1. PERINATAL
AND
MATERNAL
MENTAL
HEALTH:
INTERNATION
AL ISSUES
Judith Bass, PhD, MPH Department of Mental
Health
Johns Hopkins Bloomberg School of Public Health

2. Overview
 What is Mental Health?
 Mental health problems during pregnancy and
new motherhood
 Effects of mental health problems on women,
children, and families
 Risk factors
 Prevention and treatment

3. Overview
 What is Mental health?
 Mental health issues during pregnancy and
new motherhood
 Effects of mental health on women, children,
and families
 Risk factors
 Prevention and treatment

4. What is mental health?
 World Health Organization
 “Health is a state of complete physical, mental
and social well-being and not merely the absence
of disease or infirmity.”
 Not simply the lack of mental illness
 Complete and general state of well-
being, functionality and productivity
 Ability to contribute to self, family and community

5. What is mental illness?
 Can include:
 Emotional distress
 Sense of hopelessness or despair
 Anxiety and restlessness
 Inability to perform basic tasks
 Symptoms can be both physical and emotional

6. Mental Health/Psychosocial
Paradigms
 Some use them interchangeably
 Others differentiate
 Mentalhealth – clinical illness/clinical care
 Psychosocial – distress/support services
 Alternative option
 Continuum of needs and issues
 Varying over time and across populations
 Selection based on population needs and
resource availability

7. Overview
 What is mental health?
 Mental health issues during pregnancy and
new motherhood
 Effects of mental health on
women, children, and families
 Risk factors
 Prevention and treatment

8. Terms and Timeframes
 Perinatal period: Pregnancy and the 12
months following childbirth (Gavin et al., 2005)
 Antenatal period: Pregnancy
 Postpartum period: Definitions have ranged from
a few days up to twelve months following
childbirth
 MCH period: Services through child age 5

9. Mental Health Issues - Distress
 Fears
 sleeplessness
 Too many thoughts
 Concerns about the future
 Confusion
 Unexpected body changes and experiences for women
having first child
 Social pressures
 Changes in role – whether its first/multiple
 Additional burden – economic, social
 Shame (if unwanted)
 Isolating in some cultures

10. Mental Health Issues -
Disorders
 Depression
 Major Depressive Disorder
 Dysthymia
 Anxiety
 Generalized Anxiety Disorder
 Specific Phobias
 Post-traumatic Stress
 Severe Illness - psychoses
 Schizophrenia
 Bipolar Disorder
 Substance use disorders
 Alcohol
 Drugs

11. Overview
 What is mental health?
 Mental health issues during pregnancy and
new motherhood
 Effects of mental health issues on
mothers, children, and families
 Risk factors
 Prevention and treatment

12. Effects of maternal mental health
problems on the women and
children
 Maternal health
 Strong link between mental health and chronic
illness
 For HIV-infected women, depression linked to
adherence
 Child health and development
 Increased rates of infant malnutrition, illness and
growth problems
 Early childhood a sensitive period for
neurocognitive development – need
attentive, available mother
 Attachment in childhood relevant throughout the
life-course

13. Effects of maternal mental health
problems on the family
 Relates to functioning – as a member of the
family, as a member of the community
 During pregnancy
 Change in capacity – especially if complications
 Motherhood
 Husband/other children need attention
 Responsibilities to home/community
 Mental health problems can be
stigmatizing/isolating to the individual and the
family

14. Overview
 What is mental health?
 Mental health issues during pregnancy and
new motherhood
 Effects of mental health issues on
mothers, children, and families
 Risk factors
 Prevention and treatment

15. Risk factors
 Prior history of disorder
 Trauma – including gender-based violence
 Pregnancy/birth complications/miscarriage
 STDs and HIV
 Age
 Parity (primi/multi)
 Social status
 Gender preferences
 Substance abuse

16. HIV-infection
 HIV and mental health
 Elevated rates of mental health problems among HIV-
infected people
 Particularly Depression and Anxiety problems
 Depression linked to reduced treatment adherence
 Risk factors that are related to both HIV infection
and to mental health problems
 Example: poverty and violence
 Neurologic consequences of HIV infection

17. Trauma
 Trauma exposure
 Prevalent in low-resource countries
 Causes: war, economics, gender-issues
 Related to depression, anxiety, post-traumatic
stress, stigma, distress
 Gender-based violence
 Physical complications – can complicate the
woman‟s ability to have children/keep their
pregnancy
 Burden of having a child from rape
 Potential for rejection from husband/family – and
abandonment

18. Overview
 What is mental health?
 Mental health issues during pregnancy and
new motherhood
 Effects of mental health issues on mothers,
children, and families
 Risk factors
 Prevention and Treatment

19. Prevention
 Often lack of specialized services
 Where services exist, generally inadequate to
meet population needs
 Types of programs
 Psychoeducation – „what to expect when expecting‟
 Social support groups – for sharing experiences
 General and specialized (i.e. rape survivors, HIV-
infected)
 Family services
 Economic assistance
 Child care

20. Treatment
 Psychosocial programming
 Social support groups
 Social/economic resources
 Psychological services
 Individual
therapy
 Group therapy
 Psychiatric services
 Pharmaceutical treatment
 In/out patient care

21. Example of an Innovative
Prevention Program
 Caregiver training program to improve
neurocognitive development in at risk young
children (ages 2-5)
 Trialcurrently underway in Uganda with HIV-
infected and affected children
 Uses home health care visitors to „train‟
caregivers to be more attentive, responsive, and
proactive
 Preliminary results show impacts child
development AND caregiver mental health

22. Example of an Innovative
Treatment Program
 Cognitive Processing Therapy (CPT) to treat
severe distress among survivors of gender-
based violence in Eastern Congo
 Many reported rejected by husbands/family –
high stigma
 Group treatment provided by local psychosocial
workers
 Preliminary results
 Reduced symptoms
 Improved functioning – within family and social contacts

23. Conclusion
 Problems are real – range from distress to
disorder
 Impact full range of the woman‟s life:
self, child, family
 Recognized risk factors are common in low-
resource contexts
 Prevention programs can be simple –
integrated into existing services
 Treatment programs – possible, need
supervision structure but with task-shifting can
be implemented in low-resource settings

24. Acknowledgements
 Collaborators within the Applied Mental Health
Research Group (AMHR)
 Paul Bolton, MBBS; Laura Murray, PhD
 Department Faculty/Students
 Tamar Mendelson, PhD; Andrea Vazzano, MPH