Global maternal mental health: where you live matters

It is reassuring to see, in recent years, an increase in the profile of maternal mental health in the perinatal period. We know that maternal mental health has significant implications not only for the woman’s ongoing physical and mental health, but also that of her family both in the short and long term, but is this increased attention being matched in policy and practice internationally? Identifying women who have mental health problems and ensuring they have timely delivery of care is a universal problem. However, where you live matters. Research suggests that this is not just about what services are available, but what mental health services women will engage with. A better understanding of cultural perspectives is important to fully understand variability in care and levels of stigma related to mental health in the perinatal period.

In 2008, WHO reported that maternal mental health was studied in 90% of high-income countries (HIC), but data were only available in 10% of lower- and middle-income countries (LMIC; World Health Organisation, 2008). This lack of data is concerning because the evidence that is available suggests that common mental health problems such as perinatal anxiety and depression are more prevalent in women from LMIC compared to HIC. For example, Atif, Lovell, and Rahman (2015) report that the weighted mean prevalence of depression and anxiety during the perinatal period in low-income countries was found to be 15.6% during the antenatal period and 19.8% during the postnatal period, which is higher than the rates reported in HICs (6.5%–12.9%).

There is also high variability within LMIC on the prevalence of depression. Fisher et al. (2012) conducted a systematic review that showed that the prevalence of postnatal depression was high in India (23%), Nigeria (48%), Indonesia (22.4%), Bangladesh (33%), Pakistan (25%) and Ethiopia (59.5%), but relatively low in Brazil (15.9%), China (15.5%), Mongolia (9.1%) and Uganda (6.1%). While there was variability on how women were recruited to these studies (which may impact on the reliability of the findings), the disparity in these figures may reflect important cultural variations in the expression of mental illness that needs careful consideration. Such cultural variations have implications for screening and highlight the value of validation studies of the instruments used to screen for mental health problems in pregnancy to ensure their reliability and validity in different populations and ethnic communities.

Even if screening were successful, a large treatment gap has also been reported for mental illness in LMICs, accounting for 76%–85% patients with mental health problems not receiving intervention (Atif et al., 2015). Despite recommendations from WHO and the availability of low-cost, community-based interventions (Clarke, King, & Proust, 2013), the maternal mental health agenda has not been incorporated into the primary health care system in most LMIC. The burden of communicable and non-communicable diseases along with a lack of resources has led to the marginalisation of mental health within health care in LMIC settings despite its recognised impact on health (Atif et al., 2015).

Gaps in mental health screening and care are not just a problem in LMIC. In HIC settings, women from more deprived areas experience higher levels of perinatal mental health problems and access to care is a significant problem. For example, Orengo-Aguayo and Segre (2015) report on a study of the experiences of low-income US women taking part in a randomised trial of depression treatment delivered at the point-of-care. In the USA, 19% of mothers report clinically significant depressive symptoms and these are even more prevalent among low-income and ethnic-minority women. However, low-income and ethnic-minority mothers are faced with barriers that make them less likely to receive professional mental health care. Orengo-Aguayo and Segre (2015) spoke with women to explore ways of removing these barriers, as part of a recent US trial of an evidence-based treatment delivered by home visitors/office nursing staff. Such studies are important if we are to implement appropriate and effective services for those most in need.

Similarly, the perinatal mental health needs of mothers in rural areas in HICs are also poorly understood. There is research on the organisation of care; for example, examining the impact that midwifery-led care in rural communities can have upon birth outcomes. However, research looking at the wider health of women in pregnancy including mental health and its impact on child health and development is more limited. There are some concerning reports that highlight that more research is needed. For example, when focusing on women of reproductive age, rates of antidepressant use were higher in women living in remote rural areas (Wemakor, Casson and Dolk, 2014).

It is probably not surprising that the gap in both knowledge and services is highly variable depending on where you live and what resources you have available to you, but that does not make it acceptable. In the absence of specialist services, other low-cost, community-based, psychosocial interventions have been shown to be effective in LMIC settings, which culturally may be less stigmatising than referral to secondary care (Clarke et al., 2013). Maternal mental health is such a neglected field internationally that taking a global perspective that highlights inequalities but also identifies simple interventions is of potential benefit to all. Ultimately, accumulating and comparing evidence from across countries helps us identify sociocultural antecedents and determinants of maternal mental health that are perhaps not visible when research is population-specific. To do so, we need to ensure more access to international research on maternal mental health and over the next year we would like to see an increase in international studies, particularly from LMICs, in the Journal of Reproductive and Infant Psychology that can contribute to this neglected knowledge base.

Professor Fiona Alderdice
School of Nursing and Midwifery, Queen’s University, Belfast, Northern Ireland
[email protected]
Dr James Newham
Institute of Health and Society, Newcastle University, UK