Perinatal Mental Health Project
Project type: |
Research Project
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Objectives: |
To address the treatment gap for perinatal mental disorders in South Africa |
Brief description: |
Collaborative stepped-care model featuring counseling for mothers with mental health problems by non-specialist health workers |
Project status: |
Ongoing
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Social: |
Summary
Innovation summary
In South Africa, about one third of pregnant women experience a common mental disorder. Due in part to the shortage of mental health specialists, many individuals do not receive the care they require.
The goal of the Perinatal Mental Health Project (PMHP) is to integrate mental health care into routine antenatal and postnatal health care to address the shortage of human resources and bridge the treatment gap for perinatal mental disorders.
The innovation consists of a collaborative stepped-care approach and task-sharing strategies:
- Women are screened for psychological distress at their first antenatal booking
- Women with three or more risk factors and/or those that screen positive for psychological distress are referred to counseling sessions delivered by trained, non-specialized health workers
- Counselors refer severe cases to the on-site psychiatrist
Impact summary
- Over 21,000 pregnant women screened for psychological distress between 2002 and 2013
- 60% of pregnant women report 'much improved' or 'complete resolution' of problems relating to primary support, social environment and lifestyle transition
"Maternity nursing staff have successfully managed to incorporate mental health screening into routine procedures reporting high levels of acceptability of this integration."
Perinatal Mental Health Project
Innovation
Innovation details
The Perinatal Mental Health Project (PMHP) uses a stepped-care model and operates as below at its primary service site:
Screening
At their first antenatal booking at the maternity unit, women are screened for psychological distress and for risk factors for common perinatal mental disorders. Screening is self-administered in private and scored by nurses, and available in three local languages (English, Afrikaans and isiXhosa) and in French.
Referral
Pregnant women with psychological distress and/or at least three risk factors are offered referral to an on-site counselor for individual, face-to face counseling, which coincides with their antenatal visits. Where appropriate, counselors can refer women to a psychiatrist who attends the clinic twice a month, and to on-site services, such as HIV/AIDS peer counselors, social workers etc.
Counselling
Counseling is provided by non-specialized health workers: sessions are client-centered and include techniques such as containment, psycho-education and problem-solving. At 6-10 weeks, counselors conduct telephonic or face-to-face assessments to evaluate women’s mood and whether further counseling is necessary. Women can receive counseling for up to one year postpartum.
In order to implement this model successfully, PMHP provides the following services:
Monitoring and supervision
All counselors receive weekly, individual supervision by the clinical services coordinator, a clinical psychologist, and attend a group meeting bi-monthly to debrief and receive on-going education from the clinical services coordinator.
Training
PMHP also provides training and workshops to staff in order to attend to health workers’ emotional well-being, increase awareness of common perinatal mental disorders among health workers and equip health workers with empathic engagement skills.
Research and advocacy
PMHP operates complementary research and advocacy programs which act to refine and promote scale up of the service.
Key drivers
Training and support
Regular training updates with maternity staff ensure that health workers are aware of, and understand the importance of PMHP’s service facilitating the integration of the service into maternal care. Provided continuous training, supervision and support to non-specialist health workers to: (1) manage the high case load generated in low-resource settings and (2) avoid burnout and ensure the sustainability and quality of maternal mental health care provided.
Effective case management
Established protocol and referral systems enable more effective case management. The availability of an on-site counselor, and consolidating links with organisations in the community, strengthens the referral system and allows for more comprehensive care for distressed women.
Monitoring and evaluation
Regular monitoring and evaluation of screening and counseling procedures are essential for quality control, understanding the patterns of service use and identifying barriers to accessing mental health services.
Challenges
Overwhelmed nurses
Overwhelmed, stressed and traumatized maternity ward nurses, with little recourse to supportive services or debriefing opportunities.
Multi-language counseling
Mothers from a variety of cultural backgrounds called for multi-language counseling: English, Afrikaans, isiXhosa, and French for the large proportion of francophone refugees.
Limited availability of screening tool
Limited availability of feasible and acceptable screening tools for maternal mental disorders. PMHP uses the Edinburgh Postnatal Depression Scale. Though validated in South Africa, it is too cumbersome for low-resource settings. PMHP is developing a shorter tool which should be more feasibly integrated into the primary care setting.
Continuation
PMHP has extended its service to two other community maternity units in Cape Town. As all of the current PMHP sites are situated in urban areas, there is a need to field test the service in a rural site, where fewer resources and different challenges exist.
The literacy rate is high in South Africa (93%), compared to other African countries (e.g. 40% in Ethiopia; 73% in Uganda), where self-administered screening may not be feasible. A shorter screening tool, such as the one PMHP is currently developing, could be more pragmatic for health workers to administer during their routine history-taking. The tool will be field tested in a range of settings including New Zealand, India, UK and USA.
Partners
Partners
- Alan J Flisher Centre for Public Mental Health(South Africa)
- National Department of Health of South Africa
- Red Cross Children’s Hospital(South Africa)
- School of Child and Adolescent Health (South Africa)
- Western Cape Department of Health (South Africa)
- The University of Cape Town – Faculty of Health Sciences and Department of Psychiatry and Mental Health (South Africa)
- Programme for Improving Mental Health Care (Global)
Funders
- DG Murray Trust (South Africa)
- Discovery Fund (USA)
- Harry Crossley Foundation (South Africa)
- The Rolf-Stephan Nussbaum Foundation (South Africa)
- Eric and Sheila Samson Trust (South Africa)
- Kaplan-Kushlick Foundation (South Africa)
- SG Menell Charitable Trust (South Africa)
- Individual donors
Impact
Evaluation methods
The Perinatal Mental Health Project (PMHP) has a structured and consistent monitoring and evaluation (M&E) framework, with screening and service delivery data collated and reported monthly to the clinical services coordinator and the PMHP project coordinator. The M&E framework:
- Facilitates the identification of clients’ characteristics, risk profiles and related care requirements, which can then be addressed effectively
- Allows an assessment of the PMHP service’s impact and delivery and the barriers to accepting and attending counseling services, so that these can be overcome
The 6-8 week postnatal assessment, which also elicits information about the women’s birthing experience, adjustment to life with the baby and their experience of counseling, provides a good opportunity to:
- Evaluate women’s mood and functioning postnatally, compared to that at screening
- Assess whether the women’s presenting problems have improved
A study protocol to formally assess the effectiveness of the counseling intervention is currently underway, and should receive approval to start early in 2014
Cost of implementation
The full cost to provide maternal mental health care to one woman is $19.50 USD per year. This includes:
- As many counseling sessions as she needs (3 on average)
- The counselor’s liaison work with psychiatric services and social support agencies
- Postnatal follow-up care
In comparison, the average rate of private sector psychotherapy is $70 USD per hour for one individual counseling session alone.
In low-resource settings, where women can face many barriers to accessing health care, providing integrated mental health care at the same time and same place as routine maternity and well-baby care minimizes travel costs, time away from employment and child-care responsibilities. Thus, PMHP’s counseling intervention, which uses existing services and resources, achieves better service uptake with minimal extra costs.
Impact details
Since inception (2002) to July 2013, over the three service sites, PMHP has:
- Screened nearly 22,000 pregnant women for psychological distress
- Counseled over 3,700 women
- Provided over 8,400 individual counseling sessions
- Provided psychiatric services to approximately 130 women
Ongoing monitoring and evaluation of the postnatal follow-up assessment shows positive outcomes for women who are counseled:
- Problems relating to support from partners or family and the social environment are typically the most difficult to resolve, yet around 85% report improvement following counseling
- 90% of primary and secondary problems presented before counseling improve, including 50-60% which are either “much improved” or “resolved”
- After counseling, 86% report improved depressive symptoms and 84% report a decline in anxiety
Visit the PMHP Outcomes page for further information on this innovation's impact to date.
References
- PMHP (2013) The Perinatal Mental Health Project mid-year report. Cape Town: Perinatal Mental Health Project.
- PMHP (2013) The Perinatal Mental Health Project: impact and outcomes. Cape Town: Perinatal Mental Health Project.
Research
- Treating depression in primary care in low-income women in Santiago, Chile: a randomized controlled trial
- Depressed mood in pregnancy: prevalence and correlates in two Cape Town peri-urban settlements
- Improving child outcomes through maternal mental health interventions
- Grand challenges: integrating maternal mental health into maternal and child health programs
- Resources for mental health: scarcity, inequity and inefficiency
- Additional research resources
Tools
- Maternal Mental Health: A Handbook for Health Workers, 3rd Edition
- Basic Counselling Skills: A Guide for Health Workers in Maternal Care
- Service Development Guidelines, for Facilities Providing Maternal Mental Health Care
- Screening for Common Perinatal Mental Disorders in South Africa
- Bettercare Maternal Mental Health book
- Maternal mental health handbook
- Basic counseling skills guide
- Service development guidelines
- PDF icon Screening for common perinatal mental disorders in South africa
- Additional resources