Three approaches to improving maternal mental health from a low resource setting
By Shamsa Zafar Rizwan, Professor And Head Of Centre Of Excellence - Maternal, Neonatal Child Health (MNCH) Department, Health Services Academy, Pakistan
This post is part of “Mental Health: The Missing Piece in Maternal Health,” a blog series co-hosted by the MHTF, the Mental Health Innovation Network at the London School of Hygiene and Tropical Medicine and Dr. Jane Fisher of Monash University.
While working as an obstetrician and gynecologist for 20 years and as a reproductive and public health professional, I realized that there is a huge burden of psychosocial ill health of women that also impacts their physical health. Maternal mental health was the key area of my PhD research and I feel that I and professionals from reproductive and maternal health should be leading this cause jointly with mental health professionals.
Universal approach to well-being
The majority of developing countries have a high prevalence of maternal depression ranging from18-25%. Countries with a high prevalence of maternal depression need a universal approach to maternal psychosocial well-being during pregnancy and in the postnatal period. A universal approach means that all women in the perinatal period should receive an intervention on maternal psychosocial well-being, which is integrated into MNCH programs and is simple enough to be delivered by community health workers so as to prevent psychosocial morbidity. This approach does not require screening for depression and anxiety, which is at the moment hard to include in the programmes of LMICs. This approach will not be impacted by mental health stigma and will improve other health outcomes of the mother and child such as child development, growth and health-seeking behaviors. We have tried this approach in Pakistan and have found it to be feasible, easily integrated into MNCH programmes and acceptable by the community and community health workers.
Integrate maternal mental health into primary care
Maternal mental health interventions need to be integrated into the existing primary health care and maternal and child health programs. Integration has its challenges that include lack of human resources in the community, increased workload and lack of motivation of MNCH community health workers and difficulty garnering political and governmental buy-in. However, advocacy using local data, early involvement of politicians and government and simple, easy to integrate interventions that are developed through a participatory process are key to success.
Innovation for scale up
Scale up of maternal mental health interventions is a challenge, especially where health systems are weak. One major issue is providing quality training and supervision of mental health for community health workers at scale. An innovative way to assist the scale up of evidence-based maternal mental health interventions is a technology-assisted cascade training and supervision system. We are working on developing this innovation in a low-resource, post-conflict area in Pakistan. This system for screening, monitoring and supervision for maternal depression includes three components:
- An interactive voice response-based assessment tool to screen depression in the community: A woman is asked by the health workers to call a toll free phone number where the two questions from the Whooley’s Depression Screen are asked and can determine if further, more detailed screening for maternal depression is needed
- A tablet-based manual, based on the mhGAP Thinking Healthy Programme: The Thinking Healthy Programme is an intervention that has shown success in treating maternal depression in developing countries and is delivered by community health workers. The use of technology allows standardized training to be delivered without the need of a specialist trainer
- A cascade training model: Using this model, specialists supervise, from a distance, the community health worker program supervisors, who in turn, supervise the community health workers as part of their normal routine.
These innovative approaches to maternal mental health are all designed to enhance the availability to mental health services for the women who need them most.
Photo: “Rebuilding lives and hope in Pakistan, a year on from the floods” © 2011 Vicki Francis/Department for International Development, used under a Creative Commons Attribution license: http://creativecommons.org/licenses/by/2.0/