Maternal Depression – Not Only Reserved for the Wealthy
By Dawn Parker, AWEP and Richard Ferreira, RN
The uncomfortable truth
- Eighty percent of the world’s population lives in LAMICs (Low- and Middle-Income Countries);
- Less than 20 percent of the world’s mental health resources are shared between all the LAMICs;
- The burden of depression is 50 percent higher for females than for males;
- Approximately a quarter of all women experience maternal depression;
- Maternal depression ranges from conception up to twelve months post-delivery;
- By 2020, depression will be the second leading cause of disability (World Health Organization [WHO], 2001), and by 2030 it is expected to be the largest contributor to disease burden;
- The evidence shows that common mental health problems, including depression and anxiety, are two to three times more prevalent among pregnant women and mothers of infants in resource-constrained settings than in high-income countries (UNFPA/WHO, 2007).
A case study
This article shares the experience of Richard Ferreira and another Registered Midwifery Nurse (RMNs) who did outreach work in a low-income country (Mozambique) and the observations we made about the mental health management of mothers and mothers-to-be.
Families at the hospital’s entrance
The challenge – identifying maternal depression
According to literature, “maternal depression is associated with a substantially reduced quality-of-life.”
Identifying a reduction in the quality of life associated with maternal depression among these mothers and mothers-to-be necessitated the development of a working definition of “quality of life” for this project. As researchers, our own personal definition of quality of life (QOL) was only partially cross-transferable to the study’s population; hence, to create a working definition for “quality of life,” we submerged themselves in the daily lives of these women over a period of one year.
In general, a good QOL (Quality of Life) refers to a situation where, at a minimum, one’s basic needs as well as psychological needs are met as depicted by Maslow’s hierarchy.
credit: Plateresca for Shutterstock
With a significant number of the mothers and mothers-to-be not having their most basic of needs met ‒ i.e., lacking proper nutrition and rest ‒ QOL for these mothers could not have been derived from Maslow’s principles. The Cambridge Dictionary defines QOL as “the standard of health, comfort, and happiness experienced by an individual or group.” With substandard health and comfort experienced by these mothers in their day-to-day lives, we focused on defining what the mothers' reference point is for “happiness.” Following numerous interviews, group discussions and direct observation, it came down to a single measurable element for happiness for these women: the degree of communication.
Consistently, the study’s subjects listed variables of communication as more important than any other element of Maslow’s hierarchy. These variables included:
- Direct face-to-face communication with family, friends and random acquaintances
- Regular communication by means of mobile phones
In fact, it is common practice in Mozambique for some employers to reward an employee for good work with mobile data ‒ i.e., airtime ‒ as opposed to monetary incentives. Upon investigation, the employees in these cases stated that they preferred to be rewarded in this manner.
Previous nonprofit and nongovernmental projects equipped a number of the settlements with solar panels, and when the study’s population was interviewed about the greatest benefit these devices render to them, the answers where consistently “ability to charge my phone.”
We observed a number of cases where the mothers would reach for their mobile phones directly after a delivery, while the midwife is still busy with activities, such as suturing of a tear. We observed that in general, the local RNs used their mobile phones 12 times more frequently compared to the our own mobile phone usage. We also observed that mothers about to give birth doubled the frequency of usage of their mobile devices.
A group of expectant mothers in a pre-delivery admission unit
Communication as an indicator for maternal depression
Four hospitals’ antenatal and postnatal documents were reviewed to identify whether the mother’s level of communication or lack thereof was noted during the pre- and post-partum period.
All four the hospitals used standardized documentation very much based on the same criteria used in High Income Countries (HICs), and the mother’s level of communication was not a specific measurable element monitored as an indicator for mothers at risk of maternal depression.
The HIC documentation criteria were chosen due to the fact that these hospitals strive to benchmark themselves to what is recommended in literature.
Due to transport difficulties and the lack of a sufficient number of health facilities, pre-delivery admission units have been established at these hospitals where expectant mothers can book themselves in for the last three to four months of their pregnancy. This initiative resulted in a significant decrease in traumatic home deliveries and maternal deaths. We found that although this initiative is critical to reducing mortality, the question remains whether it is conducive for the mother’s mental health, especially as it significantly reduces the level of communication she now can have with her immediate family.
The silence of depression
Literature describes how depression remains underdetected and undertreated in HICs (High Income Countries), with subsequent adverse outcomes for mothers and their offspring.
The epidemiology of maternal depression in LAMICs is significantly less described and understood than in HICs.
The UN’s Sustainable Development Goals (SDGs) that are centered around improving maternal health, reducing child mortality, promoting gender equality and empowering women, and reducing poverty, include the WHO's mental health Gap Action Program, which covers evidence-based guidelines for the treatment of depression in the primary health care setting in LAMICs.
These goals and guidelines don’t use the individual’s level of communication, or access thereto, as a direct measure for potential risk alert of early onset depression.
The cost of communication
When expectant mothers were interviewed in a pre-delivery admission unit, most of them stated that the airtime they had upon arrival to these admission units ran out and that they had no means of replacing it.
We approached Mozambique's two main mobile service providers, and soon discovered that airtime costs were very similar to what you would expect to pay in HICs.
Conclusion
Airtime, phone calls, etc. might be considered “optional luxuries” from the perspective of an HIC, but for the expectant mothers in this LAMICs, these services are crucial to their perception of quality of life.
The ability for a mother in a pre-delivery admission unit to reach out and talk to relatives who are at home makes a world of difference.
Our research showed that communication changes could be considered the primary indicator for potential depression, yet this is an area that is not fully appreciated nor supported by medical and international support organizations.
Sources:
Report: The Interface Between Reproductive Health and Mental Health. UNFPA/WHO, Hanoi 2007; Geneva 2009
University of Michigan Health System. "Postpartum depression prevalent in under-developed countries, could impact baby health and mortality." ScienceDaily. www.sciencedaily.com/releases/2013/01/130108122447.htm (accessed June 5, 2019).