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service users, their communities and also among service providers have been cited as common barriers to accessing care. Long distances to health services, costly or unreliable transport and poor mobile phone coverage are putative factors in remote locations. 19 Access to perinatal mental health care may be facilitated in some African countries if embedded within the improvement of MCH care agenda, which encourages attendance at primary clinics. Increased uptake of these services may provide a critical entry point for screening, leading to increased detection of mental health conditions, reduced stigma, and improved linkage between mental health and maternal care. 20 Additionally, this may also enable connection to further mental health and wellbeing support within and outside the health sector. 18 PROMISING EXAMPLES Several innovative strategies have been developed across the continent to address some of the barriers to care. Detection In South Africa, a three-item, dichotomous screening tool for pregnant women was developed and has been adopted within the national maternity care programme. National guidelines and capacity building resources for maternity staff have been developed, but implementation at scale remains limited. 9 In Kenya, a 9-item locally-developed, Perinatal Depression Screening tool has shown good psychometric properties, 17 and in Malawi, a three-item screening tool for antenatal women has demonstrated good psychometric properties with high levels of feasibility and acceptability as part of a two-phase screening protocol. 21 Task-shifting In many African countries, CHW cadres constitute a cornerstone of the MCH service, representing a potential opportunity for detection, referral, case management and follow-up care. 9 These providers, may be well placed to provide mental health promotion and wellbeing interventions. 22 Evidence from The Gambia’s music- making trial 23 and Zimbabwe’s Group Problem Solving Therapy trial 24 have shown positive results. However, experience from an intervention trial for perinatal depression in South Africa, raises concerns about the capacity of CHW to adhere, with fidelity, to evidence-based psychological interventions without considerable training and supervision. The authors caution against under-resourcing these interventions in an attempt to reduce costs, and emphasise the need to integrate interventions that address social determinants within the intervention package. 25 In several African countries, the growing cadre of mid- level mental health providers, show promise with respect to providing mental health care for perinatal women. 9 In Zimbabwe, an NGO provides vocational training for high school graduates to become family therapists, at diploma level. In 2023, the Ministry of Health agreed to employ this cadre of worker through the public health system (personal communication, L Muvhu, Society For Pre and Post Natal Services). In Nigeria, primary level maternal care providers (nurses, midwives and doctors), trained and supervised in the use of mhGAP, were able to effect high remission rates in pregnant women diagnosed with depression. 26 Certainly, there is a growing body of evidence, in resource-constrained settings, for the effective use of providers who are not mental health specialists (peers, CHWs, maternity staff), to deliver psychological treatments over a limited number of sessions. 27 Interventions addressing both social determinants and mental distress symptoms In many African settings, perinatal women’s attributions for their distress are rooted in the socio-economic adversity they experience. 28,29 Nevertheless, only a limited number of perinatal mental health interventions integrate elements that address these determinants, such as unemployment, disempowerment, and food insecurity. 9 In Kenya, a psychosocial intervention targeting both gender-based violence and antepartum depressive symptoms in pregnant women showed small effect sizes for violence and medium effect sizes for depressive symptoms. Here, social workers conducted three psychosocial support sessions, increasing a sense of control in their clients through active listening, information sharing, safety planning, enhancing decision-making and problem-solving. 30 CONCLUSION Perinatal mental health needs to be seen as an integral part of improving the quality of MCH services in Africa. Access to mental health care can help to reduce maternal mortality and morbidity and improve physical and mental wellbeing for women, children and their communities. USEFUL RESOURCES FOR MATERNITY CARE PRACTITIONERS AND MANAGERS • Perinatal Mental Health Project website: www.pmhp.za.org • Maternal Mental Health: a guide for health and social workers 2018, published by Bettercare • WHO guide for integration of perinatal mental health in maternal and child health services 2022 REFERENCES EDITORIAL African Journal of Obstetrics and Gynaecology | Volume 2 | Issue 1 | 2024 | 02