Perinatal mental health around the world: priorities for research and service development in Africa

Factors associated with a positive Tilburg Pregnancy Distress Scale among hospitalized Ghanaian obstetric patients

Background

Psychological distress during the antenatal and postpartum period can negatively impact the quality of life and health of the pregnant person and fetus(es). But there is a discrepancy between Ghanaian community prevalence and engagement with mental health services leading to underdiagnosis and missed therapeutic opportunities. Therefore, it is important to identify factors that contribute to the gap of underdiagnosis and treatment, and screening for pregnancy distress is the first step in bridging this gap.

Objective

To identify factors associated with increased prenatal and postpartum pregnancy distress via the administration of the Tilburg Pregnancy Distress Scale (TPDS).

Study Design

We performed a cross-sectional study of obstetric patients who were admitted at the largest referral teaching hospital in urban Ghana between November 20, 2023, and December 22, 2023. Patients were eligible to participate if they were admitted to the 275-bed maternity block for an antepartum or postpartum indication, alert and oriented, and able to speak one of the following languages: English, Twi, or Ga. Patients below the age of 18 years, or critically ill or unstable were excluded. Participants were asked about their socioeconomics, medical history, current pregnancy and/or delivery outcomes, and satisfaction with care. All patients then completed the validated TPDS, a multiple-choice questionnaire to determine the level of pregnancy or postpartum-related distress.

Results

Among hospitalized obstetric patients in Ghana, less than 1% reported a diagnosed depression, anxiety, or mental health disorder. However, over 37% of our participants, both antepartum and postpartum, screened positive for pregnancy distress using the TPDS. Among antepartum participants, young age, low household income, and low parity were significantly associated with a positive pregnancy distress screen. Among postpartum participants, no factors were significantly associated with a positive screen in the final, controlled, model.

Conclusion

Our study is the first to identify factors associated with Ghanaian patients' pregnancy distress, which can contribute to pregnancy, maternal, and child health consequences. Over one-third of obstetric patients screened positive on the TPDS with prevalence rates comparable across antepartum and postpartum patients. Our study identified antepartum patient factors of young age, low income, and low parity for increased positive screening on the TPDS. Identifying Ghanaian pregnant patients with these factors may help to target those at the greatest need for increased screening and monitoring, which is aligned with the Sustainable Development Goals.

The role of artificial intelligence in the prediction, identification, diagnosis and treatment of perinatal depression and anxiety among women in LMICs: a systematic review protocol

INTRODUCTION

Perinatal depression and anxiety (PDA) is associated with a high risk of maternal mortality. Existing data shows that 95% of maternal mortality in low- and middle-income countries (LMICs) is due to resource constraints and negligence in addressing perinatal mental health (PMH). Research conducted in more developed countries has demonstrated the potential of artificial intelligence (AI) to assist in predicting, identifying, diagnosing and treating PDA. However, there is limited knowledge regarding the utilisation of AI in LMICs where PDA disproportionately affects women. Therefore, this study aims to investigate the role of AI in predicting, identifying, diagnosing and treating PDA among pregnant women and mothers in LMICs.

METHODS AND ANALYSIS

This systematic review will use a patient and public involvement (PPI) approach to systematically investigate the role of AI in predicting, identifying, diagnosing, and treating PDA among pregnant women and mothers in LMICs. The study will combine secondary evidence from academic databases and primary evidence from focus group discussions and a workshop and webinar to comprehensively analyse all relevant published and reported evidence on PDA and AI from the period between January 2010 and May 2024. To gather the necessary secondary data, reputable interdisciplinary databases in the field of maternal health and AI will be used, including ACM Digital Library, CINAHL, MEDLINE, PsycINFO, Scopus and Web of Science. The extracted data will be reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework, ensuring transparency and comprehensiveness in reporting the findings. Finally, the extracted studies will be synthesised using the integrative data synthesis approach.

ETHICS AND DISSEMINATION

Given the PPI approach to be employed by this study which involves multi-stakeholders including mothers with lived experience, ethical approvals have been sought from the University of Ghana and University of Alberta. Additionally, during the review process, to ensure that the articles included in this study uphold ethical standards, only peer-reviewed articles from reputable journals/databases will be included in this review. The findings from this systematic review will be disseminated through workshops, webinars, conferences, academic publications, social media and all relevant platforms available to the researchers.

PROSPERO REGISTRATION NUMBER

PROSPERO (10/06/24) CRD42024549455.

Feasibility, acceptability and preliminary effectiveness of a culturally adapted nonspecialist delivery Problem-Solving Therapy: Friendship Bench Intervention for perinatal psychological distress in Sierra Leone

In low- and middle-income countries like Sierra Leone, there is a significant gap in the treatment of perinatal mental health disorders such as anxiety, depression and somatization. This study explored the feasibility, acceptability and preliminary effectiveness of a culturally adapted Problem-Solving Therapy - Friendship Bench Intervention (PST-FBI) delivered by nonspecialists, mother-to-mother support groups (MMSGs), to perinatal women experiencing psychological distress. MMSGs provide 4 weeks of home-based, individual PST-FBI, followed by a peer-led group session called col at sacul (circle of serenity). The intervention targeted peri-urban pregnant women and new mothers screened for psychological distress. This was a two-armed, pre-post, waitlist-controlled study that employed the Sierra Leone Perinatal Psychological Distress Scale (SLPPDS) to screen and measure their outcomes. Feasibility and acceptability were examined through in-depth interviews using the Consolidated Framework for Implementation Research, analyzed thematically, while preliminary effectiveness was evaluated with chi-squared analysis for categorical and t-test for continuous variables. Twenty of the 25 women completed all four PST-FBI sessions delivered by five MMSGs. The individual PST and the peer-led session were viewed as beneficial for problem-sharing and skill building. The SLPPDS scores significantly dropped by 58.9% (17.1-8.4) in the intervention group, while the control group showed a 31.6% (18.0-12.3) decrease. The intervention's effect size was d = 0.40 (p < 0.05). The MMSG-led PST-FBI, including the col at sacul session, proved feasible, acceptable and with preliminary effectiveness in improving the mental health of peri-urban pregnant women and new mothers in Sierra Leone. Further randomized-controlled trials are recommended before nationwide implementation.

Living in a Constant State of Fear: Phenomenological Study on Experiences of Women with High-Risk Pregnancy Waiting for Childbirth in Mpumalanga Province, South Africa

Research and obstetric medicine often ignore the emotional aspect of high-risk pregnant women in clinical management and care. Even more so, research does not adequately address psychosocial well-being in high-risk pregnancies, particularly in low and middle-income countries, including South Africa. Thus, this study aimed to explore and describe the experiences and psychosocial support needs of women waiting for childbirth in high-risk pregnancies. We conducted a descriptive phenomenological inquiry in special clinics in two hospitals in the Nkangala District Municipality of Mpumalanga Province, South Africa. A purposive sampling strategy was used to select 15 women aged 22 to 43 years, and in-depth interviews were conducted. An inductive thematic analysis approach was used. The women experience high levels of negative emotions such as shock and disbelief, fear, pain and sorrow, lack of control and hopelessness, and anxiety following a diagnosis of high-risk pregnancy. Fear was the most expressed feeling by the women; their thoughts were dominated by fear, and they lived in constant fear throughout the pregnancy journey due to the unpredictable pregnancy outcomes and the potential risks in high-risk pregnancies. Overall, the negative emotions are interlinked and bonded in the experiences of women with high-risk pregnancies, are experienced throughout the journey of waiting for childbirth, and contribute to high levels of stress and anxiety. Further exploration is needed to identify effective ways to support these women.

Predominant approaches to measuring pregnancy-related anxiety in Sub-saharan Africa: a scoping review

BACKGROUND

Pregnancy-related anxiety significantly impacts maternal and fetal health in low- and middle-income countries (LMICs), including those within Sub-Saharan Africa (SSA). Most studies conducted to evaluate pregnancy-related anxiety in LMICs have utilized scales developed in high-income countries, despite significant variations in pregnancy-related anxiety due to socioeconomic and cultural contexts. This review surveyed existing literature in order to identify which scales have been used to measure pregnancy-related anxiety in SSA.

METHODS

A systematic search was conducted in PubMed, Health and Psychosocial Instruments, and APA PsycNet for relevant studies published in the English language up to March 22, 2023. Eligible studies focused on anxiety in pregnant populations within SSA, using validated scales or tools. Screening followed PRIMSA guidelines, with blinded review at the abstract/title level and subsequent full-text review. Data was extracted and analyzed to identify trends and characteristics of the screening tools used.

RESULTS

From 271 articles, 37 met inclusion criteria, identifying 24 different tools used to measure anxiety in pregnant women in SSA. The most common tools were the Generalized Anxiety Disorder 7-item scale (seven uses), State-Trait Anxiety Inventory (five uses), and the Self-Reporting Questionnaire 20 (five uses). Seven tools were pregnancy-specific, with only two designed specifically for SSA: the Risk Factor Assessment (RFA), and the 4-Item Screening Tool. Studies were most frequently conducted in South Africa, followed by Tanzania, Ethiopia, Nigeria, and Ghana.

CONCLUSIONS

This scoping review illustrates that only two tools (the RFA and 4-item Screening Tool) were created to assess pregnancy-related anxiety specifically in SSA. This highlights the need for more culturally sensitive tools tailored to the specific contexts of pregnant populations in SSA.

Exploring the return-on-investment for scaling screening and psychosocial treatment for women with common perinatal mental health problems in Malawi: Developing a cost-benefit-calculator tool

This study sought to develop a user-friendly decision-making tool to explore country-specific estimates for costs and economic consequences of different options for scaling screening and psychosocial interventions for women with common perinatal mental health problems in Malawi. We developed a simple simulation model using a structure and parameter estimates that were established iteratively with experts, based on published trials, international databases and resources, statistical data, best practice guidance and intervention manuals. The model projects annual costs and returns to investment from 2022 to 2026. The study perspective is societal, including health expenditure and productivity losses. Outcomes in the form of health-related quality of life are measured in Disability Adjusted Life Years, which were converted into monetary values. Economic consequences include those that occur in the year in which the intervention takes place. Results suggest that the net benefit is relatively small at the beginning but increases over time as learning effects lead to a higher number of women being identified and receiving (cost‑)effective treatment. For a scenario in which screening is first provided by health professionals (such as midwives) and a second screening and the intervention are provided by trained and supervised volunteers to equal proportions in group and individual sessions, as well as in clinic versus community setting, total costs in 2022 amount to US$ 0.66 million and health benefits to US$ 0.36 million. Costs increase to US$ 1.03 million and health benefits to US$ 0.93 million in 2026. Net benefits increase from US$ 35,000 in 2022 to US$ 0.52 million in 2026, and return-on-investment ratios from 1.05 to 1.45. Results from sensitivity analysis suggest that positive net benefit results are highly sensitive to an increase in staff salaries. This study demonstrates the feasibility of developing an economic decision-making tool that can be used by local policy makers and influencers to inform investments in maternal mental health.

Adapting group care to the postpartum period using a human-centered design approach in Malawi

BACKGROUND

Responsive and resilient strategies to reduce high rates of maternal and infant mortality and clinician shortages are needed in low- and middle-income countries (LMICs). Malawi has some of the highest maternal and infant mortality rates globally. Group healthcare is a service delivery model that integrates these strategies. Although primarily implemented during the prenatal period, its potential for improving both maternal and infant health outcomes during the postpartum period has not been realized. The purpose of this study was to adapt and co-design the prototype for an evidence-based group care model for the postpartum period using a human-centered design approach with key stakeholders in Malawi.

METHODS

We completed steps of a framework guiding the use of human-centered design: 1) define the problem and assemble a team; 2) gather information through evidence and inspiration; 3) synthesize; and 4) intervention design: guiding principles and ideation. Qualitative methods were used to complete steps 2-4. In-depth interviews (n = 24), and incubator sessions (n = 6) that employed free listing, pile sorting and ranking were completed with key stakeholders. Data analysis consisted of content analysis of interviews and framework analysis for incubator sessions to produce the integrated group postpartum and well-child care model prototype. The fifth step is detailed in a separate paper.

RESULTS

All stakeholders reported a desire to participate in and offer group care in the postpartum period. Stakeholders worked collaboratively to co-create the prototype that included a curriculum of health promotion topics and interactive activities and the service delivery structure. Health promotion topic priorities were hygiene, breastfeeding, family planning, nutrition, and mental health. The recommended schedule included 6 sessions corresponding with the child vaccination schedule over the 12-month postpartum period.

CONCLUSIONS

Using a human-centered design approach to adapt an evidence-based group care model in an LMIC, specifically Malawi, is feasible and acceptable to key stakeholders and resulted in a prototype curriculum and practical strategies for clinic implementation.

Antenatal depression: Associations with birth and neonatal outcomes among women attending maternity care in Harare, Zimbabwe

INTRODUCTION

Antenatal depression is highly prevalent and is associated with negative birth and neonatal outcomes. However, the mechanisms and causality behind these associations remain poorly understood as they are varied. Given the variability in whether associations are present, there is need to have context-specific data to understand the complex factors that go into these associations. This study aimed to assess the associations between antenatal depression and birth and neonatal outcomes among women attending maternity care in Harare, Zimbabwe.

METHODS

We followed 354 pregnant women in second or third trimester, attending antenatal care services in two randomly selected clinics in Harare, Zimbabwe. Antenatal depression was assessed using the Structured Clinical Interview for DSM-IV. Birth outcomes included birth weight, gestational age at delivery, mode of delivery, Apgar score, and initiation of breastfeeding within one-hour postdelivery. Neonatal outcomes at six weeks postdelivery included infant's weight, height, illness, feeding methods and maternal postnatal depressive symptoms. The association between antenatal depression and categorical and continuous outcomes were assessed by logistic regression and point-biserial correlation coefficient, respectively. Multivariable logistic regression determined the confounding effects on statistically significant outcomes.

RESULTS

Prevalence of antenatal depression was 23.7%. It was associated with low birthweight [AOR = 2.30 (95% CI: 1.08-4.90)], exclusive breastfeeding [AOR = 0.42 (95%CI: 0.25-0.73)] and postnatal depressive symptoms [AOR = 4.99 (95%CI: 2.81-8.85)], but not with any other birth or neonatal outcomes measured.

CONCLUSIONS

The prevalence of antenatal depression in this sample is high with significant associations demonstrated for birth weight, maternal postnatal depressive symptoms and infant feeding methods Effective management of antenatal depression is thus crucial to the promotion of maternal and child health.

Perceptions and experiences of prenatal mental health: A qualitative study among pregnant women in Ghana

Prenatal mental health problems can have adverse effects on the health and wellbeing of the mother as well as her baby. However, the factors associated with its etiology, expression, and coping mechanisms in Ghana remain understudied. This qualitative study explored the perceptions and experiences of prenatal mental health problems among 21 pregnant women in Accra through semi-structured interviews. Interpretative Phenomenological Analysis led to three dominant themes; "conceptions of prenatal mental disorders" (sub-themes: awareness and constructions of prenatal mental health problems), "experiences of mental health problems" (sub-themes: symptoms of prenatal mental health problems and causal attributions of prenatal mental health problems) and "coping mechanisms of the pregnancy experience" (subthemes: faith, social support and work). The lack of knowledge of mental health disorders in this study and the expression of contextually relevant and culturally defined constructions and experiences of prenatal mental health problems, highlight the need for the development of culturally suitable interventions within the Ghanaian context.

Maternal mental health and infant neurodevelopment at 6 months in a low-income South African cohort

Maternal mental health disorders and the adverse consequences for infant neurodevelopment have received substantial research attention in high-income countries over the past five decades. In Africa, where relatively little work has been done on this topic, researchers have largely focused on infant physical health outcomes. This longitudinal study investigated the neurodevelopment of infants at 6 months post-term with exposure to mothers with a clinical diagnosis of persistent mental health disorders residing in low-income communities in Cape Town, South Africa. Adjusted models revealed no significant differences on the Bayley Scales of Infant and Toddler Development (BSID-III) domains (cognitive, motor, language, socio-emotional, and adaptive behavior) between infants exposed to maternal mental health disorders (n = 62) and the comparison group (n = 35) at 3 and 6 months. Subgroup analyses found no significant differences on the BSID-III domains between infants with exposure to mood disorders (n = 31), as well as infants with exposure to comorbid (i.e., a combination of two or three) mental health disorders (n = 14) and the comparison group. However, infants with exposure to psychotic disorders (n = 14) scored significantly lower on the cognitive and the motor domains and the fine motor subscale. These novel data provide an important contribution to the scientific literature especially in the field of maternal psychotic disorders in Africa.

The importance of assessing and addressing mental health barriers to PrEP use during pregnancy and postpartum in sub-Saharan Africa: state of the science and research priorities

Introduction

Pregnant and postpartum women (PPW) in sub‐Saharan Africa are at disproportionately high risk of HIV infection compared to non‐pregnant women. When used consistently, pre‐exposure prophylaxis (PrEP) can prevent HIV acquisition and transmission to the foetus or infant during these critical periods. Recent studies have demonstrated associations between mental health challenges (e.g. depression and traumatic stress associated with intimate partner violence) and decreased PrEP adherence and persistence, particularly among adolescents, younger women and women in the postpartum period. However, mental health is not currently a major focus of PrEP implementation research and programme planning for PPW.

Discussion

PrEP implementation programmes for PPW need to assess and address mental health barriers to consistent PrEP use to ensure effectiveness and sustainability in routine care. We highlight three key research priorities that will support PrEP adherence and persistence: (1) include mental health screening tools in PrEP implementation research with PPW, both to assess the feasibility of integrating these tools into routine antenatal and postpartum care and to ensure that limited resources are directed towards women whose symptoms may interfere most with PrEP use; (2) identify cross‐cutting, transdiagnostic psychological mechanisms that affect consistent PrEP use during these periods and can realistically be targeted with intervention in resource‐limited settings; and (3) develop/adapt and test interventions that target those underlying mechanisms, leveraging strategies from existing interventions that have successfully mitigated mental health barriers to antiretroviral therapy use among people with HIV.

Conclusions

For PPW, implementation of PrEP should be guided by a robust understanding of the unique psychological difficulties that may act as barriers to uptake, adherence and persistence (i.e. sustained adherence over time). We strongly encourage PrEP implementation research in PPW to incorporate validated mental health screening tools and ultimately treatment in routine antenatal and postnatal care, and we stress the potential public health benefits of identifying women who face mental health barriers to PrEP use.

"We do not know how to screen and provide treatment": a qualitative study of barriers and enablers of implementing perinatal depression health services in Ethiopia

BACKGROUND

Qualitative studies evaluating maternal mental health services are lacking in Ethiopia, and the available evidence targets severe mental illnesses in the general population. We conducted a qualitative study to explore barriers to, enablers of, or opportunities for perinatal depression health services implementations in Ethiopia.

METHODS

We conducted a total of 13 face to face interviews with mental and maternal health service administrators from different levels of the Ethiopian healthcare system. We interviewed in Amharic (a local language), transcribed and translated into English, and imported into NVivo. We analysed the translated interviews inductively using thematic framework analysis.

RESULTS

The study identified: (i) health administrators' low literacy about perinatal depression as individual level barriers; (ii) community low awareness, health-seeking behaviours and cultural norms about perinatal depression as socio-cultural level barriers; (iii) lack of government capacity, readiness, and priority of screening and managing perinatal depression as organisational level barriers; and (iv) lack of mental health policy, strategies, and healthcare systems as structural level barriers of perinatal mental health implementation in Ethiopia. The introduction of the new Mental Health Gap Action Programme (mhGap), health professionals' commitment, and simplicity of screening programs were identified enablers of, or opportunities for, perinatal mental health service implementation.

CONCLUSIONS

This qualitative inquiry identified important barriers and potential opportunities that could be used to address perinatal depression in Ethiopia. Building the capacity of policy makers and planners, strengthening the mental healthcare system and governance should be a priority issue for an effective integration of maternal mental health care with the routine maternal health services in Ethiopia.

Systematic review of the concept 'male involvement in maternal health' by natural language processing and descriptive analysis

INTRODUCTION

Experts agree that male involvement in maternal health is a multifaceted concept, but a robust assessment is lacking, hampering interpretation of the literature. This systematic review aims to examine the conceptualisation of male involvement in maternal health globally and review commonly used indicators.

METHODS

PubMed, Embase, Scopus, Web of Science and CINAHL databases were searched for quantitative literature (between the years 2000 and 2020) containing indicators representing male involvement in maternal health, which was defined as the involvement, participation, engagement or support of men in all activities related to maternal health.

RESULTS

After full-text review, 282 studies were included in the review. Most studies were conducted in Africa (43%), followed by North America (23%), Asia (15%) and Europe (12%). Descriptive and text mining analysis showed male involvement has been conceptualised by focusing on two main aspects: psychosocial support and instrumental support for maternal health care utilisation. Differences in measurement and topics were noted according to continent with Africa focusing on HIV prevention, North America and Europe on psychosocial health and stress, and Asia on nutrition. One-third of studies used one single indicator and no common pattern of indicators could be identified. Antenatal care attendance was the most used indicator (40%), followed by financial support (17%), presence during childbirth (17%) and HIV testing (14%). Majority of studies did not collect data from men directly.

DISCUSSION

Researchers often focus on a single aspect of male involvement, resulting in a narrow set of indicators. Aspects such as communication, shared decision making and the subjective feeling of support have received little attention. We believe a broader holistic scope can broaden the potential of male involvement programmes and stimulate a gender-transformative approach. Further research is recommended to develop a robust and comprehensive set of indicators for assessing male involvement in maternal health.

Signs of the times: universalism and localism

At a time when nationalism has reappeared in Europe, when COVID-19 is not yet quarantined and when compassion coexists with grief, there is a need to consider the impact of these societal changes on international collaboration, frequency and management of perinatal mental disorder - and new roles for psychiatrists and other health professionals in the digital and AI (artificial intelligence) post-COVID era.