Integration of Maternal Depression Screening and Treatment into Maternal Health Programs in Uganda – Policy Brief

Summary

Maternal depression is a debilitating disorder that impairs women’s ability to care for themselves during pregnancy and their newborns after delivery often resulting in adverse birth outcomes including low birth weight, preterm birth and maybe a precursor to chronic depression. In Uganda, up to 16% of women have maternal depression. Acknowledging the burden of maternal depression and incorporating its screening and treatment into maternal programs is key to maintaining the momentum gained in improving maternal and child health indicators in Uganda.

Introduction

Pregnancy is a life altering event that results in marked hormonal, psychological and physiological changes(Bennett, Einarson et al. 2004). The changes during pregnancy coupled with other risk factors such as intimate partner violence experience, unintentional pregnancy, lack of social support can trigger depression with adverse effects on the mother and child (Stewart, Robertson et al. 2003, Nakku, Nakasi et al. 2006, Gelaye, Rondon et al. 2016).

Maternal depression commonly complicates pregnancy and may occur in the antepartum or postpartum period(O’hara and McCabe 2013). Antepartum depression (APD) refers to a major depressive episode during pregnancy. (Gelaye, Rondon et al. 2016). Postpartum depression (PPD) refers to psychiatric disturbances that occur among women of reproductive age following childbirth and typically arise within four weeks up to a year after delivery.

Depression during pregnancy may result in risky health affecting behavior including substance abuse, poor clinic attendance all of which are detrimental to the mother and unborn baby (Gelaye, Rondon et al. 2016). Maternal depression disproportionately affects women in low-income countries and low-income settings with about one in every five women affected (Gelaye, Rondon et al. 2016).

In Uganda, studies among women in rural areas revealed prevalence of maternal depression ranging from 10-16% (Assael, Namboze et al. 1972, Cox 1983) while the prevalence among women in urban areas is lower at 6%(Nakku, Nakasi et al. 2006). Further- more, risk factors of maternal depression identified in our setting include current physical illness, young age, unwanted sex of the baby, unplanned pregnancy, baby physical problems and negative life events (Nakku, Nakasi et al. 2006).

Currently Uganda’s total fertility rate (TFR) stands at 6.2 children per woman (UBOS 2012.), which means pregnancy episodes per woman is quite high. The fertility rate among 15-19year old Ugandans is 134 per 1000. It is worth emphasizing that young age is a significant risk factor for PPD given our teenage fertility rates.

In addition, for every Ugandan woman who is lost due to pregnancy or birth complications; up to 30 more retain disabilities chief among which is depression (Nakigudde, Ehnvall et al. 2013). To compound this dire situation, culturally in Uganda, it is believed that ancestral spirits cause mental illness which can only be treated by traditional healers (Nakigudde, Ehnvall et al. 2013).

Context and Importance of the Problem

The Ministry of health through concerted efforts has made great strides in improving maternal and child health indicators by concentrating on obstetric complications. However, the enormous burden posed by maternal depression is largely unrecognized and under-treated. Effective treatment for depression exists; it includes psychosocial support, counselling and medication.

Uganda has a well-established mental health program, but there has been little integration of mental health into maternal programs. Because of the big burden of maternal depression in the country, there is need to incorporate mental screening and treatment into maternal programs.

Critique of Policy Options

Currently the national health policy prioritizes maternal health through its mandate of safe motherhood as one of the key elements of the minimum health care package with the aim of reducing maternal morbidity and mortality (Ssengooba, Neema et al. 2003). In addition, the Ministry of Health has initiated maternal health audits among all public health facilities country wide providing maternal health services in order to highlight avoidable factors pertaining to maternal mortality (Ssengooba, Neema et al. 2003).

Nevertheless, health care providers do not routinely screen for maternal depression. Managing maternal depression in mental health facilities would be stigmatizing and discourage women from seeking skilled maternal health care services. However, if integrated into existing maternal health programs would not be more appealing to mothers but significantly contribute to improvement of maternal and child health.

Recommendations

There is need to acknowledge maternal depression as a priority in order to maintain the momentum gained in improving maternal and child health indicators in Uganda. Policy makers can mandate improvement in detection and treatment of maternal depression by:

• Integration of mental health services into existing antenatal and post-natal care programs
• Developing standardized protocols that are cross-culturally acceptable for detection of maternal mental health disorders during antenatal and post-natal health facility
• Providing guidelines for provision of appropriate treatment for maternal mental health disorders to health workers
• Producing education materials for health workers and the general public on maternal mental health