Maternal mental health matters

Maternal mental health matters

- Experiences from Nepal

Signe Dørheim, MD, PhD Stavanger University Hospital

Sandnes DPS

My background



Nepal 2000-2003

- Medical Officer UMN

- Primary Health Care

- Community Mental Health



2005-2009: PhD

Depression and sleep in the postnatal period.

- A study in Nepal and Norway



2003-2018:



Psychiatrist, Sus,

Stavanger

Millennium Development Goal (MDG) 5 - improving maternal

health

⇒ Clear links between mental health problems and maternal physical health

 increases maternal morbidity and mortality



Improving Maternal Mental Health contributes to achieving MDG 5

& MDG 3 promoting gender equality and empowering women

& MDG 4 Reducing child mortality

Maternal depression

common in LMIC

 2^ndcause of disease burden (DALY) in women

 Symptoms affect maternal functioning and role

 low mood

 loss of interest or pleasure

 feelings of guilt or low self-worth

 disturbed sleep or appetite

 low energy

 poor concentration

 More prevalent in LMICs

 & Most women live in LMICs

Maternal depression – Effects on the infant

 Pre-term birth and low birthweight

 Poor cognitive, emotional and social development of the child

 Lower rates of breastfeeding and vaccinations

 More diarrheal diseases

 Low birth weight and poor infant growth (Pakistan, India, Nigeria)

Deaths among women 15- 45 years

1998:

 1. Pregnancy & childbirth 21%

 2. Suicides 10 %

 4. Infectious diseases 9 %

2008:

 1. Suicides 16 %

 3. Pregnancy & childbirth 11 %

 5. Infectious diseases 10.5 %

Nepal Maternal Morbidity and Mortality study

2008/2009

Perinatal maternal mental disorders

 Psychosis & bipolar

 1-2/1000 births

 First-time mothers:

 2-3x risk of depression

 first 5 postnatal months

 Previous mental illness

 may worsen in the perinatal period

 Suicides

 Large indirect cause of maternal deaths

Prevalence and risk-factors in Nepal

 5-10 weeks after birth

 3 communities

 EPDS (Cox et al 1987)

 SRQ-20, ^WHO

(Harding et al 1980)

 Social, psychiatric and physical factors

Challenges

1.

Illiteracy

2.

Translation of tools

• Crosscultural validation

3.

True answers?

• Eager to please?

• Trust?

• Privacy?

4.

Logistics

Datacollection

594 possible participants 426 women included, 71%

Prevalence 4.9%

7.4%

3.9%

3.9%

Conclusions

1. Less prevalent (5% vs 12%)

2. Relationship with partner:

• Alcoholism

• Polygamy

3. Previous depression and stressfactors

• increased risk

4. Protective traditions

• Maternal home?

• Arranged marriage?

• ^Violence

2013: Dhanusha

 9078 women

 Prevalence 9.8%

 GHQ -12, >6

 Domestic violence and previous mental illness not measured

Risk factors

 Food insecurity

 multiple birth

 CS

 perinatal health problems

 no school

 few assets

 >5 children

 poor antenatal care

 never had a son

 not staying in maternal home

 low age



Termed: «Tensions», physical symptoms



Proposed causes: Poor health, lack of sons, fertility problems



Context: Limited autonomy and duty to family

Special risk factors, LMIC

(Fisher et al, 2012)

Possible risk factors

 Polygamy

 Violence

 Alcoholism

 Socially and economically disadvantaged women

 Gender-based factors

 bias against female babies

 Quality of intimate partner relationship

 Sick infant (?)

Possibly protective

 Ethnic & religious majority

 Education, good

socioeconomic status

 Seclution & extra care first 30-40 days (Quarantena)

 Supportive familiy relations

 Maternal home

Main conclusions

 1/6 pregnant women and 1/5 postpartum women are experiencing a perinatal mental disorder

 Women’s mental health is NOT protected by culturally- prescribed traditional postpartum care

 Women’s mental health is governed significantly by social factors, many beyond individual control

 Not merely biological in origin

Maternal depression can be treated

 Prevalence 28% (Pakistan)

 Cluster randomised control study

 Cognitive Therapy

 Enhanced routine care

 Village primary health workers

 400 in each group

 90% completed 1 year

(Rahman et al., 2003-2008)

(Lancet, 2008)

How to give care with limited resources?

 Acceptable and

affordable pathways of referral

 Availability of psychiatric drugs

 Teaching and supervision from mental health

professionals

 Increase awareness among Midwives &

Maternal and Child Health workers

Culturally accepted methods

Informasjonsmateriell

Signe.karen.dorheim@sus.no 22

nordicmarce.org Nordic Marcé

Working together for 1001 days –

improving perinatal mental health for all

Welcome to the 3rd Nordic Marcé Conference

Stockholm, Sweden 24-25 Oktober 2019

23

«Take home»



Maternal depression more common

 & wider consequences in LMIC



Improving Maternal Mental Health

contributes to achieving MDG 5, 3 & 4

 Maternal mental health also affects her physical health and her infant



Depression can be treated at community

level with limited resources

Thank you!