Perinatal mental health in low income countries

Less than 40% of women worldwide receive postnatal care (WHO, 2010), leaving large numbers of women potentially at risk of suffering undiagnosed and untreated postnatal mental health difficulties, including PTSD.  In the millennium year 2000, world leaders signed the United Nations Millennium Declaration and endorsed a framework of development based upon eight Millennium Development Goals (MDGs), including a goal to improve maternal health (WHO | Millennium Development Goals (MDGs)).  In 2007, a United Nations Population Fund (UNFPA)-World Health Organization (WHO) International Meeting demonstrated its commitment to the inclusion of reproductive mental health in strategies arising from the MDGs.  The report of this meeting, commonly referred to as ‘The Hanoi Expert Statement’, can be found here.

In 2011, Fisher et al reviewed, for the WHO, the prevalence and risk factors for perinatal mental health conditions in women from low and lower-middle income countries.  Prevalence rates were available from only 8% of these countries in relation to antenatal care and 15% of these countries for postnatal care.  Whilst studies were of reasonable quality, there were difficulties with samples as women from more advantaged backgrounds were often over-represented.  Furthermore, particularly for postnatal studies, there was a degree of exclusion of women on the basis of, for example, illiteracy or history of psychiatric problems, meaning that prevalence may have been underestimated.  Despite this, both antenatal and postnatal prevalence rates were higher than in high-income countries.  Most of the studies identified by Fisher et al reported risk factors for perinatal mental health conditions.  These factors were, to a large degree, reflective of the risk factors found in high-income countries.  They ranged from socioeconomic factors such as relative disadvantage, younger age and being unmarried.  Family and social relationships, such as the relationship with the baby’s father and in-laws, and social support were also associated with risk – as were general health of the mother, past mental health conditions and infant characteristics, such as child gender.  In some cases, there were interactions between factors, for example, child gender and relationship with the father (particularly violence), and a possible association with increased risk to the woman.

Unfortunately, as Fisher et al note, the studies relating to mental health in relation to low and lower-economic countries are concerned almost entirely with depression and fail to consider other disorders.  There was no focus upon PTSD within these data, a situation that is consistent with our own reviews of the literature on PTSD in low and lower-middle income countries.  However, we have identified articles reporting results that could potentially be related to PTSD.  For example: (a) Sawyer et al (2011) interviewed Gambian women and identified lack of support from men and recognition of the danger associated with childbirth as topics of concern to women; (b) Kempe et al (2013) considered Yemeni women’s perceptions of their own authority during childbirth, reporting that some women considered a loss of their own authority when attended by trained medical/nursing staff – particularly when women gave birth in institutions such as hospitals, where they felt particularly restricted – and a sense of estrangement and hopelessness.  The fact that it is not possible to substantiate such speculation, or to make cross-cultural comparisons, or to even identify prevalence rates identifies a need for further investigation in this area.

The MDGs were agreed in the year 2000 and have a target date for 2015.  We are nearing the end of 2013 and it is disappointing to note the current apparent lack of focus upon maternal mental health, and the absence of any recognition of the existence of PTSD in low and lower-middle income countries.  Of concern is the apparent failure to address the need for adequate postnatal care, including monitoring of mental health conditions, in such a large proportion of the world’s childbearing women.  There is clearly a need for greater emphasis upon research in these areas.