AFJOG

Healthcare providers to pregnant and postpartum women have a vital role to play in addressing their mental health. Perinatal mental health must be prioritized given the dearth of mental health services available on our continent, combined with the enormously high burden of Common Perinatal Mental Disorders (CPMD) such as depression and anxiety. PREVALENCE Systematic review data for Africa describe a prevalence of 23% for antenatal depression and 21% for postnatal depression. 1 While there has been less research conducted for anxiety, a recent systematic review reported prevalence of 16% for antenatal anxiety and 32% for postnatal anxiety symptoms. 2 The prevalence data of severe mental disorders (schizophrenia, affective psychosis, and psychotic and non- psychotic form of bipolar disorders) during the perinatal period in Nigeria and Tanzania are similar to those found in high-income settings and range between 1 to 16 per 1000 births. 3 Research from South Africa indicates that approximately 10% of women are at high risk of suicide during the perinatal period. 4 RISKS AND CONSEQUENCES Risk factors for CPMD observed in Africa mirror those in other settings. Women who are particularly vulnerable include those with a history of mental disorders, those exposed to poverty and food insecurity, intimate partner or domestic violence, childhood abuse and trauma, 5 lack of social support, unwanted pregnancies and distress about pregnancy. 6 Additional risks include the presence of maternal physical conditions such as HIV and obstetric fistula, as well as poor infant health. 1 Untreated perinatal mental health conditions have adverse effects for both the woman and her fetus or child, increasing risks of miscarriage and gestational diabetes, preterm birth, and low birth weight, 7 poor infant growth and development, and increased risk for childhood cognitive, behavioural and emotional difficulties. 8 Mental health conditions may also influence the way that women engage with health services, resulting in late pregnancy registration, lower attendance for maternal and child health (MCH) care, and difficulties in adherence to health regimens 9 – all of which lead to adverse obstetric outcomes and health system inefficiencies. UNMET NEED AND TREATMENT GAP There is a substantial treatment gap for mental health conditions in Africa, with only 0.9 mental health workers per 100 000 people. 10 While there are no available figures on the treatment gap for perinatal mental disorders specifically, it is likely that the treatment gap is as high or higher than that for other mental disorders. 11 This lack of information is in part, due to the absence of routine collection of mental health data in maternity settings and a lack of high quality research. 3 Although MCH services are comparatively better resourced than mental health services, competing priorities related to physical health concerns render mental health service provision in this sector, a low priority status. 3 IDENTIFICATION AND TREATMENT Perinatal women with mental health conditions may present as being aggressive, uncooperative and challenging or overly-compliant, unresponsive and avoidant. In the postnatal period, difficulties with breastfeeding or a lack of bonding with the infant could provide useful insights into compromised maternal mental wellbeing. The World Health Organization’s ‘Mental Health Gap Action Programme’(mhGAP) Intervention Guide provides a protocol for the identification and treatment of mental, neurological and substance use disorders in non-specialised health settings. 12 While pregnant and breastfeeding women are noted as special population groups, the diagnostic and treatment approaches for the general population apply. Screening for CPMDs is not routinely implemented across the continent. Some centres in a few countries have implemented mhGAP but this is not the norm. 13 Community Health Workers (CHW) may be successfully trained to conduct screening for these conditions, but without adequate resources for referral, this may not be ethical or effective. 14 Where screening and out- patient services are provided, they are usually led by nongovernmental organisations (NGOs) or research institutions, 15 and may not be sustainable. In Africa, the majority of treatments for severe mental disorders are provided in centralised hospital and specialist centres in urban areas, with a focus on in- patient treatments and the provision of medications. 16 BARRIERSAND FACILITATORS TOACCESSING CARE Several factors impede access to care. These include a lack of policies, standard operating procedures, referral resources and overall insufficient allocation of resources towards mental health and the wellbeing of women. Low literacy rates, particularly in rural locations, make self-administration of screening challenging. 17 While nurse or midwife-administered screenings may be feasible at healthcare facilities, coverage and quality may be limited due to competing demands on staff time and the necessity for additional training and supervision. 18 Furthermore, facility-based screenings may not achieve high contact coverage of perinatal women in regions where maternity care uptake and facility-based birth rates are low. To enhance coverage, some have explored the potential of automated screenings delivered via phone calls. 17 Unhelpful traditional beliefs and attitudes among Perinatal Mental Health: An African perspective Associate Prof Simone Honikman Director Perinatal Mental Health Project, Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town ________________________________________________________________________________________________________ 1 For the purposes of this piece, the term ‘perinatal’ refers to the entire duration of pregnancy up to the end of the first year postpartum, in accordance with the predominant literature on perinatal mental health. CORRESPONDENCE: Associate Prof Simone Honikman| Email: Simone.honikman@uct.ac.za EDITORIAL African Journal of Obstetrics and Gynaecology | Volume 2 | Issue 1 | 2024 | 01