The first two days of the meeting consisted of four sessions. The international and local experts presented findings from their research in the following areas: (1) prevalence and determinants of maternal mental health problems, (2) consequences of maternal depression for child health and development in resource-constrained settings, (3) interventions to promote maternal mental health in resource-constrained settings and (4) interventions to promote child health and development (see Annex 4 : Papers presented at the meeting and programme agenda).
1. Prevalence and determinants of maternal depression
Meeting participants considered the results of a systematic review of the evidence on perinatal mental health in resource-constrained settings. The review was limited to evidence from World Bank-defined low and lower middle income countries, non-psychotic disorders and English-language literature. Almost all the high-income countries of the world have data about the prevalence and determinants of perinatal depression. Such data can serve these countries as the basis for policy and practice. In striking contrast, the review found, only 11 of 112 countries classified as low or lower middle income have any prevalence data.
Systematic reviews of the evidence from industrialized countries have concluded that 10-15% of women experience major depression in pregnancy. The few studies conducted in resource-constrained settings have found rates two to three times higher. Researchers from India, Turkey and Viet Nam presented up-to-date evidence to the meeting. In all three countries at least 25% of mothers of young infants experienced depression or were experiencing clinically significant depressive symptoms.
There are some limitations to the evidence from resource-constrained countries. Many of the studies were undertaken at tertiary-level or university teaching hospitals. Therefore, it might be that only relatively socioeconomically advantaged women were assessed. In some of these countries skilled birth professionals attend relatively few births. No studies, however, involved women who had given birth at home with traditional birth attendants. It is possible that rates of common mental health problems in the general population of mothers of newborns in these contexts are therefore underestimated.
Methodological differences and limitations make comparisons among studies difficult. Some studies have conducted clinical interviews. Other studies have collected data with screening questionnaires. Only some of these questionnaires had been locally validated. Investigations did not all assess the same risk factors. Also, most of the prospective studies assessed mental health in pregnancy only as it constituted a risk for depression after childbirth.
Still, a consistent pattern of high prevalence of common perinatal mental disorders is emerging. Common risk factors include being adolescent, being unmarried, having previous reproductive losses, having an unwelcome pregnancy including pregnancy as a result of forced intercourse, being unable to confide in their intimate partners, lacking emotional and practical support from family members, poverty and lack of personal income generating opportunities, inadequate housing, overcrowding and lack of privacy.
A presentation on the local validation of psychometric instruments in Viet Nam illustrated the need for culturally and psychologically sensitive measures to generate local evidence. Assessment needs to take into account differences in literacy, including emotional literacy, familiarity with the use of self-report instruments, and the establishment of locally appropriate clinical cut-off scores.
The discussion at the end of this session concluded that poor maternal mental health is an especially serious public health concern in resource-constrained settings. This conclusion reverses the once established view that mothers in resource-constrained settings do not experience mental health problems. Participants noted that the common mental health problems of depression and anxiety are predominantly socially determined and that cross-sectoral interventions are therefore needed to address them.
2. Consequences of maternal depression for child health and development and the mother-infant relationship in resource-constrained settings
Evidence presented from India, South Africa and the United Kingdom spoke to the impact of maternal postpartum depression on child health and socio-emotional and cognitive development and on the mother-infant relationship. There is consistent evidence from resource-constrained settings that infants of mothers who are depressed are more likely to be of low birth weight, and malnourished and stunted by the age of six months. Studies also report higher rates of diarrheal disease, infectious illness and hospital admission, and reduced rates of completion of recommended immunization schedules in children whose mothers are depressed compared to those whose mothers are not. In combination, these factors are likely to contribute to an increase in child mortality.
There is evidence from developed countries that the mother-infant relationship is compromised when the mother cannot demonstrate warmth and affection, attend to her baby's cues, and respond actively and contingently. In turn, a compromised mother-infant relationship adversely affects the child's cognitive, social, behavioral and emotional development. As yet there is little evidence regarding this linkage from resource-constrained settings.
3. Interventions to promote maternal mental health in resource-constrained settings
The psychosocial and physiological demands of pregnancy and caring for an infant make a woman more vulnerable to perinatal mental health problems, especially in adverse circumstances. At the same time, however, routine antenatal and postpartum health services provide an opportunity for heightened and psychologically informed mental health care. Even in the poorest countries there is some provision for antenatal, perinatal, postpartum and infant health care and other primary health care services. Interventions to improve maternal mental health and related child survival, health and development can be integrated into these existing services.
A woman's emotional well-being and social circumstances can be assessed within routine perinatal health care, using either structured questions or appropriately validated and culturally sensitive self-report questionnaires. Stepped intervention protocols, clearly described pathways to care, professional education and health service development are needed. Participants emphasized the importance of an approach that provides care to both mother and baby.
Interventions need to be evidence-based, cost effective, simple and practical and to address both individual needs and family functioning. An intervention being tested in a cluster randomized trial being conducted in a rural area of Pakistan was presented. The intervention involved training village-based community health workers known as Lady Health Workers in a structured cognitive behavioral intervention to treat maternal depression into their routine clinical practice. Evidence from Japan illustrated the importance to maternal and child health of assessing and addressing gender-based violence. Participants also heard how a psychosocial intervention for people who had attempted suicide might be applied to women with perinatal mental health problems. The intervention has been studied in several resource-constrained countries.
Proposed strategies to integrate mental health care into the primary health care system in Viet Nam served as examples. These strategies address research, education and training, policy development and health service development.
The clear evidence that common perinatal mental disorders reflect chronic adversity indicates that social rather than medical responses are required. Improvement in maternal mental health requires a multifaceted social approach and the involvement of multiple sectors including those dealing with development, poverty reduction, human rights, social protection, violence prevention, education, gender, and security, in addition to health. Stepped approaches in which non-pharmacological interventions provided by community-based primary health care workers are the first line response, with clear referral pathways to specialised services for those whose symptoms do not improve.
4. Interventions to promote child health and development
To prevent the adverse effects of compromised caregiving on child health and development, interventions must focus specifically on the promotion of infant health and development and strengthening the mother-infant relationship as well as to maternal mental health. Participants considered two such interventions that have been tested in controlled trials in resource-constrained settings. In Khayelitsha, a periurban township in South Africa, trained lay women provided mothers with structured support and education about infant capacities. Mother-infant relationships and child health and development improved. In Porto Alegre, Brazil, a single psycho-educational session about infant behaviour and capacities was conducted individually with mothers of newborns while the mothers were still in hospital. This session improved the mothers' sensitivity and responsiveness to their infants at age six months, compared with mothers who were randomly assigned to a comparison group that received only usual information about infant care.
5. Expert statement on maternal mental health and child health and development in resource constrained settings
Overall, the international expert meeting reached a number of conclusions. First, that there is widespread lack of awareness about women's mental health in the perinatal period and its impact on child health and development in resource-constrained settings. Second, that it is essential for each country to have local evidence concerning the nature and prevalence of the problem on which to develop low-cost, non-stigmatizing and accessible interventions. Third, that all resource-constrained countries need cross-sectoral approaches; not only the integration of mental health care into primary perinatal health care, but also strategies to reduce poverty and domestic violence and to promote equality of participation in education and income-generating occupations for women. Fourth, that approaches must be multistranded and include research, education, community-based interventions, health service development, health system strengthening and social policy formation. Finally, that mental health is closely linked to achieving the Millennium Development Goals of improving maternal health, reducing child mortality, promoting gender equality and empowering women, and reducing poverty.
On the final day, in a closed meeting, the core group of 17 international experts and representatives from Viet Nam, UNFPA, WHO and other international agencies drafted The Hanoi Expert Statement entitled Maternal mental health and child survival, health and development in resource-constrained settings: essential for achieving the Millennium Development Goals which is reproduced with permission and attached here. It was subsequently reviewed by representatives of relevant departments of UNFPA and WHO and by international authorities in the field. This statement, co-signed by all these stakeholders seeks to inform countries and international agencies about the prevalence and determinants of perinatal mental health problems in women, their consequences for infants, and strategies to address these vital but under-recognized public health problems in resource-constrained settings.