Category: Resourceful Young Children | Comprehensive ECD package | 1 March, 2013 - 13:05← BACK
Mental health is a vital component to being a healthy, well rounded and balanced human. And yet, in South Africa, many challenges face the supply and delivery of mental health care, especially to those individuals living in marginalised, resource poor settings.
The state medical system is already thinly stretched meeting the physical needs of citizens, which means that the cognitive, emotional and spiritual needs are wholly underserviced. An insufficient number of state-employed, qualified psychologists and psychiatrists cannot provide comprehensive and holistic care to those in need, thus creating huge backlogs and leaving large numbers of people un-cared for. Moreover, private, professional psychologists, counsellors and psychiatrists often charge high consultation fees making these avenues of care unavailable to low-income individuals.
An even greater limit to the existing mental health care system is the lack of services available to particularly vulnerable individuals, such as pregnant women who are teenagers, substance abusers, or refugees. Women who are pregnant or in the postpartum period are at increased risk of depression. The prevalence of postnatal depression in developing South Africa is three times higher than in developed countries of the world, and in Cape Town alone, there is a documented 39% rate of antenatal depression.
In Cape Town, hospital facilities struggle to care for the mental health of pregnant teenagers and individuals with HIV, who are at high risk of depression and suicide. They also have difficulty bridging the language and cultural obstacles in order to adequately provide care to the growing immigrant and refugee population – roughly 40% of women counselled at primary facilities are refugees. Finally, in many of Cape Town’s lower-economic areas there is a strong association between depression and substance abuse among pregnant women. In one study about 33% of the sampled women were depressed, and 85% of these were alcohol dependent.
This lack of adequate and available mental health care for vulnerable pregnant women is the challenge that Hope House is addressing. Hope House has created a maternal mental health counselling service to address the needs of people in the wider Cape Town community. Our intervention hopes to lead women out of addictive behaviour and violent settings. We believe that the impact of addressing this challenge results in individuals who are better equipped (mentally) to make healthy choices relating to themselves, their new baby, their families, and ultimately their communities.
Hope House is designed to complement existing public maternal health care centres by providing for the mental health of pregnant women. Hope House has launched the Maternal Mental Health Counselling Program, which is focused on treating mental illness amongst pregnant woman and girls from several exceptionally disadvantaged communities in Cape Town, where there are inadequate or no support services available.
The goals of the Maternal Mental Health Counselling Programme are to:
In order to fulfil these goals Hope House takes the following implementation steps.
1) Partnering with others to share resources
Our implementation model is a dual initiative combining indispensable human resources from the Hope House Counselling Centre with that of the infrastructural and oversight support from the Perinatal Mental Health Project.
Hope House contributes to the program by employing two full-time lay counsellors. One stationed at False Bay Hospital and the other at Retreat Midwife Obstetrics Unit. It also offers staff to provide weekly supervision sessions. The Perinatal Mental Health Project is responsible for training, service development, technical and clinical supervision, as well as monitoring and evaluation.
2) Systematically identify patients
Women in need of mental health care are identified at the Perinatal Mental Health Project antenatal care service sites. When women book for maternity care at the sites, they are offered additional mental health screening as part of their regular care. This is voluntary, and women have the option to decline screening. Counsellors, nurses and midwives conduct the mental health screen during the routine history taking, which is performed at the first antenatal visit. Overall, this process ensures an 80% screening coverage of all pregnant women.
3) Using diverse mental health screening tools
We use the Edinburgh Postnatal Depression Scale to screen pregnant women. In addition, a Risk Factor Assessment, specifically designed by the Perinatal Mental Health Project, which screens for vulnerability to mental distress, may also be administered. The Risk Factor Assessment is a yes/no tick-form consisting of eleven common risk factors for mental disorders.
Screening questionnaires are self-administered in private. Maternity staff provide assistance when necessary. Questionnaires are available in the four most commonly spoken languages among our clients visiting the facilities in the Western Cape: English, Afrikaans, isiXhosa and French (due to a significant refugee population).
Women are referred for counselling if scores meet the cut-offs on either of the screening tools.
4) Providing counselling services when needed
At Hope House, trained counsellors provide individualised, face-to-face counselling. They assess each client and adopt a flexible intervention approach to suit the individual’s need. These interventions may include containment, psycho-education, bereavement counselling, debriefing of traumatic incidents, relaxation and breathing exercises, couple and family counselling, and suicide and impulse risk management.
The counsellors continue providing care into the postnatal period. On average, each client attends 2 – 3 face-to-face counselling sessions. Counsellors also spend extra time liaising with external agencies, social services or support organisations for their clients. Counsellors also provide additional support via telephone.
In more serious cases, the counsellor will refer the client to the Perinatal Mental Health Project psychiatrist.
The value and effectiveness of counselling services
In resources poor settings where highly skilled professionals are scarce, evidence suggests that layperson counselling is an effective way to support women in distress. Counselling that is conducted by a trained, yet semi-skilled counsellor provides a safe physical and emotional “space” for women to cathartically deal with their concerns. It allows them to tell their stories without fear of blame or judgement, and it helps them to verbally highlight their priorities and identify possible solutions. Counselling support empowers women to take the lead in managing their own problems, and it has a proven beneficial impact on mood, coping ability, general functioning, assertiveness, and resilience to face the challenges of motherhood in difficult social and economic conditions.
Suggested strategies for dealing with implementation challenges
Postnatal follow-up care is essential
Due to the many logistical limitations of caring for women in the public sector health system we find it difficult to keep track of our clients. Many women struggle to visit the health facilities after the birth of their babies. Consequently, we ensure that all our counsellors call their clients six to ten weeks after they have given birth. This is an opportunity to evaluate the mother's current mood and her bonding with baby. It can also act as an additional therapeutic intervention if necessary. The phone call usually lasts a minimum of 45 minutes.
Be flexible in the use of multiple screening tools
In South Africa, maternal mental health screening must be performed routinely and on-site, must be logistically feasible and responsive to the local risk factors that may influence mental distress.
Although the Edinburgh Postnatal Depression Scale (EPDS) has been validated to screen for maternal mental illness, it requires training to use, and is cumbersome for routine use in busy antenatal clinics. The EPDS does not address the context-specific needs of the South African health system, and is not sufficiently sensitive to a context challenged by HIV/AIDS, poverty, high rates of violence and trauma and a severe lack of social support.
What is needed is a short, easily administered tool that does not hamper already busy clinical settings. To address this gap, Perinatal Mental Health Project has developed a brief 5-question risk factor screening tool for psychological distress. This tool is used in addition to the EPDS, or as an alternative, when the EPDS is not practical.
Childrens Way, Bergvliet, Cape Town
(021) 715 0424
The case of Hope House provides a success story of how to provide mental health care to pregnant and postnatal women in the public health care system. This example shows that partnering with existing service providers enables efficient use of human and material resources, and it reveals how projects can remain true to their vision whilst being flexible and adaptive in their implementation approach, as the need arises.