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Disrespect and abuse (D&A) during facility-based childbirth

Source: Maternal Health Task Force

Researchers Share Lessons Learned From Measuring the Prevalence of Disrespect and Abuse

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By: Sarah Hodin, Project Coordinator II, Women and Health Initiative, Harvard T.H. Chan School of Public Health

Disrespect and abuse (D&A) during facility-based childbirth has been identified as a widespread problem, but just how commonly it happens is not well understood. Several studies have attempted to measure the prevalence of D&A during childbirth in health facilities across the globe, resulting in a wide range of estimates. Given that variations in reported prevalence may be at least in part the result of differences in definitions, measurement tools and data collection methods, comparing the extent of D&A across diverse settings remains challenging.

In order to better understand the trade-offs related to various methods for measuring the prevalence of D&A, the Maternal Health Task Force (MHTF)’s Rima Jolivet and Harvard Chan doctoral student David Sando conducted a systematic literature review to find all of the studies that have attempted to measure D&A during childbirth in health facilities. They then collaborated with the authors of these studies to compare methods and offer lessons learned.

The following five studies were included in the review:

The prevalence estimates in these five studies ranged from 15% to 98%. Given that all of these studies were conducted in low-resource settings in sub-Saharan Africa with similar maternal health delivery systems, the wide variation was likely due at least in part to differences in the way that researchers chose study sites and participants, defined D&A and collected data from participants.

Recommendations for future studies

The authors offered recommendations for researchers conducting studies that involve measuring the prevalence of D&A in order to maximize reliability, validity and comparability of results:

  1. Study site and population: Ensuring that there are no systematic differences in the study sample compared to the target population is important.
  2. Inclusion criteria: All women receiving maternity care in the study facility should have equal chance of being included regardless of their pregnancy outcomes. Stratified analyses can be used to examine different sub-groups of interest.
  3. Standardization vs. localization: Standardization of measurement across different study populations would ensure comparability of findings between studies, but ensuring valid measures that capture the constructs of D&A as perceived and experienced in the local context is also key. It is therefore important to acknowledge the tension between standardization and localization in developing instruments to measure the prevalence of D&A. Use of standard categories could help maximize comparability, while some leeway may be needed for context-specific operationalization of those categories.
  4. Environment: When possible, conducting interviews with women in a safe, neutral setting outside of the health facility where they may have experienced D&A can help participants feel more comfortable and open.
  5. Timing: In contrast to the typical understanding of recall deteriorating over time, in this context, women’s self-reports of D&A may be more accurate when solicited after they have had some time to process their experiences. More research is needed in this area.
  6. Data collection methods: Direct observation is generally regarded as the gold standard for measuring observable phenomena in prevalence studies. However, if the outcome of interest is women’s experiences of care, using women’s self-reports–ideally collected using patient-developed or patient-validated measures and participatory research techniques—is a better method.

Are you working on measuring the prevalence of disrespect and abuse during facility-based childbirth? We want to hear from you!

Read the full open access paper, “Methods used in prevalence studies of disrespect and abuse during facility based childbirth: Lessons learned.”

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Poverty and mental illness

Poverty and mental health

A review to inform the Joseph Rowntree Foundation’s Anti-Poverty Strategy

“Poverty increases the risk of mental health problems and can be both a causal factor and a consequence of mental ill health. Mental health is shaped by the wide-ranging characteristics (including inequalities) of the social, economic and physical environments in which people live. Successfully supporting the mental health and wellbeing of people living in poverty, and reducing the number of people with mental health problems experiencing poverty, require engagement with this complexity. […]

Although mental health problems can affect anyone at any time, they are not equally distributed and prevalence varies across social groups.”

Although this policy review is based on UK data it is relevant for everybody working in the mental health sector

 

 

Suicidal thoughts during pregnancy

Perinatal depression and anxiety are serious mental health problems and are among the leading causes of maternal morbidity and mortality worldwide!

Pregnant women are at higher risk for suicidal ideation and behaviours compared to the general population.

Suicide has been identified as one of the major contributors to the global mortality burden and there is a growing concern over the increase in suicidal ideation and behaviour among pregnant women.

Studies in low- and middle-income countries put the rate of maternal death due to suicide at somewhere between 0.65% and 3.55%. In such cases, risk factors include poverty, lack of support, lack of trust in health systems and coexisting mental illnesses.

Suicidal thoughts experienced during pregnancy can continue beyond the initial postpartum period, affecting the well-being of both mother and child.

More about pregnancy and suicidal ideation in our infographic

Mental illness among displaced, migrant and refugee women

The United Nations High Commissioner for Refugees (UNHCR) estimates that there are currently 24.5 million refugees and asylum-seekers in the world (UNHCR 2015).

Depression is the leading cause of disability worldwide and is a major contributor to the overall global burden of disease. Mental health among refugees is increasingly being discussed and researchers acknowledge:

Refugees are a vulnerable people.

We have found that uncertain refugee status is a key factor contributing to mental illness in pregnant women. Women with uncertain refugee status are particularly vulnerable to maternal mental illness. Psychological trauma, associated with political conflict, displacement, violence, loss of loved ones, torture, rape and poverty contribute to poorer general maternal health.

For more information see our Issue Brief and for a quick visual overview see our infographic below.

 

Breaking the negative cycle of mental ill-health and poverty during the perinatal period

The negative cycle of mental ill-health and poverty is particularly relevant for women and their infants during the perinatal period. During this time, major life transitions render women more vulnerable to mental illness from social, economic and gender-based perspectives.

Those with the most need for mental health support, have the least access. Overburdened maternal and mental health services have not been able to address adequately this significant unmet need. There have been limited attempts at a programmatic level, to integrate mental health care within maternal care services.

The perinatal period, where women are accessing health services for their obstetric care, presents a unique opportunity to intervene in the event of mental distress. Preventive work involving screening and counselling may have far-reaching impact for women, their offspring and future generations.

Mental health care is a notoriously neglected area – even more so in “healthy” pregnant and postnatal women. The focus on the physical to the detriment of the emotional is particularly felt now against the backdrop of HIV and AIDS. The public health service has been unable to address the mental health needs of women from poorer communities – neither within maternity services nor within mental health services. This is despite a wide body of evidence showing that distress in the mother may have long-lasting physical, cognitive and emotional effects on her children.

Integrating mental health into maternal care in South Africa

The PMHP aims to integrate mental health service routinely, within the primary maternal care environment.
Based at selected government MoU facilities in Cape Town, we offer counselling and support services focused on the emotional wellbeing of pregnant women with a strong focus on postnatal and clinical depression.

International Day of Action For Women’s Health: Ensuring Respectful Maternity Care

Crosspost from Maternal Health Task Force blog by Kayla McGowan, Project Coordinator, Women and Health Initiative, Harvard T.H. Chan School of Public Health

“As we celebrate International Day of Action for Women’s Health on May 28, we reflect on the physical, emotional and psychosocial dimensions of women’s health as well as the reasons to support girls’ and women’s health throughout the lifecycle.

With Sustainable Development Goal (SDG) 5 calling for an end to all forms of discrimination against all women and girls everywhere, the elimination of all violence against women and girls and universal access to sexual and reproductive health and rights by 2030, now is the time to draw attention to the many elements of and impediments to women’s health and rights […]

Read the full blog entry: International Day of Action For Women’s Health: Ensuring Respectful Maternity Care | Maternal Health Task Force

Mental health and new care models – The King’s Fund lessons from the vanguards

Emerging evidence suggests that integrated approaches to mental health can help to support improved performance across the wider health system.

Key findings

  • Knowledge and skills around psychology and mental health are important features of integrated care, whatever the client group.
  • Despite this, the level of priority given to mental health in the development of new models of care has not always been sufficiently high.
  • Some areas report that new models of care have made it easier for local professionals to obtain informal advice from mental health professionals without making a referral, creating a more seamless experience for patients.
  • Working closely with voluntary sector organisations has allowed integrated care teams in some vanguard sites to better support the mental health and wellbeing of people with complex needs.

Policy implications

  • Testing the mental health components of existing vanguard sites must be a central part of the evaluation strategy for the new care models.
  • Other local areas rolling out multispecialty community providers, primary and acute care systems and related care models should go further than the vanguard sites in four key areas:
    • complex needs: enabling local integrated care teams to draw on and incorporate mental health expertise to support people with complex care needs
    • long-term care: equipping primary care teams to address the wide range of mental health needs in general practice (including among people presenting primarily with physical symptoms)
    • urgent care: strengthening mental health support for people using A&E departments and other forms of emergency care
    • whole-population health: placing greater emphasis on promoting positive mental wellbeing in the population, in particular among children and young people, and during and after pregnancy.
  • All sustainability and transformation plans should set out ambitious but credible plans for improving mental health and integrating mental health into new models of care.

Source: The King’s Fund

Perinatal depression and anxiety: Let’s talk about moms and dads in Africa

In low- and middle-income countries (LMICs), competing health priorities, civil conflict, and a lack of political will mean that expenditure on mental health is a fraction of that needed to meet the mental health care needs of the population.

For mothers, this treatment gap is most notable in regions where health agendas focus on maternal mortality indicators.

Source: Essentials of Global Mental Health

Who is at risk of perinatal mental health disorder?

Common mental disorders during pregnancy and in the first year after birth are associated with certain risk factors. These include poverty, migration, extreme stress, exposure to violence (domestic, sexual and gender-based), previous history of mental disorders, alcohol and other drug use as well as low social support.

– Migration
– Violence and abuse
– Alcohol and drug use

In South Africa, there is a very high prevalence of adolescent pregnancies with 39% of 15- to 19-year old girls being pregnant at least once. When adolescent mothers suffer from depression, the likelihood of a subsequent teenage pregnancy nearly doubles.

SAsouthAfrica

– Teenage pregnancy
– HIV/AIDS

How to address maternal mental illness among economically disadvantaged parents? 

Integration of services!

Mothers in many settings are using maternal and child health services as well as social services. Thus, detection and access will increase if maternal health screening and services are integrated into these public care platforms.

How to implement a maternal mental health intervention in low-resource settings?

We are sharing our lessons learned in this learning brief. 

We have also developed a Service Development Guidelines which demonstrates how to develop a mental health intervention at your facility, even with limited resources.

Find more free & open access resources for professionals on our website

And what about dads?

Postnatal depression can affect dads too. Find out about common concerns for new dads and discover helpful tips on how they can become more involved. We compiled a leaflet with information that could help you be better prepared for what is happening. The leaflets are available in

EnglishisiXhosa • Afrikaans • French

Women’s voices report on maternal mental health

Women’s Voices – Maternal Mental Health

The Royal College of Obstetricians and Gynaecologists (RCOG), supported by the Maternal Mental Health Alliance (MMHA), have published a survey Women’s Voices – Maternal Mental Health which highlights the urgent need to improve maternal mental health-care.

The survey of over 2,300 women who had given birth in the last five years in the UK, explores their experiences of perinatal mental health problems, engagement with healthcare professionals and the quality of care they received.  It reveals the impact of low rates of specialist referral, long waits, as well as lack of consensus over medication and little support for their partners.

The results present a stark picture of how services are letting down some of the most vulnerable women in our society, and provides key recommendations for healthcare professionals, managers, providers, commissioners and policy-makers.

Key findings

– Women reported experiencing low rates of referral, long waits, regional variation of care, a lack of continuity of care, misunderstanding and stigma

– The mental health of women’s partners is also often neglected by healthcare professionals and services

Source: RCOG survey women’s voices

Download the RCOG survey

Download the RCOG infographic

One in three migrant women from low- and middle-income countries has symptoms of perinatal depression

Migration and perinatal mental health in women from low- and middle-income countries.

In this systematic review and meta-analysis the authors summarising the prevalence, associated factors and interventions for perinatal mental disorders in migrant women from low- and middle-income countries (LMIC).

Even though they found that the prevalence of perinatal depression is very high among migrant women, the data they found was insufficient to assess the burden of anxiety, post-traumatic stress disorder or psychosis in this population.

Furthermore the authors stress, that given the adverse consequences of perinatal mental illness on women and their children, further research in low-resource settings is a priority.

Read the abstract in the BJOG – International Journal of Obstetrics and Gynaeocology

migrant_women_mental_health

Interested in mental illness among displaced, migrant and refugee women in South Africa? Read our Issue Brief

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