As 2015 quickly approaches, the global health community has been made increasingly aware of our progress toward Millennium Development Goals (MDGs). Some remarkable progress has indeed been made. For example, the proportion of underweight children under the age of five in developing countries has declined from 28% to 17% between 1990 and 2011. Significant progress has also been made in reducing mortality among children under the age of five. In 1990, 12 million children under five died, compared with 6.9 million children in 2011. In 2011, 2.5 million people were newly infected with HIV, representing a 24% decrease from the 3.1 million people newly infected in 2001. However, one millennium development goal has shown particularly slow progress: MDG 5, namely, improving maternal health. Few countries are on track to achieve the first part of MDG 5’s goals, reducing maternal morality by 75%. Sub-Saharan Africa is in the most dire position, with a regional maternal mortality rate of 640 maternal deaths out of 100,000 live births, and a decline rate of merely 0.1%. In the summer of 2012, the University of Cambridge hosted a conference on the topic of “New Approaches to Maternal Mortality,” recognizing the crucial need to address the question of what is going on with global maternal mortality rates and to begin to address potential solutions.
While numerous factors are still converging to produce this grim picture, one key element is often missing from the discussion: improving maternal mental health. Working toward solutions to mental health problems that plague new mothers in a wide variety of settings, including in developing countries, could go a long way in improving both maternal and child health. Integrating mental health programs with maternal health programs is not only as important in saving mothers’ lives as screening for malaria and treating HIV in pregnant women but it could also prove essential in achieving two distinct but interrelated Millennium Development Goals: improving maternal health and reducing the number of deaths in children under the age of 5.
A recent article in PLOS Medicine delineates some reasons why maternal mental health is not a high priority on maternal health agendas. For one thing, a number of myths prevail that make maternal mental health seem irrelevant or unimportant in comparison to other threats facing maternal health. One especially troubling myth is the notion that maternal mental health problems are rare in developing countries, where maternal deaths represent a more significant problem than in the developed world. The authors note that this perception is misguided and cite evidence that rates of perinatal depression in low- and middle-income countries are actually higher than in high-income countries, ranging from 18% to 25%. Another misperception involves the idea that maternal depression is only tangential to maternal health. There is a conception that obstetric complications and infectious diseases represent much more immediate threats to maternal health than mental health issues. Yet this notion turns out not to be entirely true. Maternal depression certainly contributes in a very direct and striking manner to poor outcomes in infants. Maternal depression has been associated with pre-term birth, low birthweight, undernutrition, and higher rates of diarrheal disease. Suicide is actually a leading contributor to maternal mortality worldwide, and suicidal thoughts and tendencies occur in up to 20% of mothers in low- and middle-income mothers, in comparison with 5 to 14% of mothers in high-income countries.
Part of the problem with treating maternal depression is that it can be difficult to detect, especially in resource-poor countries. Core symptoms of depression such as fatigue and poor sleep are also effects of motherhood and often go unnoticed in new mothers. Screening for depression should be an integral component of antenatal visits and health care professionals who do not specialize in mental health should be trained to recognize symptoms of depression in pregnant women and new mothers. Over the last decade, interventions by non-mental health specialists have produced promising results, and efforts are being expanded to low- and middle-income countries with encouraging outcomes. The Perinatal Mental Health Project (PHMP), based at the Mowbray Maternity Hospital in South Africa, included screening by midwives of all women in antenatal care for mental health problems and referrals for counseling and psychiatric care if necessary. The intervention resulted in high coverage (90%) and uptake (95%) of PMHP screening, and staff responsible for the screening expressed relief, rather than a feeling of burden, about the integration of maternal and mental health systems in order to address a previously unmet need.
International donors and stakeholders should be made aware of the dire effects of maternal depression on maternal and child health and should be encouraged to provide funds and aid specifically for maternal mental health. In particular, the evidence for the effects of mental health on physical health should be emphasized in communication with international donors. In addition, donors should be made aware that integrating mental health services into existing treatment platforms could prove an important opportunity to leverage resources efficiently, a major current preoccupation of the global health community.
If the Millennium Development Goals are to be achieved, the international health community needs to stop viewing them in isolation from each other and recognize that many of them are intertwined and require integrated interventions. At the same time, holistic views of both health systems and individual health are vital. Strengthening across health systems, which includes strengthening local mental health services, will bring us closer to achieving the MDGs. In a similar manner, viewing individual health holistically, as the combined effect of the health of various systems, including not only the body but also the mind, will help ensure that we pay due attention to a wider variety of factors contributing to poor health worldwide.