Full article with references and graphs is available freely on the PLoS website: http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001222
The Perinatal Mental Health Project (PMHP)’s recognises the enormous need for public maternal mental health services, and thus its vision is for all women to have access to mental health care during and after pregnancy, as part of their ordinary maternity care.
In our last learning brief, we outlined our role as an incubator for the development of a package of proven tools for agencies capable of delivering maternal mental health interventions to scale. This involves:
• the development of a maternal mental health service through on-site service provision
• training health workers to support integrated service delivery
• conducting in-service research to generate evidence-based models of good practice
• lobbying the Health Department and other State agencies to develop appropriate policies in order to implement mental health legislation.
We also outlined the high prevalence of maternal mental illness: nearly 50% of women living in poverty in South Africa experience mental health problems related to pregnancy; and described the negative outcomes for mother, child and society should maternal mental illness remain untreated.
The PMHP is in the modelling phase, developing and testing service delivery elements and a maternal mental health screening tool. In this brief, we systematically outline our process of model development. The data presented refers to our primary service site at Mowbray Maternity Hospital in Cape Town.
Maternal mental health care in South Africa
Despite high levels of maternal depression, there is a lack of routine programmatic maternal mental health care in South Africa. This is despite evidence that such interventions may be successfully implemented in primary care settings.
Currently, maternal care involves:
• an average of 3 antenatal clinic visits
• a focus on physical examinations
• postnatal care, at a different facility, where the focus is on the infant for immunisation and growth monitoring.
The lack of integration between maternal health services, child health services and mental health services in primary care creates a large gap in the screening and treatment of maternal mental disorders. Where referral services are available, women are often required to incur additional costs related to transport, child care and loss of income to attend appointments. Women may also be referred to services at a different site which exacerbates these costs and frequently results in women not taking up services.
Addressing the gap: developing a model for maternal mental health care
The PMHP has developed a stepped-care intervention for maternal mental health that is integrated into antenatal care. Midwives at the health care facility are trained to screen women routinely for mental distress during their antenatal visits. Those who screen positive for a mental illness or for being at risk of mental illness are referred to on-site counsellors who also act as case managers. If specialist intervention is required, women are referred to an on-site psychiatrist. The PMHP raises funds to provide these services free of charge.
The PMHP works directly with facility managers and health workers through collaborative partnerships, focusing on problem-solving and capacity development in the primary health care system.
Stakeholder engagement: Before launching the service in 2002, the PMHP began a process of planning and design with practitioners working in the fields of social work, psychology, psychiatry and midwifery. A draft service model was developed and this was presented for comment and permission to a range of stakeholders, including provincial representatives in the related sub-directorates of the Department of Health, senior and junior health managers and lead clinicians at the proposed service site as well as all cadres of health and administrative staff working within the primary care obstetric facility. Simultaneously, training and capacity building workshops were conducted with midwives and nursing staff based at the proposed service site. From these it emerged that on-going mental health training for general health workers would form an integral part of the PMHP intervention.
Training for effective task-sharing: PMHP training employs an informal, participatory style of training. On-going engagement with staff through training and supervision has assisted in motivating staff to engage with their own mental health needs, and has helped nursing staff to manage their workload more effectively and address feelings of ‘burn out’. The PMHP has developed complementary training materials, which are freely available for download from our website.
Women are offered screening at their first antenatal visit by nurses and midwives during routine history taking. The screening tools used are the Edinburgh Depression Scale (EPDS), a questionnaire which has been validated for use in South Africa, and a Risk Factor Assessment (RFA) tool. The RFA was designed by the PMHP. It is a yes/no tick-form consisting of 11 risk factors for mental distress.
After signing informed consent, women self-administer the mental health screening questionnaires in private. In this urban setting, most women are literate, but midwives assist those who experience difficulties with the questionnaires. All forms are available in the languages most frequently spoken at our sites, which are English, Afrikaans, isiXhosa and French (provided to a large population of Francophone refugee women who attend the facility).
Screening scores are calculated by the midwives and screening data is recorded for monitoring. The scores indicate whether or not women need a mental health intervention. If they do, they are referred to attend on-site counselling. Counselling appointments are made to coincide with subsequent antenatal visits or when convenient for the women.
Individual counselling is provided free of charge, on an appointment basis, during pregnancy and up to one year post-partum. A full-time clinical psychologist co-ordinates the clinical services. She provides a liaison role with personnel at the hospital, counsels clients and manages the counselling team.
The PMHP team includes a lay counsellor, a qualified counsellor and a psychiatrist. A number of therapeutic modalities are used in the counselling sessions, including psycho-education, bereavement counselling, problem solving and interpersonal therapy. Alcohol and substance use, which is ascertained by nurses as a part of routine history-taking, is explored further in counselling. Women who present with alcohol and substance abuse are referred to the hospital social worker for further intervention, according to the management protocol of maternity facilities.
Each counsellor manages her own case load and collaborates with the psychiatrist and allied health workers when necessary. Care is usually supplemented by liaison with external agencies such as NGOs. Women receive consistent and structured follow-up management including telephonic contact for those who are unable to attend the facility or who default counselling appointments.
The psychiatrist provides a fortnightly session at the obstetric facility. She liaises with the referring counsellor who retains the central role in therapeutic management of the client. Counsellors engage with women to explore whether they would take up psychiatric services. This enables counsellors to rationalise referrals to psychiatry for those clients who are most likely to engage positively with this care, making the most effective use of this scarce resource.
Every woman counselled receives a routine six-week postnatal follow-up phone call. Using a feedback questionnaire which is designed to gather information about the birthing experience, the counsellor explores:
adjustment to life with the baby
how well the presenting problem had been dealt with
the experience of counselling
whether further intervention or referral to external resources is required
Regular clinical supervision of counselling staff is an important aspect of the PMHP model. Attendance of peer support group meetings and external clinical supervision is compulsory for all counsellors.
The PMHP evaluated impact data for the period July 2008 to the end of June 2011.
90% of 6,347 women who attended the facility for primary level care were offered mental health screening (see Figure 1).
95% (5,407 women) of these women accepted the screening
average age of women screened: 25 years
average gestation at screening: 24 weeks
47.1% of women screened were in their first pregnancy
32% of women screened qualified for referral to a counsellor
62% (1,079 women) of those who qualified agreed to be referred to a counsellor
Of this group, 77% attended their appointments and received an average of 3 face-to-face sessions
The main reason for missing or cancelling counselling appointments were related to logistical and resource issues; a small number of women felt that their problems had improved since they were screened.
A total of 1981 counselling sessions were conducted during this period
832 of these sessions were first sessions
A small proportion (2%, N = 20) of the women who were counselled, were referred and seen by the PMHP psychiatrist. Of these women
75% reported inadequate partner or family support
45% reported past psychiatric problems
40% reported past or present abuse (any form)
5% had problems with substance abuse
From the beginning of 2010, formal postnatal evaluation procedures were instituted.
Counsellors attempted telephonic contact with all counselled women.
For the 12-month period ending 30 June 2011, 170 postnatal follow-up phone calls were made.
A preliminary analysis of women’s self-reported data reveals that at 6-10 weeks post-partum
- 87.8 % of women reported an improvement in their presenting problem
- 79.9% of mothers reported to be coping at the time of the telephone assessment
- 74.6 % reported positive mood at the time of the assessment
- 91.7% of these women rated the sessions as a positive experience.
In low-resource primary care settings, where common mental disorders are often overlooked, integrating screening into routine antenatal procedures has the potential to narrow the treatment gap significantly. Universal screening allows for early detection of psychological distress in most cases. Women who meet the criteria may then be immediately referred to counsellors. Early identification, referral and treatment can, in turn, be preventative by reducing the need for specialist, more resource-intensive care.
Training maternity nursing staff to screen and refer for mental health care makes use of existing resources as well as building the capacity of health workers. Maternity staff trained by PMHP report improved capability to identify and deal with women’s mental health problems. In this way, staff morale is improved by empowering staff, which in turn improves the overall quality of care nurses are able to provide.
Establishing a referral system enables more effective case management. Where women need mental health services, the availability of an on-site counsellor allows staff to make a direct referral and ensure that there is continuity of care. Rather than adding to their workload, staff reported a sense of relief that systems have been developed to meet the previously ignored need.
The high coverage and uptake (90% and 95% respectively) of PMHP screening may be attributed to factors such as:
the consistency with which the health care staff offered screening
the involvement of the clinical coordinator in motivating, supervising and supporting the staff to conduct screening
the investment in training health care staff, which is regarded as an integral part of the PMHP stepped-care model.
Transferability of the model
The transferability of a model, and whether it can be taken to scale, requires consideration of its feasibility to deliver, and acceptability to those it aims to serve.
In this initial evaluation, the counselling intervention appears to be feasible and acceptable. This is a positive finding, especially as the number of sessions received by each woman counselled is relatively low (an average of 3 in this study). However, our findings corroborate other evidence which shows that even one or two individual counselling sessions are beneficial to women experiencing distress.
The way forward
In South Africa, the availability of resources and the quality of health care varies substantially from rural to urban areas. As all of the current PMHP sites are situated in urban areas, there is a need for the PMHP to establish a rural site in order to evaluate a model in settings where fewer resources and different challenges exist.
Although the combined use of the EPDS and RFA screening tools has proven to be workable in some settings, they remain cumbersome and time-consuming tools. A single and shorter screening tool may be more useful given the number of tasks that health workers are required to complete during routine antenatal care. The PMHP is currently developing and testing a shorter screening tool, designed to facilitate ease of use in busy settings with high patient volumes.
In the South African obstetric system, postnatal care is limited. The PMHP advocates for a comprehensive continuum of care for women during the perinatal period and provides its clients with the option to continue counselling postnatally, up to one-year after birth.
By operating in 4 diverse maternity settings in the Cape Town metropole, the Project has been able to test and extend its stepped-care model. This has been done with the generous support of the DG Murray Trust and in partnership with Hope House Counselling Centre .
The following have been key lessons learnt in the PMHP’s model development.
Maternity health workers may be trained to screen and refer for mental distress in low resource primary care settings.
Training programmes that address and support the mental health needs of health workers may help staff to manage their workload and prevent compassion fatigue and ‘burn out’.
On-site screening and counselling fosters the establishment of efficient referral mechanisms and access to mental health care often lacking in maternity settings in low and middle-income countries.
On-site, integrated mental health services increase access for women who have scarce resources and competing health, family and economic priorities.
Coordinating mental health visits with subsequent antenatal visits further facilitates access for women with insufficient resources.
Dedicated, supervised mental health counselling personnel are required to meet the mental health needs of mothers living in adversity.
Mental health counsellors require adequate training, supervision and support to manage the high case load generated in low resource settings.
The project provides a mental health service in a real-world obstetric setting where resources are limited and patient volumes are high. The PMHP model takes into account pragmatic issues such as the capacity development of general health workers to provide primary mental health care. Secondly, the PMHP model optimises access to care for vulnerable patients. These principles may inform the development of services in similar primary health settings.
The PMHP would like to acknowledge the support of the management at Mowbray Maternity Hospital, as well as the Provincial Department of Health, Western Cape. The PMHP is grateful for the crucial contributions of the nursing staff at Mowbray Maternity Hospital as well as the clients, counsellors and psychiatrists of the PMHP. Guidance and assistance from the Alan J Flisher Centre for Public Mental Health have been invaluable. We also gratefully acknowledge the generous support of the DG Murray Trust and our other donors. We are indebted to our implementing partner, the Hope House Counselling Centre, for their collaboration in developing and adapting new maternal mental health services at False Bay Hospital and Retreat Midwife Obstetric Unit.