1. Maternal Mental Health
Interventions in LAMIC
A few diverse thoughts about
global implementation
CORE presentation, 2012
CORE presentation, 2011

2. More than “Baby Blues”
Under diagnosed
Under treated
Often misunderstood
Beliefs and practices are
often culture bound
Making global
implementation of
interventions complex

3. 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

4. A FEW OBSERVATIONS ON GLOBAL
TREATMENT APPROACHES…

5. 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.

6. 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

7. Psychoeducation:
International Resources
• Marcé Society • Postpartum Support
• Founded in 1980 International
• Mission- to promote, • Founded in 1987
facilitate and communicate • Mission- to increase
about research into all awareness among public
aspects of mental health of and professional
women, their infants and communities about the
partners connected with emotional difficulties that
childbirth. women can experience
• www.marcesociety.com during and after pregnancy.
• www.postpartum.net

8. Step by Step
A Guide to Organizing a
Postpartum
Support Network in your
Community
Available from the author
I’m Listening
A Guide to Support Books by Jane I. Honikman, M.S.
Postpartum Families
Founder, Postpartum Support International
Available from Amazon

9. 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

10. 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

11. Window of Opportunity in Bangladesh
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

12. Example with US Immigrants from Mexico:
Support groups
The HEAL Project
Health
Education
Action for Latinas
Janine Schooley, MPH
PCI

13. 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

14. How does HEAL work?
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
CORE Presentation Fall 2011

15. Does HEAL work?
Outcomes
Improved depression
scores by 40%
Pregnant women
improved depression
scores by 60%
CORE Presentation Fall 2011

16. 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

17. 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

18. 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

19. 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

20. A FEW COMMENTS ABOUT GLOBAL
IMPLEMENTATION…

21. Not just “blues”
Perinatal conditons were ranked 1st and
depression 4th as contributors to the global
burden of disease (GBD) experienced by
women globally.

22. A couple of provocative questions
• Is it POST partum?
• Is it depression?

23. 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

24. • 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

25. Perinatal mental ill health may not be as “preventable” by single interventions
as polio or iodine deficiency, but given
High prevalence of problems for child bearing women, including suicide
Known untoward effects of mothers’ functioning and child development
And relative ease of intervention within naturally occurring health care
WHAT ARE WE WAITING FOR?