Engaging traditional birth attendants to reduce maternal depression

Christine Musyimi is a Grand Challenges Africa (GC Africa) grantee based in Kenya. GC Africa is an African Academy of Sciences (AAS) Programme that seeks to promote Africa-led scientific innovations to help countries better achieve the Sustainable Development Goals by awarding seed and full grants to the continent’s most impressive solutions.

GC Africa is implemented through AESA (Alliance for Accelerating Excellence in Science in Africa), a funding, agenda setting and programme management platform of the AAS in partnership with the African Union Development Agency (AUDA-NEPAD). GC Africa is supported by the Bill & Melinda Gates Foundation.

Background

Christine’s study measures the effectiveness of training Traditional Birth attendants (TBAs) in the adoption of mental health Global Action Programme Intervention Guidelines (mhGAP-IG) to identify signs of depression and provide psychosocial interventions to expectant mothers with depression. mhGAP-IG provides a step by step assessment, decision-making and management of priority mental health conditions for use by non-mental health specialists with support and supervision from specialists. It also provides special considerations and discussion plans for vulnerable populations such as expectant women. The goal is to improve the mental wellbeing of mothers and children.

There is an increase in the number of people with mental health problems in Africa and this unfortunately occurs on a backdrop of insufficient human resources to detect them. Most African governments have deployed psychiatrists to rural settings, but such visits are typically short-term, with practitioners moving onto private practice after about a month.

In Kenya, for example, several counties with a population of nearly a million have no psychiatrist and fewer than ten psychiatric nurses. In Africa, with a dearth of mental health professionals, TBAs could be used to provide psychosocial interventions to expectant mothers, make referrals to health facilities for complicated cases of depression and provide regular follow-up for these patients, since practitioners and patients reside in the same communities. This would promote a sense of belonging and ensure accessible and acceptable basic mental health care in under-resourced areas while linking these mothers to primary care, increasing the number of safe deliveries and promoting maternal and child mental well-being and quality of life.

Description of study

Researchers led by Dr Christine Musyimi from the Africa Mental Health Research and Training Foundation engaged 20 TBAs to screen a total of 1,711 pregnant mothers in Makueni County, Kenya, for a period of one year (mean maternal age 26 years and range 12- 46 years; 45% were 10-24 years) using the Edinburgh Postnatal Depression Scale (EPDS), a screening tool that warrants referral if a mother scores at least 11 points. Community Health Workers (CHWs) were also trained to confirm diagnosis of the referred cases (EPDS score of 11) using the Mini-International Neuropsychiatric Interview (MINI). The MINI is a structured diagnostic interview tool for priority mental health conditions including depression and requires only “yes” and “no” answers. A total of 470 mothers (27%) were confirmed to have mild to moderate depression; 73% experienced some form of Intimate Partner Violence (IPV) (controlling (58%), emotional abuse (49%), physical abuse (25%) and sexual abuse (18%)), with 50% experiencing at least two forms of IPV. A total of 281 women subsequently received psychosocial interventions for depression adapted from the mhGAP-IG while the rest received standard care by TBAs (who had not received training on mhGAP-IG) and were referred to the local health facility for antenatal care and delivery.

Outcome of the study

Qualitative assessment of community perspectives regarding integration of TBAs into mental health care revealed receptivity to their involvement, indicating a need for their roles to be clearly defined and for TBAs to be trained on evidence-based mental health care to improve the mental wellbeing of mothers and children[1].

Mothers who received psychosocial intervention from TBAs experienced a reduction of depression symptoms, with significantly improved quality of life at 3 and 6 months compared to those who were only referred to a health facility.

 “Let’s reduce depression among pregnant women” [Translation from the Kamba language]

It is important to note that IPV is also common among adolescents. A senior TBA stated, “Young boys are taking drugs and abusing their wives [shaking her head with frustration]. The women get stressed and have no peace. This predisposes them to mental illness such as depression and suicidal thoughts.”

The ENGAGE-TBA study is the first one in Africa or globally to provide evidence that TBA training in maternal mental health care is worthy of support due to the promising results and the active engagement of these providers by pregnant women in communities. In most countries, symptoms that can be related to mental illness (e.g. depression), such as fatigue and sleep problems, are assumed to be normal during motherhood. This inevitably leads to missed diagnosis, lack of improvement after visiting a health facility and even the attribution of symptoms to witchcraft. The deployment of mental health evidence-based practices among TBAs who have no basic training but play roles that are comparable to Community Health Workers (CHWs) could be a mechanism to reduce the high rate of maternal mortality from suicide. Stakeholders including local policy makers, women, community members and formal health workers must coordinate to define an expanded role for TBAs so that they are not in conflict with other providers. In some countries, TBAs are the first point of contact during pregnancy because of their accessibility and good rapport with women. TBAs can become a critical resource to promote safe mental health in childbirth and child development.

Impact

A greater impact on mental health treatment can be achieved by training lay community workers such as TBAs to timely detect and manage acute mental illnesses. This is an opportunity to reduce the high numbers of people with severe mental illnesses in rehabilitation centres or referral mental health hospitals. It is a good idea to train more psychiatrists in Africa but unless they become evenly distributed or motivated to work in rural communities, there could be delays in significantly reducing the mental health treatment gap in the near future. It is also important to target mental disorders in pregnancy to reduce mortality rates related to depression and other mental illnesses and improve the health of the mother and the baby.

Lessons

Use of evidence-based training of lay workers to identify and manage mental health conditions in pregnant women could reduce the mental health treatment gap in low-resource settings, as it has proven to be feasible and effective for this purpose. Other countries can adopt this strategy to improve the wellbeing of women during pregnancy and after delivery, which could make a contribution to reduction of pregnancy-related suicide. Each country could develop a collaborative strategy among TBAs, other health care workers and citizens based on coordination and trust among stakeholders.