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Maternal mental health and early childhood development in RESOURCE-CONSTRAINED settings

Professor Jane Fisher Jean Hailes Research Unit School of Public Health and Preventive Medicine Monash University. Maternal mental health and early childhood development in RESOURCE-CONSTRAINED settings. WHAT IS YOUR PRIMARY ORGANISATIONAL AFFILIATION?. Government department

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Maternal mental health and early childhood development in RESOURCE-CONSTRAINED settings

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  1. Professor Jane Fisher Jean Hailes Research Unit School of Public Health and Preventive Medicine Monash University Maternal mental health and early childhood development in RESOURCE-CONSTRAINED settings

  2. WHAT IS YOUR PRIMARY ORGANISATIONAL AFFILIATION? • Government department • Multilateral organisation • International or local NGO • Health service provider • Research, Academic, or Training Institution • Other

  3. IS MATERNAL AND INFANT HEALTH YOUR PRIMARY AREA OF FOCUS? • Yes • No, but I am interested in this field

  4. OBJECTIVES To summarise the evidence about the major factors governing early childhood development in the context of poverty; To describe current conceptualisations of what constitutes poor mental health and the available evidence about the prevalence and determinants of common perinatal mental disorders in women; To describe current theories and evidence about the mechanisms whereby maternal mental health determines early childhood development

  5. FACTORS GOVERNING HUMAN DEVELOPMENT Human development is governed by: • the interactions among biological, psychosocial and environmental factors; • risks accrue at the lower end of the socioeconomic spectrum. The early childhood years are vital because: • general and neurological growth, reflected in cognitive, physical and social-emotional domains, is very rapid; and • exposures during these early years may have lasting effects.

  6. FACTORS GOVERNING EARLY CHILDHOOD DEVELOPMENT IN THE CONTEXT OF POVERTY Source: Walker et al, The Lancet 2007

  7. FACTORS GOVERNING EARLY CHILDHOOD DEVELOPMENT IN THE CONTEXT OF POVERTY • Intrauterine growth restriction (poor maternal nutrition and coincidental infectious diseases): leads to impaired foetal growth and low birthweight; • Under nutrition in infancy (stunting and being underweight): lower cognitive abilities and school performance; • Anaemia (attributable to iron deficiency) in pregnant women: increasing risks of premature birth, low birthweight; in early childhood: worse mental, motor, social, emotional and/or neurological functioning (Walker et al, 2007, Walker et al 2011)

  8. FACTORS GOVERNING EARLY CHILDHOOD DEVELOPMENT IN THE CONTEXT OF POVERTY • Iodine deficiency: associated with child cognitive and developmental deficits ; • Lack of early learning opportunities and sensitivecaregiver–child interactions: related to low cognitive development and social-emotional problems; • Family violence and violent neighbourhoods: worse cognitive and socio-emotional development, higher rates of infant and deaths; (Walker et al, 2007, Walker et al 2011)

  9. PERINATAL MENTAL HEALTH IN WOMEN There is no baby without a mother…. Donald Winnicott, The Child and the Family (London: Tavistock, 1957)

  10. FACTORS GOVERNING EARLY CHILDHOOD DEVELOPMENT IN THE CONTEXT OF POVERTY 7. ‘Common mental disorders’ or non-psychotic maternal mental health problems during pregnancy and postpartum: worse cognitive development and behavioural and emotional problems in infants and young children; (Walker et al, 2007, Walker et al 2011)

  11. PERINATAL MENTAL HEALTH IN WOMEN • Since 1964 major increase in awareness in high income countries of the prevalence, determinants and adverse effects of poor mental health in women during: • Pregnancy • Childbirth • Early years of mothering • Mental health problems make a substantial contribution to maternal morbidity and mortality; • Adverse impact on infant health and development

  12. WHAT IS POOR MATERNAL MENTAL HEALTH? • Maternity, third day or postpartum blues; • Postnatal or puerperal psychosis 1-2: 1000; • Antenatal or postnatal depression and anxiety (Common Perinatal Mental Disorders): Persistent presence for at least two weeks of cognitive and affective symptoms including: Low mood Impaired concentration Guilt Irritability, Despondency Elevated anxiety Self-deprecation Social withdrawal Anhedonia Hopelessness • Prevalence of CPMD in high-income countries: • ± 10% of pregnant women • ± 13% of mothers of infants Hendrick, 1998; O’Hara and Swain, 1996

  13. PERINATAL MENTAL HEALTH PROBLEMS ARE A ‘CULTURE BOUND SYNDROME’ ? • Women who live in low and lower middle income countries experience traditional ritualized care after birth including: • Mandated periods of rest; • Honoured status; • Increased practical support and freedom from household and income-generating work; • Social seclusion; • Gift giving and prescribed foods; • These protect mental health and therefore; • They do not experience perinatal mental disorders. Stern and Kruckman, 1983; Howard, 1993

  14. PREVALENCE OF COMMON PERINATAL MENTAL DISORDERS IN WOMEN IN LOW AND LOWER MIDDLE INCOME COUNTRIES: A SYSTEMATIC REVIEW Most published since 2000 13 studies about antenatal CMD from 9 countries; No evidence from 103 / 112 (92%) LALMI countries; 34 studies about postnatal CMD from 17 countries; No evidence from 103 / 112 (85%) LALMI countries; Diverse methods and endpoints; Mental health problems in pregnant women and mothers of newborns detectable in all studies; Study settings contribute to selection biases; (Fisher, Cabral de Mello, Patel, Rahman, Tran, Holton, Holmes, Bulletin of the World Health Organization, 2012)

  15. PREVALENCE OF MATERNAL COMMON PERINATAL MENTAL DISORDERS IN LALMIC Fisher et al., Bulletin of the World Health Organization, 2012

  16. PREVALENCE OF MATERNAL COMMON PERINATAL MENTAL DISORDERS IN LALMIC OF THE ASIA PACIFIC REGION

  17. PREVALENCE OF MATERNAL COMMON PERINATAL MENTAL DISORDERS IN HIGH AND UPPER-MIDDLE INCOME COUNTRIES OF THE ASIA PACIFIC REGION

  18. MENTAL HEALTH AND MATERNAL MORTALITY POSTPARTUM MORTALITY • Suicide rates are underestimated because maternal mortality data is restricted to the first 42 days after childbirth • Ascertainment extended to one year: • Deaths by suicide as common as deaths from pregnancy hypertension in UK, • Risks: young, unmarried, low socio-economic status and ethnic minorities.

  19. MENTAL HEALTH AND MORTALITY MORTALITY IN WOMEN OF REPRODUCTIVE AGE VIETNAM • Detailed review of 2882 deaths in women of reproductive age • Three provinces of Vietnam, • Leading cause (29%) suicide, murder and accidents, • Suicide 14% (Hieu, Hanenberg, Vach, Vinh and Sokal, 1995)

  20. MENTAL HEALTH AND MATERNAL MORTALITY POSTPARTUM MORTALITY VIETNAM • All pregnant or parturient women aged 15 – 49 who died in a two year period 2000 – 2001, • In total 8% were by suicide, but in some provinces 16.5% were by suicide, • Motherless children 0 – 5 twice as likely to die compared to those with mothers, • Community behaviors towards women Vietnam MOH, WHO WPRO, Maternal Mortality in Vietnam 2000 - 2001

  21. RISK FACTORS FOR MATERNAL COMMON MENTAL DISORDERS IN LALMIC Socio economic disadvantage (OR range: 2.1–13.2) : adolescent; religious or ethnic minority group; rural rather than an urban area; hunger in previous month, unable to pay for essential health care; low-income; holding a ‘poor card’; Quality of relationship with intimate partner (OR range: 2.0–9.4): unsupportive, rejecting the pregnancy; polygamy; alcoholism; Family violence (OR range 2.11–6.75): criticism, coercion, intimate partner violence, worse if the baby is a girl than a boy; Quality of family relationships (OR range 2.1–4.4): critical mother-in-law, geographic separation from own mother; Reproductive health (OR range: 1.6–8.8): unwanted or unintended pregnancy; previous stillbirth; coincidental illness; premature birth; caesarean birth Past history of mental health problems (OR range 5.1–5.6)

  22. PROTECTIVE FACTORS FOR MATERNAL COMMON MENTAL DISORDERS IN LALMIC • Education (RR 0.5; p=0.03) ; • Employment (OR: 0.64; 95% CI: 0.4–1.0) including security while away from the workforce to care for an infant; • Provision of structured direct care by a trusted person, preferably a woman’s own mother (OR: 0.4; 95% CI: 0.3–0.6) ; • Confiding affectionate relationship with the intimate partner (OR: 0.52; 95% CI: 0.3–0.9).

  23. HOW MIGHT ANTENATAL MENTAL HEALTH INFLUENCE EARLY CHILDHOOD DEVELOPMENT Through three possible mechanisms: • less likely to use preventive antenatal health care. • increasing stress-related hormones including cortisol, • worse physical health and weaker immune system, These may affect fetal development, birth outcomes, and have lasting effects on early childhood development

  24. CONSEQUENCES OF PERINATAL CMD FOR SELF-CARE Bulletin of the World Health Organization, 2011; 89: 813 - 820

  25. BIRTH OUTCOMES AND EARLY CHILDHOOD DEVELOPMENT AFTER EXPOSURE TO ANTENATAL CMD Evidence of the associations with birth outcomes: • Increased rate of premature birth (RR=2.3, Rondo et al 2003) and • Increased risk of low birthweight (<2,500 grams) (RR=1.9,Rahman et al 2007); Evidence of the associations with ECD: • increased risks for underweight, stunting (Rahman et al 2004); • worse infant cognitive development (Bergman et al 2010), • behavioural and emotional problems in pre-school children (O'Connor et al 2002).

  26. POSTPARTUM MENTAL HEALTH PROBLEMS AND CAREGIVING CAPABILITY Postpartum depression and anxiety characterised by: • Flat affect, lowered interest; reduced cognitive clarity and increased irritability These can contribute to: • Reduced sensitivity and responsiveness to the baby; • Neglect of care: • Inaccurate interpretation of infant cues; • Developmentally inappropriate expectations; • Hostile or inconsistent responses

  27. HOW POSTPARTUM MATERNAL MENTAL HEALTH CAN INFLUENCE EARLY CHILDHOOD DEVELOPMENT • Day-to-day interactions between primary caregivers and babies influence the infant’s neurological, cognitive, emotional and social development; • Effective care involves a mutually rewarding and affectionate relationship with the infant; • Caregiver sensitivity and responsiveness involve observing infant cues, interpreting what these indicate, and acting consistently, contingently and effectively in response; • Maternal sensitivity is associated with more secure infant to parent emotional attachment; • Higher maternal responsivity is associated with higher infant cognitive ability and lower rates of behaviour problems in preschool children. Agarwal et al, 1992; Murray and Cooper, 1996; Valenzuela, 1997; Posada et al, 1999; Richter et al, 2000 and 2004; Tomlinson et al, 2005; Eshel et al, 2006.

  28. MATERNALPOSTNATAL MENTAL HEALTH AND INFANT DEVELOPMENT IN RESOURCE-CONSTRAINED SETTINGS In resource-constrained settings maternal postnatal depression has been linked directly to: • higher rates of stunting in infants, • higher rates of diarrhoeal diseases, infectious illness and hospital admission, • lower completion of recommended schedules of immunization, (Patel et al 2003; Rahman et al, 2003; 2004 and 2007)

  29. HOW MMH AND ECD CAN BE ADDRESSED IN THE CONTEXT OF POVERTY Mental health problems can be identified in women in resource-constrained settings; Limit self-care and caregiving capacity; Women and infants are in touch with health services and integrated mental health promotion strategies are most likely to be acceptable and accessible; Care for the woman in her life context so that she can care for her very young children

  30. THINKING HEALTHY PROGRAM CONDUCTED IN RURAL PAKISTAN (Rahman et al, 2009) • Manualised intervention involving CBT techniques of: • Active listening, problem solving, collaboration with the family to increase empathy; • Practice activities between sessions • Provided by Lady Health Workers (LHWs) who had no mental health training but were given: • Two days THP training and one day refresher after 4 months • Half-day supervision per month

  31. THINKING HEALTHY PROGRAM (Rahman et al, 2009) Cluster Randomised Controlled Trial: • Participants were: married women aged 16 – 45 years, in third trimester of pregnancy, diagnosed with major depression by a psychiatrist using a structured clinical interview; • Intervention clusters LHW’s provided one THP session per week for last month of pregnancy; three sessions in first postpartum month and monthly sessions until ninth postpartum month (16 visits); • Control group same number of visits, but from an untrained LHW without the THP

  32. THINKING HEALTHY PROGRAM (Rahman et al, 2009) Cluster Randomised Controlled Trial: • Outcomes were assessed by interviewers using a structured schedule, blind to group allocation; • After adjusting for covariates, women in the intervention group were at 6 and 12 month follow-up: • Less likely to be depressed (p<0.0001); • Less functional disability (p<0.0001); • Better global functioning (p<0.0001); • Higher perceived social support (p<0.0001) than women in the control group

  33. THINKING HEALTHY PROGRAM (Rahman et al, 2009) At twelve month follow-up infants of mothers in the intervention group were: • More likely to be fully immunized (p = 0.001); • Had fewer episodes of diarrhoea in past two weeks (p = 0.04); Than infants of control group mothers

  34. CONCLUSION Common perinatal mental disorders are prevalent among women in low-income settings, Prevalence is highest among the poorest women with the least access to services; Maternal mental health affects early childhood development Intervention: multi-sectoral integration which includes maternal mental health in both pregnancy and postpartum

  35. HANOI EXPERT STATEMENT ON MATERNAL MENTAL HEALTH AND CHILD SURVIVAL HEALTH AND DEVELOPMENT http://www.who.int/reproductivehealth/ publications/general/rhr_09_24/en/index.html

  36. ACKNOWLEDGEMENTS • KanithaKongrukgreatiyos • IvelinaBorisova • Minh Le • Thach Tran • Sara Holton

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