Babies and mothers in the Western Cape of South Africa now have a brighter future, thanks to a provincial government’s decision in September 2018 to start screening the mental health of pregnant women and new mothers during routine checkups.
Maternal depression and anxiety are estimated to affect roughly one-third of women in South Africa before or after the birth of a child. Routine mental health screening, integrated to primary care, will allow common conditions like these to be picked up and treated early, with benefits for both infants and mothers.
The screening tool used in the initiative was developed by the Perinatal Mental Health Project (PMHP), led by Dr Simone Honikman, based on research conducted at a midwife obstetric unit in Cape Town.
A nonprofit entity based at the Department of Psychiatry and Mental Health of the University of Cape Town, the PMHP was launched in 2002 and has been providing counselling services ever since, ensuring screening and support for pregnant women in low income areas dealing with psychological distress.
“Our screening tool picks up depression and anxiety, and now it is part of the maternal case record. It is brief and simple to use,” Honikman said, describing its adoption by the Western Cape as a victory for mothers and babies.
The tool consists of a standardised questionnaire, developed by the PMHP team and administered by nurses, midwives or counsellors at the first antenatal visit. The questionnaire is available in the four languages spoken by most of the project’s beneficiaries — English, Afrikaans, isiXhosa and French.
Infant and child psychiatrist Dr Anusha Lachman, from Stellenbosch University, said the decision to adopt this screening tool was long overdue. “I hope it will be rolled out to the rest of the country,” she added. ”Maternal depression in Africa is about three times higher than the international average, which is around 10 percent of pregnant women. The reasons for the high prevalence are clear: people’s socio-economic situations, high levels of intimate violence and substance abuse, and not being able to access support,” said Lachman.
Support for women’s mental health before and after birth is particularly lacking in underprivileged communities. The PMHP is run by a professional counsellor working at the maternity unit of the Hanover Park Community Health Centre, in Cape Town — an area notorious for gang violence. “We see patients whose partners have been killed in gang shootings, who have recently been diagnosed with HIV, who are unemployed, who deal with substance abuse and domestic violence at home, and teenagers whose parents have kicked them out,” said PMHP counsellor Liesl Hermanus.
Sharmaine Miller, a government health promotion officer who has worked at the maternity unit for 29 years, has taken on the mental health screenings and Hermanus does the counselling. They have developed a positive relationship with the nursing staff. “They have really embraced what we do and tell us when they identify vulnerable patients, like a mum who is very tearful in the labour ward,” said Miller.
Hermanus has worked at the midwife obstetric unit for the last eight years. She usually sees patients in her office, where her energy, organisation and a basket of toys make women feel they are in safe hands. “I do lots of listening and psycho-education about bonding, explaining the importance of touch and talking to babies. Later on in a pregnancy, I see patients start feeling better and getting excited about their baby,” she said.
Since its creation, the PMHP has screened more than 37,000 women, and counselled nearly 7,000 mothers in distress. Miller screens up to 15 pregnant women and new mothers on a daily basis, and teaches them skills such as breastfeeding. Practical advice, like how to apply for a child support grant, is also provided to parents, some of whom do not have enough money for the next meal, let alone nappies.
One of the women helped by the PMHP said she felt so desperate she thought of taking her own life, until her counsellor made her feel safe. “I feel better when I talk to her; she’s always active, taking the positive side,” she said during a consultation. Then she addressed her counsellor directly: “I’m here now, I’m fine, because I know I have you on my side. I’m very proud to be a mum.”
The project also trains nurses and health care professionals from across Africa to respect and care for women before and after childbirth. One of its programmes, for instance, teaches patients and health workers to step into one another’s shoes through role play. Honikman said that it helped increase empathy and respect between the maternity staff and their patients, which is crucial to screening.
Cassey Chambers, operations manager for the NGO South African Depression and Anxiety Group, said it was common to get calls from mothers who were overwhelmed months after their babies were born. “They are feeling stressed, depressed and anxious. Many feel like they don’t have any support but are too afraid to speak to anyone in case others think they are bad mums or that something is wrong with them,” she said.
“Everyone assumes that having a baby is the best thing ever, but no one addresses the issue that it is also the most stressful, loneliest and scariest time,” she added, noting that postnatal depression was a serious condition and that new mothers should be encouraged to seek support and treatment.