Maternal Mental Health

Key and Emerging Evidence

This page includes a maternal mental health (MMH) landscape analysis, select sessions from a global MMH technical consultation, a systematic review on Common Perinatal Mental Disorders (CPMDs) in low- and middle-income countries (LMICs), a foundational perinatal mental health series in the Lancet, and a review of the evidence on gender and MNCH that discusses reduction of CPMDs.

The Silent Burden: A Landscape Analysis of Common Perinatal Mental Disorders in Low- and Middle-Income Countries

MOMENTUM Country and Global Leadership, 2021.

Giving Voice to the Silent Burden: Maternal Mental Health Technical Consultation

Hosted by USAID’s MOMENTUM Country and Global Leadership (MCGL), in collaboration with the World Health Organization and United Nations Population Fund, September 2021.

The “Giving Voice to the Silent Burden: Maternal Mental Health Technical Consultation”, conducted in September 2021 and hosted by USAID’s MOMENTUM Country and Global Leadership (MCGL), in collaboration with the World Health Organization and United Nations Population Fund, was a pivotal three-day convening that brought together members of the maternal, newborn, child health, nutrition, humanitarian and fragile settings, and mental health communities to collaborate and inform the path forward for maternal mental health to ensure that pregnant and postpartum women, and their families, receive the respectful and nurturing care they need and deserve. Key discussions included an overview of the global burden of CPMDs and current evidence on effective interventions, country experiences introducing and scaling up maternal mental health programs, integrating mental health care into existing service delivery platforms, strengthening provider capacity to deliver maternal mental health care, and the role of community, civil society, and faith organizations in supporting mental health.

Landscape Analysis Brief

This landscape analysis brief, published in October 2021 and developed by USAID’s MOMENTUM Country and Global Leadership (MCGL), describes the current state of perinatal mental health and the burden of common perinatal mental disorders for women, newborns, and families in low- and middle-income countries (LMICs). To date, mental health has lacked proper attention in the health sector in terms of funding and action. The perinatal period is associated with an elevated risk of mental health conditions – women with a history of a major postnatal depression had a 25% risk of a recurrence in a subsequent pregnancy,[4] and postnatal depression is a major risk factor for maternal death by suicide, accounting for 20% of mortality in the year after childbirth. [5] Perinatal mental health conditions have also been associated with adverse physical, emotional, and neurological development in newborns and children. [6] Studies from LMICs found that depressed mothers had a higher risk of preterm births and low-birthweight babies. [6] The presence of CPMDs in mothers also appears to increase the risk of stunting and wasting in children. [7] There also appears to be an association between CPMDs and the extent to which mothers seek immunization services or care for ill children. [8]  

Key Findings

  • Mental health remains underfunded and often ignored in the face of more visible physical health concerns. The global treatment gap for mental health disorders is estimated at nearly 90%.[1]
  • CPMDs pose significant and lasting implications for women’s health and quality of life, and have been associated with adverse development in newborns and children.[2]
  • Perinatal mental health needs to be better integrated across multiple health sectors and sectors outside of health, away from centralized institutions to the primary care and community level, and into health care provider education and practice.
  • Future research should include findings from different contexts, avoid inappropriate generalization, generate more evidence for vulnerable populations, expand beyond postnatal depression, center on the expressed desires of women, and explore integrated approaches that improve both women’s and children’s health at scale.

The following sessions from the technical consultation highlighted select key and emerging evidence. Note that to view all consultation session recordings, including those listed here, you must register.

Highlighted Sessions

    • We need to understand the many context-specific factors, including gender and family dynamics, social pressures, and localized knowledge and conceptualizations of mental health, that impact perinatal mental health.
    • Measurement tools have been developed and validated in higher income settings, and the language used may not translate appropriately into other contexts.
    • Targeted, low-intensity interventions delivered by non-specialists (supported by training and effective supportive supervisory systems) at the public health care level can reduce the treatment gap in LMICs.
  • Evidence and Gaps for Women in Fragile and Crisis-Affected Contexts. In this session, speakers reviewed current evidence and reflected on gaps in approaches for addressing CPMDs in fragile and crisis-affected settings, including for displaced populations and those living in areas affected by conflict and complex emergencies. Participants and panelists explored how needs and service delivery platforms may vary across different types of settings and discussed priorities for strengthening maternal mental health programming.
    • Local terms for mental health conditions vary from country to country. We must understand local terms and engage local people to help, to provide effective treatment.
    • Sequential care, or treatment for one issue at a time, is problematic because many people are coping with multiple mental health-related issues. The Common Elements Treatment Approach treats conditions simultaneously and customizes the response by using different solutions for each condition a person may have.
    • Greater investment is needed in lay people who come from the communities they serve, and who are trained to respond to mental health issues, to sustain services.
  • Overlapping Risks: Evidence and Gaps for Vulnerable Populations. This session reviewed the current state of evidence around perinatal mental health for vulnerable populations such as adolescents, women experiencing gender-based violence (GBV), minority populations and women living with HIV. Speakers discussed global initiatives, contextualized programming, and outstanding knowledge and program gaps. They drew lessons from diverse vulnerable populations and identified areas that must be addressed to better include and support these vulnerable women and girls.
    • Use youth as navigators and consider them key development partners to co-design mental health programs and contextualized approaches. Greater involvement of adolescents in program decision-making yields better results.
    • A research study in Ethiopia found significant marginalization exists among migrant workers, which have led to high levels of depression associated with violence and social isolation.
    • A research study on perinatal mental health in rural Rajasthan, found that women with co-morbidities, women experiencing IPV, and women from low-income families are vulnerable to poor well-being outcomes. In addition, there is a need for an integrated interventions that deal with mental health, GBV, and suicidal ideation.
    • There is a strong need to integrate men and boys, and the community, into mental health programs to ensure they are equal partners in improving women’s mental health.
  • Interventions Addressing CPMDs through the Continuum of Perinatal Care: Evidence and Gaps. This session presented evidence from a variety of interventions in one South Asian, one Southeast Asian and two African countries, that address the needs of women during and after pregnancy. Speakers touched on when and how women were screened for CPMDs, linkages with appropriate care, post-intervention follow up, and intervention outcomes. Speakers discussed care provided at community and facility levels by trained community health workers, peer counselors, and nurses/midwives.
    • Mental health programs have historically been siloed and difficult to scale. Systems-wide change is needed.
    • Support systems are critical for maternal mental health interventions. Community health workers, midwives, and other healthcare workers need support systems to effectively task shift and scale programs for their own mental health.
    • Maternal mental health requires significant advocacy to reduce shame and stigma, for policy-change and scale-up, and for resource mobilization and financing.

Prevalence and Determinants of Common, Perinatal Mental Disorders in Low- and Lower-Middle-Income Countries: A Systematic Review

Bulletin of the World Health Organization, 2012.

While the nature, prevalence, and determinants of mental health conditions in women during pregnancy and in the year after birth have been heavily investigated and researched in high-income countries, the perinatal mental health of women living in LMICs is not as widely researched. The systematic review summarizes the nature, prevalence and determinants of CPMDs in women living in LMICs.

Key Findings

  • In LMICs, about 1 in 6 pregnant women (as compared to 10% in high income countries), and about 1 in 5 women who have recently given birth (as compared to 13% in high income countries), experienced CPMDs.
  • The prevalence of CPMDs is highest among the most socially and economically disadvantaged women, particularly those living in crowded households and rural areas.
  • Gender-based violence, including emotional and physical abuse, was consistently found to increase the risk of CPMDs.
  • The risk of CPMDs was lower among employed women with higher levels of education, women with access to sexual and reproductive health services, and those with supportive family relationships.
  • In LMICs, maternal depression is associated with higher rates of malnutrition, stunting, diarrheal diseases, infectious diseases, hospital admissions, lower birth weight, and reduced completion of immunization schedules among infants.

The Lancet Perinatal Mental Health Series

The Lancet Perinatal Mental Health Series, published in 2014, reviews the effects of perinatal mental disorders on both the mother and the child. Three papers include:

Gender and MNCH: A Review of the Evidence

Bill and Melinda Gates Foundation, 2020.

This report provides a landscape and evidence review of how gender influences maternal and newborn health behaviors in LMICs. The report draws on existing literature, program reports and evaluations, case studies, and interviews to provide evidence on how gender inequality contributes to challenges for women and their newborns. It also includes a section on reducing the prevalence of CPMDs using gender-intentional approaches and provides examples from South Africa, China, and the Thinking Healthy Programme in Pakistan, which integrates men and extend families into CPMD programs to increase household-based social support.

Citations
The Silent Burden: A Landscape Analysis of Common Perinatal Mental Disorders in Low- and Middle-Income Countries
MOMENTUM Country and Global Leadership, 2021

1 Meltzer-Brody S, Stuebe A. The long-term psychiatric and medical prognosis of perinatal mental illness. Best Pract Res Clin Obstet Gynaecol. 2014;28(1):49-60. doi:10.1016/j.bpobgyn.2013.08.009

2 Lindahl V, Pearson JL, Colpe L. Prevalence of suicidality during pregnancy and the postpartum. Arch Women’s Ment Heal. 2005;8(2):77-87. doi:10.1007/s00737-005-0080-1

3 Glover V. Maternal depression, anxiety and stress during pregnancy and child outcome; What needs to be done. Best Pract Res Clin Obstet Gynaecol. 2014;28(1):25-35. doi:10.1016/j.bpobgyn.2013.08.017

4 Dadi AF, Miller ER, Mwanri L. Antenatal depression and its association with adverse birth outcomes in low and middle income countries: A systematic review and meta-analysis. PLoS One. 2020;15(1):1-23. doi:10.1371/journal.pone.0227323

5 Surkan PJ, Patel SA, Rahman A. Preventing infant and child morbidity and mortality due to maternal depression. Best Pract Res Clin Obstet Gynaecol. 2016;36:156-168. doi:10.1016/j.bpobgyn.2016.05.007

6  Stewart RC. Maternal depression and infant growth – A review of recent evidence. Matern Child Nutr. 2007;3(2):94-107. doi:10.1111/j.1740-8709.2007.00088.x

7 World Health Organization. MhGAP Operations Manual. World Health Organization; 2018. http://apps.who.int/bookorders.

8  Dadi AF, Miller ER, Mwanri L. Antenatal depression and its association with adverse birth outcomes in low and middle income countries: A systematic review and meta-analysis. PLoS One. 2020;15(1):1-23. doi:10.1371/journal.pone.0227323

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