Interventions for common perinatal mental disorders in women in low- and middle-income countries: a systematic review and meta-analysis
Atif Rahman a, Jane Fisher b, Peter Bower c, Stanley Luchters d, Thach Tran e, M Taghi Yasamy f, Shekhar Saxena f & Waquas Waheed c
a. Institute of Psychology, Health and Society, University of Liverpool, Alder Hey Children’s Hospital, Mulberry House, Eaton Road, Liverpool, L12 2AP, England.
b. Jean Hailes Research Unit, Monash University, Melbourne, Australia.
c. NIHR School for Primary Care Research, University of Manchester, Manchester, England.
d. Centre for International Health, Burnet Institute, Melbourne, Australia.
e. Research and Training Centre for Community Development, Hanoi, Viet Nam.
f. Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland.
Correspondence to Atif Rahman (e-mail: firstname.lastname@example.org).
(Submitted: 09 July 2012 – Revised version received: 26 March 2013 – Accepted: 28 April 2013 – Published online: 18 April 2013.)
Bulletin of the World Health Organization 2013;91:593-601I. doi: http://dx.doi.org/10.2471/BLT.12.109819 [PDF]
Perinatal mental health problems are common worldwide.1 In high-income countries, about 10% of pregnant women and 13% of women who have just given birth experience a mental disorder, primarily depression or anxiety.2,3 A recent systematic review showed higher rates of common perinatal mental disorders (CPMDs) among women from low- and lower-middle-income countries, where the weighted mean prevalence of these disorders was found to be 15.6% (95% confidence interval, CI: 15.4–15.9) in pregnant women and 19.8% (95% CI: 19.5–20.0) in women who had recently given birth.4 The review identified several risk factors for CPMDs among women: having a partner lacking in empathy or openly antagonistic; being a victim of gender-based violence; having belligerent in-laws; being socially disadvantaged; having no reproductive autonomy; having an unintended or unwanted pregnancy; having pregnancy-related illness or disability; receiving neither emotional nor practical support from one’s mother, and giving birth to a female infant.4 The day-to-day interactions between neonates and their primary caregivers influence neurological, cognitive, emotional and social development throughout childhood. Maternal mental health problems are not only detrimental to a woman’s health; they have also been linked to reduced sensitivity and responsiveness in caregiving and to higher rates of behavioural problems in young children. There is growing evidence that, in low- and middle-income (LAMI) countries, the negative effects of maternal mental disorders on the growth and development of infants and young children are independent of the influence of poverty, malnutrition and chronic social adversity.5,6 In low-income settings, maternal depression has been linked directly to low birth weight and undernutrition during the first year of life, as well as to higher rates of diarrhoeal diseases, incomplete immunization and poor cognitive development in young children.7–10
In some high-income countries, including England and Australia, the detection and treatment of CPMDs are prioritized.11 However, this is not so in most LAMI countries, where many other health problems compete for attention.4 Psycho-educational interventions that promote problem solving and a sense of personal agency and help to reframe unhelpful thinking patterns, including cognitive behaviour therapy and interpersonal therapy, have consistently proven effective in the management of CPMDs.12,13 Although few LAMI countries have sufficient mental health professionals to meet their populations’ mental health needs,14 several have tried to deliver acceptable, feasible and affordable interventions based on evidence generated locally.15 The aims of this study were to investigate systematically the evidence surrounding the impact of such interventions on women and their infants and on the mother–infant relationship, and to understand the feasibility of applying them in LAMI countries.
We conducted a systematic search, without language restrictions, of seven electronic bibliographic databases: MEDLINE, EMBASE, CINAHL, PsycINFO, the British Nursing Index, the Allied and Complementary Medicine database and the Cochrane Central Register. The search terms were: depression, maternal depression, perinatal depression, postnatal depression, postpartum depression, common mental disorders, mental health and postpartum psychosis. These terms were individually combined with the terms randomized controlled trial, controlled clinical trial, clinical trials, evaluation studies, cross over studies AND with the names of countries classified as LAMI countries by the World Bank.16 China is a middle-income country. Despite ambiguity in its economic status, we included Taiwan, China, in the middle-income category. We hand-searched the reference lists of all included articles. When necessary, we also approached experts to identify unpublished studies.
We included all controlled trials from LAMI countries, published up to May 2012,17 that involved structured mental health interventions targeting women during pregnancy and after childbirth, or that measured maternal mental health outcomes up to 36 months postpartum. Two reviewers scanned the abstracts of all identified sources to determine eligibility independently. Disagreements were resolved consensually. Using a standard form, we extracted information on the following for all eligible studies: study design, study setting, sample characteristics, recruitment strategies, measures of mental health, main outcomes of interest and follow-up intervals. We also summarized the details of each intervention, including its acceptability to patients and providers, if assessed.
We undertook a meta-analysis of selected outcomes. We translated continuous outcomes to a standardized effect size (mean of intervention group minus mean of control group, divided by the pooled standard deviation); we translated dichotomous outcomes to a standardized effect size using conventional procedures.18 To maximize consistency, we chose the outcomes reported in the review a priori according to an algorithm. Thus, in studies that had more than one follow-up assessment, we chose the outcome for the assessment closest to 6 months after the intervention. If both categorical and continuous data were reported, we used the continuous data for the meta-analysis. To adjust for the precision of cluster trials, we used the methods recommended by the Cochrane Collaboration19 and assumed an intra-class correlation of 0.02. We conducted meta-analysis using random effects modelling to assess the pooled effect of maternal mental health interventions. The I2 statistic was used to quantify heterogeneity.20 To assess possible publication bias, we conducted the Egger test and generated a funnel plot.
Studies were heterogeneous in terms of the setting, nature and content of the interventions, as well as outcomes and outcome measures, so we also undertook a realist review using Pawson et al.’s method.21 With this method, similarities and differences between studies are considered on the basis of study design, methodological quality, intervention characteristics and delivery, presumed mode of action, fidelity of implementation, acceptability to participants, recognition of the sociocultural context and appropriateness of the outcome measures for the particular setting.
Of the 52 records we retrieved, we retained 15 after screening. We excluded one study because it lacked a comparison group. The 13 eligible trials, described in 13 papers and a thesis, represented 20 092 participants. Their findings were used for the meta-analysis (Fig. 1).22–35 China contributed three trials; India, Pakistan and South Africa contributed two trials each, and Chile, Jamaica, Mexico and Uganda contributed one each. Twelve studies were controlled and randomized either at the individual or the cluster level and one study28 used a historical matched control from another epidemiological study. The main outcomes assessed were maternal mental health, the mother–infant relationship, and infant or child cognitive development and health.
Fig. 1. Flowchart showing selection of studies on interventions for common perinatal mental disorders among women in low- and middle-income countries
Study characteristics and quality
In the trials, outcomes were assessed at one or more points from 3 weeks to 3 years after childbirth. The following self-reported symptom checklists were used in the different studies to assess maternal depression: the World Health Organization’s 20-item Self-reporting Questionnaire (SRQ-20),36 the Edinburgh Postnatal Depression Scale (EPDS),37 the 12-item General Health Questionnaire (GHQ-12),38 the nine-item Patient Health Questionnaire (PHQ-9),39 the Centre for Epidemiologic Studies Depression Scale (CES-D),40 the interviewer-administered Structured Clinical Interview for DSM-IV Axis 1 Disorders (SCID-I),41 the Mini International Neuropsychiatric Interview (MINI),42 the Hamilton Depression Rating Scale (HDRS),43 the Revised Clinical Interview Schedule (CIS-R),44 the 10-item Kessler Psychological Distress Scale (K10),45 the Short Form (36) Health Survey (SF-36),46 the Symptom Checklist-90-R (SCL-90-R)47 and the Beck Depression Inventory–II (BDI-II).48 In nine studies, the self-report measure was supplemented by a psychiatric interview (Table 1, available at: http://www.who.int/bulletin/volumes/91/8/12-109819).
Table 1. Design, methods and main findings of 13 trials of interventions for common perinatal mental disorders in women in low- and middle-income countries
The interventions varied in content and structure, mode of implementation and method of assessing acceptability to providers and participants (Table 2, available at: http://www.who.int/bulletin/volumes/91/8/12-109819). Four studies addressed maternal depression directly. Rahman et al.’s25 multimodal approach in the Thinking Healthy Programme (THP) included specific cognitive behaviour therapy methods to identify and modify maladaptive thinking styles – e.g. fatalism, inability to act, superstitious explanations and somatization – and replace them with more adaptive ways of thinking.49 It aimed to improve women’s social status by using the family’s shared commitment to the infant’s well-being as an entry point. Mao et al.32 also used a culturally adapted approach based on cognitive behaviour therapy to teach emotional self-management, including problem-solving and cognitive re-framing, in a facilitated group programme. Rojas et al.23 sought to maximize the uptake of antidepressant pharmacotherapy and treatment compliance. Their intervention also involved professionally-led, structured psycho-educational groups that focused on symptom recognition and management, including problem-solving and behavioural strategies. Hughes et al.27 focused on a specific social determinant that had been identified in their study site, namely, the “male child fixation” in pregnant women whose older children were all female.50 This problem was addressed through specific education about sex determination and strategies to empower women to challenge ill-informed reactions devaluing the birth of a female child.
Table 2. Nature of interventions for common perinatal mental disorders in low- and middle-income countries and acceptability to consumers and providers
Two studies in China29,33 and one in Mexico31 addressed adjustment to motherhood through programmes integrated into existing hospital-based antenatal education or postpartum health care. These studies also took a psycho-educational approach, with structured content provided in a psychologically supportive context. Gao et al.’s programme29 was derived from interpersonal therapy and used learning activities and the social support of a group process to promote a problem-solving approach, including ways to manage interpersonal conflict in intimate relationships. Ho et al.33 and Lara et al.31 provided information about the symptoms and causes of postpartum depression in an information booklet and supplemented this with either supportive discussion with a primary care nurse to encourage early help-seeking behaviour,33 or participation in a series of group discussions facilitated by professionals.31
Five studies22,24,26,28,35 did not address maternal mental health directly. However, the researchers hypothesized that individual parenting education provided by a supportive home visitor or within the context of a mother’s group might also improve maternal depression and improve infant health and development. In South Africa, Cooper et al.26,28 demonstrated what neonates could do using a neonatal assessment scale. In a study conducted by Baker-Henningham et al.22 in Jamaica and in the adapted Learning Through Play (LTP) programmes implemented in Pakistan24 and northern Uganda,35 mothers were shown age-appropriate play activities and how to craft toys out of affordable, accessible materials to stimulate infant cognitive development. In broad terms, the theoretical rationale underpinning these approaches was that optimal child development requires maternal caregiving that attends explicitly to development in the physical, social, emotional and cognitive domains. The interventions carried out in these five studies aimed to enhance mothers’ knowledge about normal child development, improve maternal sensitivity and responsiveness towards infants and, through group programmes,24,35 reduce social isolation and improve maternal mood by means of peer support.
Tripathy et al.’s intervention34 also addressed maternal depression indirectly. It focused on educating mothers about pregnancy, birth, neonatal health and health-care seeking through locally designed illustrative case studies and stories. With the help of a trained local woman, community participatory action groups devised local interventions designed to reduce maternal and neonatal morbidity, with potential flow-on benefits for maternal mental health.
All studies except those from China and Mexico were conducted with participants of low socioeconomic status who experienced difficulties that could have contributed to their mental health problems. In these studies, the social determinants of perinatal depression in women were either reported as relevant by participants or explicitly recognized on a theoretical level.24–28,35 Such determinants include, for example, living in poor and overcrowded housing, suffering social exclusion as a result of illiteracy and unemployment, being a victim of the gender stereotypes that restrict women’s social participation or underpin hostility towards women, and experiencing social instability and neighbourhood violence.22 No study addressed these determinants directly.
All the studies drew on evidence generated in high-income countries. However, authors acknowledged that such evidence could not be transferred directly to resource-constrained settings and that, before being adopted, the interventions had to be supported by local evidence about effectiveness, affordability, acceptability and cultural appropriateness. The study interventions were all assessed in settings with very few specialists in mental health. Chile, China and Mexico were the only countries where the interventions were implemented by mental health professionals.23,29,31,33 In all other studies they were implemented by local trained community health workers under professional supervision. In seven interventions involving individual home visits,22,24–28,35 the therapeutic relationship between the health worker and the study participant was regarded as an important determinant of improvements in mental health. In this relationship, trust was of utmost importance. Equally important was the selection of local health workers who understood their clients’ sociocultural circumstances and who possessed basic psychological counselling skills, including knowing how to listen and to be non-judgmental, empathic and supportive. In settings where many women lived in multigenerational households, members of the extended family were engaged during home visits to reduce women’s reticence and encourage long-term behaviour change.22,24
Effects on maternal mental health
Psychiatric labels and the conceptualization of illness differed widely among studies. In Rojas et al.’s intervention,23 participants were assessed for depression and received education about symptom recognition and the importance of compliance with psychotropic medication. Some interventions were applied to women in the general community;22,24,29,34,35 others were applied only to women who were attending programmes not specifically dealing with mental health.29,33 In these interventions, mental health was assessed by means of symptom checklists rather than diagnoses or psychiatric assessment. Although all participants in the THP met the diagnostic criteria for depression, the intervention was positioned as a maternal and child health promotion strategy in which the use of psychopathological labelling was likely to have increased stigma and reduced compliance.25
All 13 studies reported outcome data on maternal depression that was sufficiently detailed to be included in a meta-analysis. The resulting pooled effect size was −0.38 (95% CI: –0.56 to −0.21; I2 = 79.9%) (Fig. 2). The funnel plots were symmetrical (Fig. 3). Egger test statistics confirmed the lack of asymmetry indicative of publication bias (P = 0.97).
Fig. 2. Forest plot presenting the standardized effect size (and 95% confidence intervals, CI) for 13 interventions for common perinatal mental disorders among women in low- and middle-income countries
Fig. 3. Funnel plot showing the standardized effect sizea and pseudo 95% confidence limits for 13 interventions for common perinatal mental disorders among women in low- and middle-income countries
Two trials assessed secondary maternal psychological outcomes. Rojas et al.23 reported that women who received multi-component group therapy were more compliant with their antidepressant drug schedules, attended primary care more frequently and had better functioning, as measured by the SF-36, than those in the usual care group. Women in the THP intervention clusters in Pakistan25 had less disability, better overall functioning and greater perceived social support at their two follow-up assessments than women in the control group.
Child health and development
Direct, between-study comparisons of the effects of the various interventions on infant health and development are limited by differences in design, intervention content, the age at which outcomes were measured and the parameters that were assessed. Six of the 13 interventions22,24,25,27,28,34 aimed specifically to enhance infant health and development either by improving maternal knowledge, sensitivity, responsiveness or caregiving skills, or, less directly, by improving maternal mood (Table 2).
In three studies that focused specifically on child health and development, information on the benefits of age-appropriate activities for stimulating cognitive capacity and of structured parent–infant play was provided during home visits by community health workers.22,24,35 Women who participated in the LTP programme in Pakistan showed significantly better knowledge about their infants’ needs and development than those who had received standard care.24 Even under crisis conditions in Uganda, there was a notable improvement in mothers’ use of play materials to stimulate their infants in the Acholi adaptation of the LTP programme.35 In a Jamaican programme, mothers were shown how to engage their infants’ interest with affordable toys, picture books and household materials,22 and the results showed a negative association between the development quotient in boys – not girls – and the number of depressive symptoms found in the mother. None of these studies reported specifically on child health or physical development.
In an intervention conducted by Hughes,27 anganwadi workers explained to mothers, using dolls, how massaging their infants could improve child development. No differences were noted in child health and development outcomes, but average weight was significantly lower in infants whose mothers were at high risk of becoming depressed. The THP study aimed to improve child health by reducing maternal depression. Although infant stunting and low weight were not improved, infants experienced fewer episodes of diarrhoea and rates of completion of the recommended immunization schedule improved.25
The mother–infant relationship
Six interventions sought to improve the relationship between mother and infant as a primary26,28,35 or subsidiary22,25 goal (Table 1). The pooled effect size of the corresponding interventions was 0.36 (95% CI: 0.22–0.51).
In Cooper et al.’s studies,26,28 which focused on the mother–infant relationship, behavioural assessment items were used to show mothers what their infants could do (e.g. tracking objects with their eyes or imitating others’ facial expressions) and the reciprocal influence of the infant–child interaction. In one of the two studies, mothers were given direct, tailored advice about how to recognize and respond to normal infant needs in a manner intended to make the mother–infant interaction more gratifying and to enhance maternal competence and self-confidence.28 The pilot intervention led to improved infant weight and length.28 Cooper et al.’s studies were the only ones that assessed the quality of the mother–infant relationship through independent scoring of videotaped interactions. Mothers’ sensitivity and expressions of affection towards their infants improved, and, in one trial, rates of secure infant–mother attachment increased.26
The interventions conducted by Baker-Henningham et al.22 were manifold. They included demonstrations of activities for stimulating infants’ cognitive development; praise for mothers who showed sensitivity and imagination in their interactions with their infants, and facilitator-initiated discussions about infant nutrition. A less direct but explicit approach was used in two Pakistani studies that focused specifically on the mother–infant relationship. In these studies,25 the THP sought to help mothers become more aware of their infants’ needs and replace “unhealthy” thoughts about their infants with more productive thinking based on improved knowledge. In LTP programmes in Pakistan and Northern Uganda, as a way to stimulate discussion mothers were shown educational images illustrating activities that they could engage in with their infants.24,35
In the two Pakistani studies, the interventions’ beneficial effect on maternal depression and on the mother–infant relationship was assumed to be attributable to a common pathway: that improving maternal knowledge, caregiving skills, sensitivity and responsiveness towards infants enhances the mother–infant interaction and maternal self-efficacy and satisfaction. Mood lifting effects were demonstrated to some degree. Morris et al.35 found no improvement in maternal sadness or irritability when they controlled for the effects of interview site and baseline scores, but Baker-Henningham et al.22 and Rahman et al.25 did note improvements in maternal depression. In Rahman et al.’s study, knowledge about infant care improved not just among mothers, but also among fathers; as a result of the THP, both parents became more playful with their infants, with potential flow-on benefits in terms of the parent–infant relationship and the infants’ cognitive, social and emotional development.25 Overall the interventions had significant positive effects on growth, development and rates of infectious diseases among infants, and they resulted in lower neonatal mortality (Table 3).
Table 3. Outcomes of interest, effect measures and effect sizes from studies of interventions for common perinatal mental disorders among women in low- and middle-income countries
This is the first systematic review of the evidence surrounding interventions for the relief of CPMDs. Its findings show that such interventions can be effectively implemented in LAMI countries by trained and supervised health workers in primary care and community settings. The results are concordant with the findings of meta-analyses of psychological and psychosocial intervention studies for perinatal depression from high-income countries, which report a summary relative risk of 0.70 (95% CI: 0.60–0.81) for women in the intervention arm versus controls receiving standard care.13
There was substantial heterogeneity in estimated treatment effects, but the small number of studies precludes a meaningful assessment of the reasons for the variation. The psychotherapeutic content of the interventions, the number of therapy sessions, and staff training and supervision practices may have differed across studies. This is true of the THP in Pakistan25 and of the anganwadi intervention in India conducted by Hughes et al.,27 which had the largest and the smallest impact, respectively. The THP in Pakistan was based on cognitive behaviour therapy combined with active listening, measures for strengthening the mother–infant relationship and mobilization of family support. The anganwadi intervention, on the other hand, was based on a more general supportive psycho-educational approach. The interventions also differed in intensity: 1625 sessions as opposed to 5, respectively.27 Although the THP had a shorter training period (3 days compared with 1 month for the anganwadi workers), the Lady Health Workers in Pakistan had monthly half-day supervision throughout the intervention. This suggests that continuous supervision is more effective than one-off training.
Our findings suggest that the relationship between maternal mood and infant health and development is not unidirectional. Interventions in which mothers are taught about infant development and are shown how to engage and stimulate their infants and to be more responsive and affectionate towards them appear to improve maternal mood, in addition to strengthening the mother–infant relationship and leading to better infant health and development outcomes. Similarly, interventions expressly designed to improve maternal mental health have a positive impact on infant health and development. An intervention’s effect on infant health and development appears to be stronger when the maternal and infant components are integrated and infant health is a direct, rather than an incidental focus of the intervention.
Collectively, the studies in this review provide important lessons in terms of service development. First, approaches that are culturally adapted and grounded in cognitive, problem-solving and educational techniques can be applied effectively to groups or individuals. Most of the interventions described in the studies targeted mothers and infants and were conducted in women’s homes. In settings where women live in multigenerational households, this approach makes it possible to engage the whole family in the common pursuit of caring for the new infant. In all the studies, except for Lara et al.’s in Mexico, the interventions were delivered by supervised, non-specialist health and community workers without any training in mental health care. Thus, the studies provide evidence of the feasibility of training such workers to deliver mental health interventions effectively in a relatively short time. For low-income countries, where mental health professionals are scarce and tend to concentrate in big cities, this has important implications.51,52
A second lesson learnt is that the psychological and educational components of the interventions must be adapted to the circumstances in which women in LAMI countries live. In places where women live in densely populated communities and crowded households, involving the entire family and community in their care tends to be more beneficial than an individualistic approach. Interventions that engage the family can mitigate some important risk factors for depression in women: a poor sense of personal agency, pejorative and limiting gender stereotypes, lack of financial autonomy and intimate partner coercion and violence.
Common perinatal mental disorders are difficult to recognize. Furthermore, the fear of stigma can make women and their families reluctant to seek care. In the studies included in this review, health workers integrated the mental health interventions into their regular work activities, which may prove less stigmatizing to women. Maternal mental health and infant development interventions appear to act synergistically and the perinatal period provides an opportunity to deliver them in an integrated fashion. These data indicate that community-based approaches are beneficial and might be preferable to stand-alone vertical programmes. They may also be relevant to high-income countries, where providing equitable mental health services is becoming increasingly costly.15
No interventions targeting the more severe perinatal mental disorders, such as postpartum psychosis or suicidal behaviour, were found in this review. Future studies should address this gap. Nevertheless, our meta-analysis provides grounds for believing that the large global burden of CPMDs, particularly perinatal depression in women, can be addressed in resource-constrained settings through appropriate interventions. District-level primary care programmes providing integrated training and supervision and outcomes assessed in the general community are required to inform strategies for taking such interventions to scale.
We thank the authors of trials who provided additional information for our review and meta-analysis.
The study was sponsored by the Department of Mental Health and Substance Abuse of the World Health Organization, the United Nations Population Fund (UNFPA) and Compass, the Women’s and Children’s Health Knowledge Hub funded by the Australian Agency for International Development (AusAID) and the Victorian Operational Infrastructure Support Programme. The views expressed in this article do not necessarily represent the decisions, policy or views of WHO, the UNPFA or AusAID. The authors had full control over the analysis and reporting of the results.
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