenges. Despite this, from what we experienced the focus on mental health was lacking compared to what we have seen in the MOU at Hanover Park. We would say maternal mental health was a bit of a “forgotten child”, which is fitting as the effects of impaired maternal mental health will have lasting impacts on children. It was inspiring to see how the PMHP is addressing these issues.
Another lesson from our work at the PMHP was the importance and necessity of community involvement. This is something we observed both during the annual Department of Psychiatry and Mental Health Research Day we attended as well as in the conversations we had with the team and the assignments we worked on. Community involvement is of great importance at every level of research and of policy implementation. Without consulting with community members about their values and needs, it is not possible to undertake relevant research for that community. What a researcher finds relevant will in all likelihood differ from the community’s values and needs. In our experience, in The Netherlands, the importance of community involvement is far less recognised. In our time as medical students, neither of us has seen a particular emphasis on community involvement in research spaces. Research endeavors tend to be structured in a more ‘top down’ fashion. In future, we will keep the importance of the community in mind and try to address this issue in the work and research that we will undertake.
We are truly grateful for the opportunity to experience everything the PMHP does and for the guidance we have had during our time here. The lessons we have learned with the PMHP are valuable foundations for becoming compassionate and inclusive healthcare professionals.
My experience working with PMHP: The Power of Community and the value of human connection
Leah Smith, doctoral Occupational Therapy Student, Boston University, USA
When I applied for the opportunity to work with Simone and the PMHP team for my doctoral attachment abroad, I never knew that my experience at the Hanover Park service site would extend far beyond the Midwife Obstetric Unit. Tyla and Liesl were gentle, transparent, warm, and welcoming. Their ‘therapeutic use of self’ shone through to me, as well as the women they interact with. In my time with PMHP, I only scratched the surface in my understanding of the lived experience of the mothers in the Hanover Park community.
From the PMHP team to strangers selling me Gatsbys, warmth, and kindness penetrated nearly every interaction and reignited my passion for community work. I was surprised by the interconnectedness of it all and the ease I felt, even being an ocean away from home, as if I had forgotten just how natural and vital the strength of a community is to our sense of belonging.
A street art tour by Liesl highlighted the importance of spaces that Hanover Park can be proud of, in spite of the violence that seems to define the community from the public’s perspective. This perspective, of course, only tells a one-dimensional story, and fails to acknowledge the sociopolitical and historical context or the concerted efforts of the community. I met an HIV counselor, who spoke about the stigma, burden, guilt and shame experienced by expecting mothers with a diagnosis. Auntie Avril shared her reason for starting the Alcardo Andrews Foundation–a son lost to gang violence–and how she feeds her community and provides a safe space for men. Jade from the Department of Social Work, who works closely with PMHP, described the dangerous and exhausting work she does, but demonstrated how crucial it is to build relationships with the community through the work of Auntie Fatima, a safety parent for children picked up by the system.
My doctoral project was to co-design a short training film to help maternity healthcare providers in South Africa to integrate empathic care and primary-level mental health care into their routine practice. In collaboration with PMHP team, as well as several community stakeholders, we developed and refined a storyboard for the film that reflected real-world challenges and opportunities for both healthcare providers and their clients. We developed four scenes showing naturalistic interactions among midwives and between midwives and their clients in a range of everyday settings.
On a small budget, we had great fun using PMHP staff and relatives as actors and extras and were lucky to have the skills of local filmmaker, Ross Cupido and his team. Mowbray Maternity Hospital graciously allowed us to use their outpatient clinic over the weekend for our location and donations of time, food and various other necessities were forthcoming from a wide range of people. The film, “No Maternal Health without Mental Health” was shown to a range of stakeholders who reflected on its acceptability and feasibility for dissemination across South Africa. We plan to embed the film within several training across the country to support the realisation of the new Maternity Care guidelines that PMHP is contributing towards for mental health and respectful care.
So many people in South Africa are filling a gap, including PMHP, in order to better serve the health of the community and generate community wellness. Wellness encompasses multiple components, spanning mental health to financial health to access to green spaces and environmental health. Through my occupational therapy lens, I thought I already knew the meaning of “person-centered care,” but I believe my original view neglected the value of human connection. We must regard our clients and the populations we work with as experts in their own care, in their own health – then work to build relationships in order to sustain real change.
Youth Day – 16 June 2023
They say it takes a village to raise a child, but it also takes a village of strong networks to support a mother. The work of protecting our youth can be done by uplifting and strengthening the family system. At the Perinatal Mental Health Project (PMHP), our counsellors aim to meet and guide perinatal women in their understanding of emotional wellbeing so that they flourish and can be meaningful role models for their children. Teenage pregnancy is often a stressful time for young women attending a Midwife Obstetric Unit (MOU). This is the story of Babalwa* who made use of our maternal support service.
Babalwa, attended the Hanover Park MOU for her first antenatal appointment. She became aware of the maternal support service when she listened to a PMHP counsellor conduct a Prevent, Promote, and Prepare (PPP) session in the waiting room. During the PPP, our counsellors opt for a warm, interactive approach to health promotion discussions where they hope to destigmatise mental health, prevent women from feeling isolated, and promote help-seeking behaviours by describing the maternal support service.
One of our counsellors, Liesl Hermanus, conducting a PPP session in the waiting room.
In more ways than one, an unintended teenage pregnancy is tremendously overwhelming. The Health Promotions Officer, Sharmaine, conducted the preliminary mental health screening with Babalwa and noticed her anxiety and tearfulness. Sharmaine referred Babalwa to the PMHP counsellor, Tyla, for an in-depth screening, known as the Engage, Assess, Triage (EAT) session. The EAT allows for containment and appropriate referral based on the client’s need. During the EAT, Babalwa shared her fears and disappointment regarding her pregnancy, including her worry about not having support and feeling unprepared for motherhood.
An EAT session taking place in one of our counselling rooms.
Teenage clients accessing the PMHP service are provided with a safe space to express their emotions and process the reality of their pregnancy. Babalwa was unable to see a way forward for herself and felt overwhelmed and confused. She was disappointed in herself and hoped that she would somehow be able to finish school. She did not know how to go about solving the problem of her exam timetable clashing with her estimated date of delivery. Her situation was made worse by her fear of the unknown (labour and birthing) and her concern about providing for and raising her baby.
After a few counselling sessions, Babalwa invited her mother to join her at a follow-up appointment with Tyla. Here she voiced her concerns to her mother and together they began to develop a plan for the future care of the baby. This session allowed Babalwa and her mother to embrace forgiveness and explore parenting in a safe setting. Babalwa was able to rebuild her self-esteem, which enabled her to feel confident about motherhood.
As Babalwa continued her counselling appointments, Tyla noticed the shift in her demeanor as she grew more confident and self-assured. This enabled her to draw on her own personal resources. Babalwa was able to reflect on the changes in her mood and the ways in which she was regulating her emotions when she felt stressed. She found meaningful ways to rewrite her story, one where she is capable and confident.
As is routine for all teenage pregnancies, Tyla completed a referral to the Department of Social Development so that a social worker could conduct a home visit to ensure that Babalwa’s home environment is conducive for raising a baby.
After Babalwa’s baby is born, Tyla will conduct a postnatal assessment with Babalwa to evaluate her mood, functioning, bonding with her baby, and breastfeeding. The postnatal assessment will also serve as an additional therapeutic intervention if necessary.
*Pseudonym. This story depicts a common therapeutic intervention style for teenagers who use our service.
The Journey for maternal mental health in Nairobi, Kenya
Written by Stella Waruingi.
My name is Stella Waruingi, a psychologist from Nairobi, Kenya. While I practiced as a therapist in my initial years post-qualification, I have spent the last seven years in health management, coordinating mental health services in the public service. This informed my search for a course that would improve my skills in mental health management, improve my research acumen and equip me with skills of developing strategies and frameworks towards improving the mental wellbeing of the population while reducing the treatment gap[1].
I was lucky to be admitted at University of Cape Town to undertake a Master of Philosophy in Public Mental Health where my dissertation is in the area of perinatal mental health. My interest in perinatal mental health is two-pronged: first, from my personal experience of postpartum depression after the birth of my 3rd baby. This made me want to make a change for other women who may be at risk of mental illness; second, being the Head of Mental Health in Nairobi County, I have the mandate of improving the mental health services of the population. Through my position, I have been able to both establish a perinatal mental health unit at our largest maternity hospital and also develop and report on perinatal mental health indicators across the county. Further, we trained more than 200 nurses and midwives in maternal mental health.
As I progress, my study reaffirms my belief that it is possible to integrate maternal mental health at the primary healthcare level to improve maternal and child outcomes. This was made clearer by my interaction with the Perinatal Mental Health Project (PMHP) team at Hanover Park, Cape Town led by Associate Prof. Simone Honikman[2]. I had the opportunity to visit the PMHP site while I attended my course orientation.
Some of the key aspects of the project that fascinated me were as follows:
- How seamlessly they had integrated perinatal mental health screening, treatment, and follow-up into the routine services at the Midwives Obstetric Unit (MOU).
- I was impressed at how coordinated the process was and by the close working relationship between the PMHP team and the MOU staff.
- How critical the data/medical registry team was in ensuring mothers were booked for mental health services and reminded when their clinic day was.
- The ability to coordinate the perinatal woman’s appointment both at the MOU and PMHP mental health service was crucial. This was a huge learning point for me and got me thinking about how to gain the support and goodwill of the health records team for the integration to be a success.
- The willingness, and commitment of the nurses offering perinatal services to screen for common mental disorders
- The reminders for the mothers who need to be seen by the PMHP mental health team or to refer them. This was central to the success of the project.
All of this means that the staff must be involved from the very beginning in designing the program, their concerns addressed and training provided on how to screen for common maternal mental health problems.
I spent slightly less than two hours at the facility, learning from PMHP and MOU staff but I felt like I had interned for months. I learnt a lot, and noted several aspects that I needed consider as I adopt the model:
- Top on the list was to identify a facility that was more receptive to the idea, has fewer bureaucratic handles, and has both an outpatient department and a MOU.
- To develop a short screening tool for our context.
- To involve the midwives and the registry staff in the process.
- To create a dedicated mental health team.
- To ensure the ability of the mental health intervention to be flexible to accommodate the needs of the mothers in terms of timings and scheduling of appointments.
My dream is to see a Nairobi chapter of the Perinatal Mental Health Project, where mothers can feel safe to share their stories, and pain and to be a support for each other.
The gains I have received in this space encourages me to do more so that when I see a mother smile and report improvement in her depressive symptoms, it warms my heart.
I will keep on doing this: mobilize for better maternal mental health services and facilitate capacity building for healthcare workers and undertake research in this area until I can do no more.
[1] The difference between the prevalence of mental health conditions and the proportion of people with these conditions who have received treatment.
[2] She will co-supervise my research for my MPhil.
Disability and Gender-Based Violence
Emma is a Senior Research Officer at the PMHP and is a woman with a hearing disability. As we celebrate the International Day of Disabled Persons on the 3rd of December and think about the 16 Days of Activism for No Violence Against Women and Children Campaign, she shares some thoughts.
Multiple layers of discrimination
At least 10-15 percent of the global population comprises of people with disabilities (WHO, 2021). People with disabilities experience many challenges on a daily basis in all sectors of life including accessing education and employment through to getting the healthcare services that they need. Women with disabilities experience additional barriers relating to their gender, race, and type of disability they have. For example, a black woman with a psycho-social disability such as schizophrenia, depression, or bipolar disorder may be discriminated against because of the colour of her skin, where she lives, as well as because of the stigma associated with her mental health condition and unfounded assumptions of her capabilities.
Women with disabilities are at a higher risk of developing mental health conditions than non-disabled women, which can be compounded by the multiple challenges that they face as a result of their disabilities (Rees et al, 2011).
In South Africa, we talk about inclusivity, diversity, and equality, but in practice, does this include disability? Are the voice of people with disabilities heard, valued, and included?
GBV and women with disabilities
Regarding gender-based violence, many women and children with disabilities are extremely vulnerable to violence and abuse. Some women and children with disabilities are reliant on others for their care, and experience imbalances of power and abuse at the hands of their partners, family members, or those who are expected to provide care and assistance. This can include physical, sexual, emotional, or verbal abuse, through to inappropriate care and neglect. If I am a wheelchair user, reliant on 24/7 physical care from someone including to bathe, dress, and feed me – and I experience abuse, will it be questioned? Will I be believed when someone is ‘helping’ me? If I report GBV, who will assist me with the care I require? Will I be worse off as a result of my reporting?
Of the very small number of cases of GBV that are reported by women with disabilities, the rates of prosecution towards perpetrators are very low (Hunt et al, 2018; Watermeyer et al, 2019).
What should we do?
- We need to ensure that our campaigns, policies, programs, and interventions that address GBV issues are accessible, appropriate, and relevant to the needs and experiences of women and children with disabilities, regardless of the type of disability they have. Issues relating to accessibility of venues, materials, technology, and interpretation should be key in leveling the playing field.
- We need to address and deal with the stigma towards disability, especially mental health conditions, rather than hiding behind ignorance. We need to look at the words and terms we use and make sure that they are appropriate and do not discriminate or exclude. For example, terms like ‘Deaf and dumb’ are outdated and discriminatory, just like the word ‘handicapped’ which comes from ‘cap in hand’ referring to begging. Other words such as ‘normal’ or ‘whole’ when referring to people without disabilities. What does this say about those with disabilities? That we are ‘abnormal’ and ‘incomplete’?
- Most importantly, we need to ensure that the voices of women and children with disabilities are heard. So often women with disabilities are the last to be consulted on issues directly relating to us. Our input is the priority. To do this, it is vital that we are consulted at all stages, from design through to implementation and evaluation of policy and practices. This active participation will improve the sustainability and suitability of any intervention. Without our voice, these may have far-reaching and sometimes dire consequences.
- Including people with disabilities should not just be a ‘ticking boxes’ activity. Our experiences are real and valid. Rather than making assumptions on our behalf, we need to actively engage and participate. We know what we need best which aligns with the disability slogan of ‘nothing about us, without us.’
Advocating for the rights of clients at Hanover Park Midwife Obstetric Unit
By Tyla Prinsloo, PMHP Mental Health Counsellor
It is often incredibly difficult to discuss issues of gender-based violence. It seems as if its nuances have become lumped together, and the gravity thereof lost in translation. Its component parts need to be brought to light with empathy and sincerity, so as to disrupt the patterns of behaviour that may result in our desensitisation and complicity. We ought to pay careful attention to our language, in this way we avoid victim-blaming and shame.
Hanover Park is not notorious, it’s bleeding
Gang violence, in particular, presents itself as a devastating by-product of our historical relationship with state-sanctioned violence and how it embedded itself into the psyche of marginalised communities. Hanover Park is a community deeply affected by this reality. Having worked at the PMHP in Hanover Park for almost two years now, I have had to confront the preconceived ideas held about this community and others like it – that the people who live here are passive victims stuck within a pit of despair. It is our responsibility to acknowledge the ingenuity of people within difficult and violent contexts and be able to recognise the beauty that exists therein. We need to avoid sensationalising the traumatic consequences of violence. And, the language of healing and intervention needs to belong to the community itself. The work of addressing violence in marginalised communities means that you have to surrender yourself to the answers that the community provides for itself. There is intergenerational trauma, but there are opportunities to foster resilience too. Violence does not mean that a community should be forgotten or blamed, but the cries of its people need to be heard. Hanover Park is not “notorious” for anything, Hanover Park is bleeding.
Tyla Prinsloo at a protest against gun violence in Hanover Park, 2021
Disempowerment and inequalities project into violence
When we pay close attention to the experiences of women in the area, we can uncover some insights into the way violence emerges. There is a delicate interplay between projection and displacement. A community like Hanover Park experiences intense levels of impoverishment, many basic needs are not met and when there is this kind of suffering, it is seldom that one has access to psychological care and safety, within the home. The complexity of these stressors occupies the mind of community members and violence may emerge as a by-product of disempowerment. Oftentimes the anger and pain that is felt, as a result of systemic inequalities, is projected onto family members- and women in particular. When people are pushed to the fringes of society, they’re forced to create a life out of ruin. When there is little to no opportunity to heal and restore, pain is reproduced in order to survive.
We cannot exclude men
The discussion around violence against women and children cannot exclude men, because to address the woundedness of a community, the woundedness of men cannot be ignored. Masculinity in and of itself is built on the premise of ‘strength, provision, and stoicism,’ but if these elements remain rigid and immovable, the consequences are dire. Advocating for, and defending, the rights of women using the Hanover Park Midwife Obstetric Unit necessarily must incorporate attention being drawn to systemic healing, individual unlearning, and restoring dignity.
2021 protest against gun violence in Hanover Park, with the Alcardo Andrews Foundation and Moms Move for Justice.
Community Health Intervention through Musical Engagement (CHIME)
The CHIME project for perinatal mental health
We are excited to be collaborating with researchers from Goldsmiths University of London, Imperial College, London, and Australian National University, on the Community Health Intervention through Musical Engagement (CHIME) project for perinatal mental health. CHIME aims to investigate, together with local stakeholders, how indigenous and interactive musical practices might be developed to support perinatal mental health in Africa. CHIME was trialed as an intervention in The Gambia, using existing women’s community music groups (Kanyeleng groups) to help pregnant women and new mothers with their mental wellbeing. Kanyeleng women, who play an important role in community ceremonies and public health campaigns, co-developed and then facilitated the intervention with all women attending an antenatal facility. Symptoms of depression were significantly reduced in women who received the intervention. Read more about the development of CHIME-Gambia here.
Adapting CHIME in South Africa
The CHIME-SA project aims to describe how local and indigenous interactive music-making may function to support maternal mental wellbeing. We wish to investigate the feasibility of adapting existing musical traditions for this purpose and thus we organised a series of focus groups with a range of key stakeholders. We also aim to co-develop and prototype a musical intervention and an initial repertoire of songs together with community health workers (CHWs).
Focus groups
One to One Children’s Fund Africa is an organisation that delivers a range of interventions to support maternal and child health in Mankosi, rural Eastern Cape. Through their Enable project, they train local women to become CHWs. After we worked with One to One on our Nymakela4Care (N4C) project in 2021, where singing about health matters emerged as a spontaneous part of our N4C training workshop, we were excited to explore co-developing a musical intervention with them.
Remote focus group discussion with One to One management.
In February 2022 we facilitated a focus group discussion with the One to One management team to explore the feasibility of such an initiative. The team spoke about the experiences of pregnant women and mothers living in Mankosi. They shared their experiences of the singing and music-making the CHWs have been doing in their organisation, arising from an existing tradition in the local communities. They were strongly supportive of strengthening existing musical engagement practices of the CHWs to support maternal mental health.
In the same week, we had an enriching discussion with musicologists and musicians from Gauteng, Eastern Cape, Western Cape, and KwaZulu Natal. They spoke about the benefits of various South African music practices for healing and social connection. We had a vibrant conversation about the intersections of culture, spirituality, music-making, the body, and mind. The group shared some useful suggestions to support our co-design workshop structure.
Remote focus group discussion with musicians and musicologists
On a sunny Saturday morning in March 2022, our researcher Lele Sigwebela and co-facilitator Thandi Davies held a discussion with traditional healers. These healers represented various traditional healer organisations in the Western Cape and many of them work all over Southern Africa. The healers shared their personal narratives about how music has assisted them with their own mental well-being and with their training as healers. They all expressed that cultural music can act powerfully to connect and heal because music is an integral part of African tradition. It is a way ‘to uplift oneself’, express your thoughts, process your feelings, and create with others.
PMHP junior researcher, Lele, and the traditional healers focus group participants.
In the first week of April 2022 PMHP director, Simone Honikman, and co-facilitator, Thandi Davies, held a discussion with healthcare workers to establish their thoughts on music-making and mental health. They shared several examples of interactive music-making interventions and cautioned that younger participants may not easily engage in traditional music-making practices. They recalled the tradition of health staff in facilities starting the day with religious singing and engaging the patients in the waiting areas for this. There were mixed views as to whether music-making within health facilities could feasibly be used to enhance maternal mental health.
CHIME-SA co-design workshop
In the first week of March 2022, our researcher Lele Sigwebela, and local research assistant, Ncumisa Waluwalu, were in the rural village of Mankosi, collaborating with seven of One to One’s mentor mothers/CHWs. These women were purposively selected as the most skilled composers, from among a much bigger group of CHWs.
Set against a backdrop of the beautiful Wild Coast, we ran a three-day workshop to co-design a musical engagement intervention for pregnant women and mothers in the surrounding villages. The workshop was a huge success! Despite the windy weather, poor cellular network signal, and power outages; the workshop achieved its main goals. The group composed and recorded a total of 14 songs that featured themes of engaging with difficult mothers-in-law and partners, destigmatizing emotional distress, encouraging social support through understanding, soothing babies, and offering messages of self-efficacy and resilience. The workshop participants generated the idea of facilitating choirs for all pregnant and postpartum women in their villages.
Our view from the workshop venue and Mdumbi Beach.
Throughout the workshop, there were sincere and in-depth discussions about the difficulties faced by pregnant women and mothers in the area but in equal measure, there was laughter, singing, and dancing. Lele and Ncumisa were affectionately welcomed by the mentor mothers and were struck by the kindness and warmth shown to them by the community.
The talented women of the CHIME workshop rehearse a song before recording.
Two workshop participants composing a song and dance.
What’s next?
The analysis from the focus group discussions and the methods we developed for the co-design workshop will be written up in academic papers and be presented at the International Marcé Conference later this year. We plan to develop a simple workshop guidance brief for others who may wish to run a similar process in South Africa, or elsewhere. As per the agreement of the composers, and a creative commons license, we plan to disseminate the songs that were developed on several platforms.
We hope that different types of health providers, in a wide range of settings, will be inspired to bring interactive music-making, into their practice with perinatal women. If we are able to obtain further research funds, we may be able to test the intervention for effectiveness.
Keep an eye out for the release of the songs composed at the workshop which will be shared on the PMHP website or you can access them now on the CHIME YouTube.
Thank you
A huge thank you goes out to One to One Children’s Fund Africa and all our enthusiastic focus group participants for their support in making this project happen. Our UK and Australian collaborators have been wonderful to work with – we are very grateful for all your support!
PMHP Blog 