With declining rates of maternal mortality worldwide, researchers are recognizing the importance of addressing maternal morbidity
Progress in maternal health have been traditionally measured by examining the reduction in maternal death measured through Mortality Rate (MMR). MMR is defined as the number of deaths during pregnancy or within 42 days of pregnancy per 100,000 live births (WHO). Since the adoption of Millennium Development Goals (MDG) maternal death has fallen significantly. Globally, the ratio declined from 400 maternal deaths per 100,000 live births in 1990 to 210 in 2010. Maternal mortality has declined by about two-thirds in Eastern Asia, Northern Africa and Southern Asia. While important gains have been made, progress falls short of achieving MDG 5. The maternal mortality rate in developing regions is around 14 percent higher than in developed nations and the highest rate of maternal deaths is in sub-Saharan Africa and Southern Asia, which collectively accounted for 86 percent of global maternal deaths.
Unequivocally, maternal mortality remains an integral Sustainable Development Agenda with respect to maternal health, with SDG 3 aiming to reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030.
However, maternal mortality is only one part of the story. According to WHO statistics, for every woman who dies of pregnancy-related causes, 20 or 30 others experience acute or chronic morbidity, often with permanent sequelae that undermine their normal functioning which has adverse effect on families, communities and societies. WHO defined the term morbidity in women who has been pregnant (regardless of the site or duration of pregnancy) from any cause related to or aggravated by the pregnancy or its management. Following a similar trajectory of maternal mortality rates, the burden of maternal morbidity is estimated to be highest in low and middle-income countries, especially among the poorest women. Maternal morbidities include conditions, such as uterine prolapse, stress incontinence, hypertension, hemorrhoids, perineal tears, urinary tract infections, severe anemia, depression, fistula, and ectopic pregnancy.
A conceptual framework for maternal morbidity and its consequence adapted from Koblinksy M et.al (2012)(1) describes the long and short term consequences of maternal morbidity, outlining the effects on the child, family/household (social/economic), and the woman (physical, psychological). With two thirds (122) of countries having already met the Sustainable Development Goal (SDG) target to reduce the number of women dying from pregnancy-related causes to less than 70 for every 10,0000 live births by 2030(2), the emphasis must be on improving the quality of the life of the mother.
Maternal mental health is emerging as public health priority due to its impact on both maternal and child health
One important determinant that impact the well-being of mothers and in turn the child health is maternal mental health. It is well established that several psychiatric disorders are common during pregnancy, with depression being the most common that significantly contributes to the increasing maternal morbidity. According to WHO, 10% of pregnant women and 13% of women who have just given birth experience a mental disorder, primarily depression globally. In developing countries, this is even higher, i.e. 15.6% during pregnancy and 19.8% after child birth.
High prevalence of mental health problems during the perinatal period can be attributed to various factors ranging from biological (e.g., hormones and neurochemical modifications) to psychological (e.g., personality types and ways of thinking). In the recent years, there has growing emphasis on understanding the social determinants- poverty, migration, extreme stress, exposure to violence (domestic, sexual and gender-based), emergency and conflict situations, natural disasters, and low social support(3) as strong predictors of postpartum depression.
Perinatal mental health, postnatal and antenatal depression have documented impact on maternal health including pregnancy outcomes and well-being of children. Maternal depression during pregnancy is a risk factor for low fetal birth-weight and premature delivery and other illnesses, such as anxiety disorders, eating disorders and psychotic illness, which may predict adverse birth outcomes. Pregnant women or mothers with mental health problems was found to have have poor physical health and display high-risk behaviors including alcohol and substance abuse. Also, mental health problems in mothers can lead to increased maternal mortality, both through adversely affecting physical health needs as well as more directly through suicide.
With mothers being the primary caregivers responsible for the continued care of children, postnatal depression can result in long term emotional, cognitive, and behavioral problems in children. According to WHO, maternal depression in low income countries can be directly related to lower infant birth weight, higher rates of malnutrition and stunting, higher rates of diarrheal disease, infectious illness and hospital admission and reduced completion of recommended schedules of immunization in children.
Mental health care remains conspicuous by its absence in large scale global maternal and child health (MCH) programs
The importance of indirect causes in maternal mortality is well established: 27·5% of all maternal deaths results from indirect causes—effects of pre-existing disorders, such as HIV infection, mental disease, and diabetes. However key policy and strategy documents of leading international maternal health non-governmental organisations and UN organisations do not focus much on indirect causes. According to Storm et. al. (2014)(4), poor mental health as an underlying causal factor for maternal mortality and morbidity is a neglected area which is yet to gain momentum as part of stated donor agenda.Integrating maternal mental health into health programs and policies is critical for advancing the maternal and child health status. The SDG goals, by having an explicit focus on mental health, may provide the necessary ammunition to push the agenda of maternal mental health and propel national governments to deliver health services for mental health for women.
However, for the better integration of maternal mental health and development of evidence-based, potentially scalable interventions certain obstacles must be addressed. Certain steps in this direction will include:
Greater awareness on possible synergies between mental health intervention within maternal and child health area: Evidence must be presented to national policy makers and program managers to better integrate mental health interventions within current maternal and child health services. By exploring synergies with MCH programs, the interventions will have the added advantage of being equitable and accessible as most of the MCH interventions in low and middle income countries are premised on community-based model. Sensitivities associated with mental health disorder (stigma associated with mental health) can be better managed through the involvement of MCH worker as they have better understanding of the local context and specific needs of the communities. This could also result in improved care seeking behavior.
Explore avenues for integration of core mental health services within routine primary healthcare (antenatal and postnatal visits): Future research should also explore avenues to make efficient incremental additions or design tweaks that could be made to existing maternal health interventions, to optimize their impact on maternal mental health outcome. There are opportunities to integrate maternal mental health facilities into existing programs which relates to: Basic Antenatal Care; Contraception; Non-Communicable Diseases; Essential Postnatal Care; HIV/ AIDS; Child Care and Protection; Early Childhood Programs- Immunization Programmes; Substance Abuse; Victim Empowerment.
The research will provide evidence on effectiveness of various strategies employed in the prevention, support and treatment of maternal mental health disorders that can be incorporated into broader programmatic strategies at lower cost and examine models are likely to be more adaptable and replicable, and more efficient to scale up.
Better monitoring and surveillance to estimate the actual burden of maternal mental health and maternal morbidity: The current health information systems in many of the developing and low incomes countries largely tracks maternal mortality rates and institutional deliveries including antenatal visits. To a smaller extent, there has been growing emphasis on tracking some of the complications associated with pregnancy including anemia and hypertension. Currently the measurement of maternal mental health indicators are nearly absent in policy, programs and national frameworks. Improvement in measurement would prove to an important tool that can lead to better understanding on prevalence and treatment of maternal mental health and quality of obstetric care.
References:
1. Koblinsky M et. al. (2012). Maternal Morbidity and Disability and Their Consequences: Neglected Agenda in Maternal Health. J HEALTH POPUL NUTR 2012 Jun;30(2):124-130 ISSN 1606-0997 retrieved from http://bioline.org.br/pdf?hn12019
2. The Lancet. "Global burden of disease study 2015 assesses the state of the world's health." ScienceDaily. ScienceDaily, 6 October 2016. Retrieved from https://www.sciencedaily.com/releases/2016/10/161006102549.htm
3. Stewart, Donna M et.al (2003). Postpartum Depression: A literature Review of Risk Factors and Interventions
4. Storm, Frederikke et.al (October 2014). Indirect causes of maternal death. Lancet Global Health, Vol.2, No.10