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Addressing the treatment gap for perinatal depression

Reposted blogpost by Tasneem Kathree, first published at @MHInnovation

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Making the link between food insecurity and maternal mental health

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

References

  • 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)

Working towards perinatal mental health support for all mothers!

“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

Clinical Services

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.

Training and Capacity Building

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.

Research

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.

Advocacy and Policy Development

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

 

Why we need to talk about maternal mental health

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.

Bringing mental health of mothers into the spotlight in Africa

In most societies, mothers are the primary providers of care to young children. This is a demanding task and the mental health of a mother is not only essential to her well-being, but that of her child’s physical health, nutrition and psychological well-being. However, most child development programmes do not adequately address maternal mental health.

Recent research has shown that about 20% of mothers in developing countries experience some form of mental health problems during or after childbirth. The United Nation’s Secretary-General António Guterres has recently acknowledged that the issue of mental health remains a largely neglected issue and announced the UN’s commitment to “working with partners to promote full mental health and well-being for all”.

Moreover, professionals in the field are pointing out that the mental health of mothers is critical to the success of the UN Sustainable Development Goals on health, nutrition and gender equality (SDG 3, 2 and 5).

In South Africa, the rate of pregnant and postnatal mothers suffering from common mental disorders (depression and/or anxiety) can reach up to one in three. Many of them are poor, come from disadvantaged communities and face many obstacles in accessing services and care.

Across Africa, the majority of women experiencing challenges to their mental health during the perinatal period (pregnancy and up to one year after the birth) are also exposed to gender-based violence, economic and gender inequalities, physical illnesses (including HIV), complications of childbirth and the stresses of childcare. Suicide has been identified as one of the leading causes of maternal death worldwide.

Unfortunately, health care systems in most African countries are not equipped to deal with the complex health and social challenges faced by most mothers. With competing physical health priorities and constrained resources, mental health care remains seriously neglected.

To challenge the status-quo and to improve the mental health of mothers in Africa, a group of individuals and organisations are working together in the newly established African Alliance for Maternal Mental Health (AAMMH).

AAMMH believes that a multi-sectoral approach is needed to tackle the causes of poor maternal mental health in Africa. The alliance calls for the integration of existing evidence-based interventions for the detection, prevention and treatment of maternal mental health problems into reproductive and child health programmes, supported by mental health services with specialist expertise.

This call for action is very close to the PMHP’s mission to develop and advocate for accessible maternal mental health care that can be delivered effectively in low-resource settings. We have thus become involved with the Global Alliance for Maternal Mental Health (GAMMH) over the past year since its formation and are now a proud founding partner of its first regional off-shoot, the AAMMH.

Together with colleagues in Malawi, we have been preparing for the upcoming launch on the 19 June in Lilongwe, Malawi. Prior to the launch, we will conduct a training workshop with health care providers and managers in maternal, mental and child health. On the launch day itself, we will be delivering a keynote address sharing the experience of the PMHP and will also be conducting a workshop towards establishing strategies for working partnerships across sectors for maternal mental health.

We hope our experience and work in South Africa, and in other low and middle-income countries, will contribute to the development and growth of this pan-African advocacy initiative. At the same time, we look forward to collaborating and learning from advocates, practitioners, trainers and researchers across Africa to strengthen the work we do in South Africa.

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The African Alliance for Maternal Mental Health (AAMMH) is part of the Global Alliance of Maternal Mental Health and works in close collaboration with the Marcé Society African Regional Group.

AAMMH will be officially launched in Lilongwe, Malawi on 19 June 2018. You can follow the event by using the hashtag #AAMMH #GAMMH

Read more about aims and objectives of the AAMMH here.

Addressing the Maternal Mental Health Diagnosis Gap through screening tools

Source: Maternal Health Task Force blog

Diagnosis gap in Low- and Middle-Income Countries (LMICs)

Despite contributing significantly to maternal deaths and unproductive life years, common perinatal mental disorders (CPMD) often go undetected among women in low-resource regions. This can mean that up to 80% of women remain untreated in such settings. Resource-constrained primary care centers, high patient volumes, lack of recognition by health workers as well as increased task shifting to semi-skilled health workers contribute to this treatment gap. In order to encourage timely identification of CPMD among mothers followed by referrals, antenatal care provision centers are a promising platform in LMICs due to the high level of touchpoints between expectant women and health systems. In South Africa, for example, a mother’s contact rate with any antenatal care facilities is quite high at approximately 91%. […]

Empathic engagement training

Lead author Thandi van Heyningen shares insight into progress and next steps for improving maternal mental health in low-resource settings:

“Where health system resources are scarce, one way of improving detection and improving access to treatment, is to integrate these services into existing, routine, primary health care services using a stepped care approach. Improving detection through routine antenatal screening may provide a vital first step, however there is a need to generate further evidence on the feasibility and acceptability of existing screening tools for use in such settings, and by non-specialist health care workers.”

Read the full paper “Comparison of mental health screening tools for detecting antenatal depression and anxiety disorders in South African women” in the MHTF-PLOS collection on NCDs and maternal health

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

Posted on 

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.”

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.

 

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