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Perinatal mental health care differs around the world. We provide a global perspective on the current status of service provision, barriers and facilitators to access, and strategies to improve access in high-income and low- and middle-income countries across five continents (Asia, Africa, Europe, North America and South America). Many of the countries considered do not have universal healthcare coverage. This poses a challenge to perinatal mental health care access. However, there are other social and structural barriers to access, including stigma and other sources of marginalization and discrimination. Yet there are opportunities discussed herein to learn more about what perinatal mental health services work for what populations* and in what circumstances, by adopting a global lens to examine innovative solutions utilized across geographical settings., Competing Interests: Disclosures NB has received salary and/or funding support from Massachusetts Department of Mental Health via the Massachusetts Child Psychiatry Access Program for Moms (MCPAP for Moms). She is also the Medical Director of Research and Evaluation for MCPAP for Moms and the Executive Director of the Lifeline for Families Center at UMass Chan Medical School. She has served as a consultant for The Kinetix Group, VentureWell, and JBS International. SKS received speaker`s and author's honoraria from Takeda, Medice and Janssen. No other conflicts of interest to disclose by authors., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Pregnant and postnatal adolescent women are a high-risk group for common mental disorders (CMDs); however, they have low levels of engagement and retention with mental health services. Negative consequences of CMDs have been documented for both mother and child., Aim: The study aimed to explore the barriers and facilitators to service access for adolescents in low-resource settings., Setting: We interviewed 12 adolescents, aged 15-19 years, from low-resource settings in Cape Town, South Africa. Participants had previously engaged with a mental health service, integrated into maternity care., Methods: Twelve semi-structured, individual interviews were used for this qualitative study. Interviews were recorded, transcribed and coded. A framework analysis was employed for data analysis., Results: Adolescents perceived considerable stigma around both teenage pregnancy and mental illness, which inhibited use of mental health services. Other barriers included fearing a lack of confidentiality as well as logistical and environmental obstacles. Service uptake was facilitated by support from other adults and flexible appointment times. Face-to-face individual counselling was their preferred format for a mental health intervention., Conclusion: Several key components for adolescent-friendly mental health services emerged from our findings: integrate routine mental health screening into existing obstetric services to de-stigmatise mental health problems and optimise screening coverage; coordinate obstetric and counselling appointment times to rationalise the use of limited resources; and sensitise care providers to the needs of adolescents to reduce stigma around adolescent sexual activity and mental illness. A non-judgemental, caring and confidential relationship between counsellors and clients is crucial for successful interactions.

South Africa, like many low-and-middle-income countries, is integrating mental health services into routine Primary Health Care (PHC) through a task-shifting approach to reduce the gaps in treatment coverage. There is concern, however, that this approach will exacerbate nurses' abuse of patients currently common within PHC in the country. To address this concern, the Perinatal Mental Health Project developed its Secret History method, a critical pedagogical intervention for care-providers working within maternity settings. This article describes the method's theoretical underpinnings and practical application amongst nurses. Drawing on Augusto Boal's Theatre of the Oppressed and contrary to traditional nursing training in South Africa, the method creates a space for nurses to interrogate and reimagine nurse-patient relations. By introducing nurses to a counter ideology of empathic care, the method seeks to prepare the maternity environment for mental health task-shifting initiatives and ensure these initiatives are more democratic, responsive and humane.

Background:  Changing global health and development trends have resulted in a need for continued professional development (CPD) within the health and development sectors. In low-resource settings, where the need for training and CPD may be highest, there are significant challenges for disseminating information and skills. There is a need to improve mental health literacy and reduce levels of stigma about maternal mental illness. The Bettercare series of distance learning books provides a peer-based format for CPD. We aimed to evaluate the Bettercare Maternal Mental Health book as a format for CPD., Aim:  The aim of this study was to determine whether the Bettercare Maternal Mental Health book significantly improves knowledge and decreases stigma around mental health for care providers from the health and social development sectors., Setting:  One hundred and forty-one participants (social workers, nursing students and health professionals) were provided with the Bettercare Maternal Mental Health book to study., Methods:  Before and after studying the book, the same multiple-choice knowledge test and the Mental Illness Clinicians' Attitude Scale were used to assess cognitive knowledge and mental health stigma, respectively., Results:  Participants' knowledge showed a statistically significant (p < 0.001) improvement between the pre- and post-test results, for all six chapters of the book. However, participants' attitudes towards mental illness did not show a statistically significant change between the pre- and post-test results., Conclusion:  We found that this method of learning elicited significant improvement in mental health knowledge for care providers. Continued professional development policy planners and curriculum developers may be interested in these findings.

Background: Perinatal mental illness is a common and important public health problem, especially in low and middle-income countries (LMICs). This study aims to explore the barriers and facilitators, as well as perceptions about the feasibility and acceptability of plans to deliver perinatal mental health care in primary care settings in a low income, rural district in Uganda., Methods: Six focus group discussions comprising separate groups of pregnant and postpartum women and village health teams as well as eight key informant interviews were conducted in the local language using a topic guide. Transcribed data were translated into English, analyzed, and coded. Key themes were identified using a thematic analysis approach., Results: Participants perceived that there was an important unmet need for perinatal mental health care in the district. There was evidence of significant gaps in knowledge about mental health problems as well as negative attitudes amongst mothers and health care providers towards sufferers. Poverty and inability to afford transport to services, poor partner support and stigma were thought to add to the difficulties of perinatal women accessing care. There was an awareness of the need for interventions to respond to this neglected public health problem and a willingness of both community- and facility-based health care providers to provide care for mothers with mental health problems if equipped to do so by adequate training., Conclusion: This study highlights the acceptability and relevance of perinatal mental health care in a rural, low-income country community. It also underscores some of the key barriers and potential facilitators to delivery of such care in primary care settings. The results of this study have implications for mental health service planning and development for perinatal populations in Uganda and will be useful in informing the development of integrated maternal mental health care in this rural district and in similar settings in other low and middle income countries.

The prevalence of perinatal common mental disorders in South Africa is high, yet little is known about mental health service use among pregnant and postnatal women. This paper reports on pregnant women's patterns of use of a counselling service at a primary level obstetric facility in Cape Town, South Africa, between January 2010 and December 2011. It investigates whether these are associated with demographics, severity and risk of depressive symptoms. Participants (N = 3311) were screened for psychological distress using the Edinburgh Postnatal Depression Scale (EPDS) at their first antenatal visit. Risk factors for antenatal depression were assessed using a 11-item checklist. Questionnaires were self-administered, but some participants required assistance. Participants scoring positive (≥13) on the EPDS were offered referral to on-site, individual counselling, and assigned to one of three groups according to their service use: declined referral; accepted referral and attended counselling sessions; and accepted referral but defaulted all appointments. Consent to participate was received by 3437 (96.4%) participants who were offered screening, of which 627 (18.9%) screened positive on the EPDS. Of these, 363 (57.9%) attended counselling. Both bivariate analyses and regression analyses revealed that age and risk factor assessment score were associated with screening positive on the EPDS. Odds ratios (OR) for accepting counselling were OR = 0.94 (95% CI = 0.92-0.97) for gestation, OR = 1.27 (95% CI = 1.15-1.39) for EPDS score and OR = 0.48 (95% CI = 0.23-0.99) for reporting three or more risk factors. OR for attending counselling were, for age: OR = 1.06 (95% CI = 1.00-1.12) and for reporting three or more risk factors: OR = 0.60 (95% CI = 0.37-0.97). While the majority of women with psychological distress accessed the counselling service provided, strategies to increase service use of younger pregnant women specifically are required., (© 2014 John Wiley & Sons Ltd.)

Background: Maternal depression carries a major public health burden for mothers and their infants, yet there is a substantial treatment gap for this condition in low-resourced regions such as sub-Saharan Africa. To address this treatment gap, the strategy of "task sharing" has been proposed, involving the delivery of interventions by non-specialist health workers trained and supervised by specialists in routine healthcare delivery systems. Several psychological interventions have shown benefit in treating maternal depression, but few have been rigorously evaluated using a task sharing approach. The proposed trial will be the first randomised controlled trial (RCT) evaluating a task sharing model of delivering care for women with maternal depression in sub-Saharan Africa. The objective of this RCT is to determine the effectiveness and cost-effectiveness of a task sharing counseling intervention for maternal depression in South Africa., Methods/design: The study is an individual-level two-arm RCT. A total of 420 depressed pregnant women will be recruited from two ante-natal clinics in a low-income township area of Cape Town, using the Edinburgh Postnatal Depression Scale to screen for depression; 210 women will be randomly allocated to each of the intervention and control arms. The intervention group will be given six sessions of basic counseling over a period of 3 to 4 months, provided by trained community health workers (CHW)s. The control group will receive three monthly phone calls from a CHW trained to conduct phone calls but not basic counseling. The primary outcome measure is the 17-Item Hamilton Depression Rating Scale (HDRS-17). The outcome measures will be applied at the baseline assessment, and at three follow-up points: 1 month before delivery, and 3 and 12 months after delivery. The primary analysis will be by intention-to-treat and secondary analyses will be on a per protocol population. The primary outcome measure will be analyzed using linear regression adjusting for baseline symptom severity measured using the HDRS-17., Discussion: The findings of this trial can provide policy makers with evidence regarding the effectiveness and cost-effectiveness of structured psychological interventions for maternal depression delivered by appropriately trained and supervised non-specialist CHWs in sub-Saharan Africa., Trial Registration: Clinical Trials (ClinicalTrials.gov): NCT01977326, registered on 24/10/2013; Pan African Clinical Trials Registry (http://www.pactr.org): PACTR201403000676264, registered on 11/10/2013.

As one article in a series on Global Mental Health Practice, Simone Honikman and colleagues from South Africa provide a case study of the Perinatal Mental Health Project, which delivered mental health care to pregnant women in a collaborative, step-wise manner, making use of existing resources in primary care.

In low-resource settings, a stepped care approach is necessary to screen and provide care for pregnant women with mental health problems. This study sought to identify screening items that were most robust at differentiating women experiencing psychological distress and requiring counselling [assessed by screening with the Edinburgh Postnatal Depression Scale (EPDS) and a Risk Factor Assessment (RFA)] from those with a psychiatric disorder as diagnosed by a psychiatrist. Case records of women in an antenatal mental health service in Cape Town were reviewed. Composite scores and individual items on screening scales (EPDS, RFA) of participants who qualified for counselling ( n = 308) were compared to those of participants who were diagnosed with a psychiatric disorder ( n = 58). All participants with a psychiatric disorder were diagnosed with either depression or anxiety disorders. These participants had higher mean scores on the EPDS and RFA than those who qualified for counselling ( p < 0.01). Logistic regression and ROC analyses suggested that the best items to distinguish women with depression or anxiety from those qualifying for counselling were 'I have felt sad and miserable', 'I am not pleased about being pregnant' and 'I have had serious depression, panic attacks or problems with anxiety before' (sensitivity 0.655, specificity 0.750 for this combination of three items). A small number of items may be useful in screening for mental illness in pregnancy which requires higher levels of care. Such screening may contribute to a more efficient stepped care approach. [ABSTRACT FROM AUTHOR]