Maternal Mental HealthInterventions in LAMIC

A few diverse thoughts about global implementation

CORE presentation, 2012CORE presentation, 2011

More than “Baby Blues”

Under diagnosed

Under treated

Often misunderstood

Beliefs and practices are often culture bound

Making global implementation of

interventions complex

Treatment, general

The World Health Organization (WHO) offers hopeful statistics related to maternal mental health, estimating that 70% to 80% of women with maternal mental disorders can be treated successfully and recover.

• Earlier treatment is associated with a better prognosis.

• The woman and her partner should be involved in the full continuum of care, including education and treatment options.

• Screening may best occur at primary healthcare facilities

• Antidepressants have been shown to be effective in treating perinatal depression.

• Non-pharmacologic treatment strategies have been useful for women with mild to moderate depressive symptoms. – Individual or group psychotherapy (cognitive-behavioral and interpersonal therapy)– Psycho-educational or support groups may also be helpful. – These modalities may be especially attractive to mothers who are nursing and who wish

to avoid taking medications.

CORE Presentation Fall 2011

A FEW OBSERVATIONS ON GLOBAL TREATMENT APPROACHES…

Maternal Child Mental Health (MCMH) Working Group

A recently formed multidisciplinary and cross agency group developed to facilitate attention, policies, and practice in maternal care globally.

At present, the Working Group’s core members in the United States come from various disciplines, including psychologists, nutritionists, public health experts, and others, as well as diverse organizations

Including the CORE Group, Catholic Relief Services, CARE, Duke University, Johns Hopkins University, Post-partum Support International, University of Maryland, and World Vision.

MCMH database

Nanmathi Manian (URC) is creating a database of perinatal mental health publications related to LAMIC

Exhaustive

Primarily effects of maternal depression on child growth and development

Very few studies on intervention, one RCT

Psychoeducation: International Resources

• Marcé Society

• Founded in 1980• Mission- to promote,

facilitate and communicate about research into all aspects of mental health of women, their infants and partners connected with childbirth.

• www.marcesociety.com

• Postpartum Support

International

• Founded in 1987• Mission- to increase

awareness among public and professional communities about the emotional difficulties that women can experience during and after pregnancy.

• www.postpartum.net

Step by StepA Guide to Organizing a PostpartumSupport Network in your Community

I’m ListeningA Guide to Support Postpartum Families

Books by Jane I. Honikman, M.S.

Founder, Postpartum Support International

Available from Amazon

Available from the author

Global application in Bangladesh: Facilitator’s Training Guide:How to help families cope with

postpartum depression

This guide can be downloaded at: http://thewindowofopportunity.info/resources

Addressing Maternal Depression within the Context of a Nutrition Program

Window of Opportunity Infant Feeding Project

Ann DiGirolamo, CARE

– Goal: Protect, promote, and support related maternal nutrition (rMN) and infant and young child feeding (IYCF) practices in resource poor settings in 5 countries

– Main strategies:

• Mother-to-Mother Support Groups (MtMSGs)

• Nutrition Counseling

• Participatory Group Education

Desire to build in education and support on maternal depression •Mechanism: existing nutrition counselors and MtMSGs•Training on how to support women suffering from post-partum depression (PPD)•Identify resources for more intensive services when necessary and where available

Ongoing Birth Cohort Study In Bangladesh•Purpose: Provide data to evaluate the Window of Opportunity program•Measurement of maternal depressive symptoms at 9 months postpartum (EPDS, UNICEF 6-item screener) to assess prevalence of PPD

Window of Opportunity in Bangladesh

Example with US Immigrants from Mexico: Support groups

The HEAL Project

Janine Schooley, MPHPCI

Health

Education

Action for Latinas

Support Groups

• The HEAL Educator lead a series of six small group sessions designed around the theme of “Es Dificil Se Mujer?” (“Is it Difficult to be a Woman?”) to help women identify areas of their lives they wish to change or improve.

• Sessions address stress, depression and provide women with the information, skills, and support necessary to deal appropriately with these issues.

• Curriculum is designed to reduce stigma around mental health issues and promote communication, empowerment and expanded self-care, including proper nutrition, exercise and general well-being.

CORE Presentation Fall 2011

Group setting

Guided discussion around specific topics

Time set aside for women to reflect & dialogue

A program that builds self esteem

Educational, psychological, reflexive

Gender-specific

How does HEAL work?

CORE Presentation Fall 2011

Does HEAL work?

Outcomes

Improved depression scores by 40%

Pregnant women

improved depression scores by 60%

CORE Presentation Fall 2011

Primary example of global implementation: An RCT in Pakistan

Lay health visitors used CBT to treat postnatal depression in rural Pakistan (Rahman et al, Lancet 2008)

By building the intervention into the routine of community based primary health care

Randomized by region

Task shifting – training lay health workers

The RCT in rural Pakistan

16-45 year old married women

Identified with depression in 3rd trimester

All women received visits

Trained lay counselors compared to

Untrained, routine health visits

Results

6 months postnatally maternal depression reduced: 53% versus 23%

12 months postnatally maternal depression reduced: 59% versus 27%

No differences in weight for age at either time

The approach: SUNDAR Simplify the message

UNpack the treatment and

Deliver it where people present to the health care system, using

Affordable and available human resources, whom you

tRain and supervise effectively

Rahman et al., 2008

A FEW COMMENTS ABOUT GLOBAL IMPLEMENTATION…

Perinatal conditons were ranked 1st and depression 4th as contributors to the global burden of disease (GBD) experienced by women globally.

Not just “blues”

A couple of provocative questions

• Is it POST partum?

• Is it depression?

Lessons learned

• Traditional perinatal practices can be protective or create increased risk or both (Hanlon et al., 2010 BJP; Ethiopia)– Prohibitions, prescribed practices

– Celebratory, respect for transition

• So deeply embedded in cultural beliefs– U.S.- “It’s all hormones, so it cannot be treated

psychologically?”

– Vodou in Haiti- Lait passe

• Consider the ethnographic approach for assessing– Local idioms: How do you enter the discussion?– “Blue?”; “overwhelmed?”

• Assess in more than one way– Entry idiom– Short series of questions– Locally adapted tools, e.g., PHQ9; Edinburgh

• LAMIC implementation requires task shifting, but that is not so bad– May be easier to train to deliver a proscribed protocol with fidelity– May be more acceptable as embedded in community practice

Perinatal mental ill health may not be as “preventable” by single interventionsas polio or iodine deficiency, but given

High prevalence of problems for child bearing women, including suicideKnown untoward effects of mothers’ functioning and child developmentAnd relative ease of intervention within naturally occurring health care

WHAT ARE WE WAITING FOR?