Four broad themes were identified: i) knowledge and attitudes about maternal mental illness, which describes knowledge about causes and effects of perinatal mental illness and availability of services for women with perinatal mental illness, ii) Patient, household health system and community related barriers to accessing mental health services for women with perinatal mental illness, iii) the perceived feasibility and acceptability of delivering maternal mental health services at primary health care level and iv) proposed recommendations for maternal mental health services.
Knowledge and attitudes concerning perinatal mental health problems
We explored knowledge about mental health problems among pregnant and postnatal women. The women were aware, to some extent that mental health problems occur during pregnancy and after child birth. Women attending the antenatal clinic described a range of behavioral symptoms of mental health problems in a mother:
Her ways change (embeeraze zikyuka) …She can do things she doesn’t do normally. She may become very talkative and yet normally she is a quiet person. Another person could be there peacefully with her husband. They never quarrel. But then the minute she gets pregnant they start quarreling and even fight. (
Focus group: pregnant woman)
The mothers also had an explanation for causes of mental ill health. They believed that ‘thinking too much’ or ‘not loving their husband enough’ could result in one developing mental health problems.
Sometimes it is due to thinking a lot. She just gets fed up (yekyawa bwekyaye) and doesn’t want to talk to anyone. It could be that she has lost love for the husband (Focus group: pregnant woman)
The mothers also attributed perinatal mental ill health to lack of support and neglect of women by their male partners,
For me, I think it could be neglect from the husbands
. (Key informant: Nurse)
Actually, I think the problem is big, only that we have not really followed up. It seems they have problems at home with their husbands. Some women are not facilitated to come for medical care. Some husbands drink a lot and the women end up having a lot of stress
(Key informant: Clinician)
Many of the women said they did not really know what the effects of mental illness in the mother or their baby would be, but they believed that it could cause the mother to be “struck by pressure”. This was explained to mean being extremely distressed to the extent of losing consciousness. Suicide was also mentioned as a possible consequence of such illness in a mother.
She may get ‘pressure’ (yandimukuba), sometimes some women strangle themselves (Focus group: pregnant woman)
On the other hand, the health workers believed that these mothers, once mentally ill, are at risk of being sexually abused, neglecting themselves and even neglecting their babies.
Sometimes the women end up sleeping on verandas or bushes when they become ill and are unable to look after their babies. They can even get raped.
(Key informant: Midwife)
It was evident therefore that participants, both the women in the focus groups and key informants, had some ideas that mental ill health occurred among perinatal women. The women in particular believed that the causes of such illness was mainly social and had some explanation regarding the effects of perinatal mental illness on the mother and the baby.
Barriers to delivery of perinatal mental health services in Kamuli district
Household, health-system and community level factors emerged as important barriers to uptake and delivery of perinatal mental health care. Household barriers revolved mainly around poverty in individual households which led to many women not having enough money to pay for transport to the nearest health facility should they need care. Long distances of up to seven kilometers to the health facilities did not help matters. Distance from health facilities and lack of transport money did not only limit access to mental health services but also to general antenatal care, where mental health problems would be recognized early and managed.
A mother may be aware of the service, know the advantage of going to a health facility but she doesn’t have transport money. Even if you give a health education talk, she will be aware but she will not have transport.
(Focus group: Village Health Team member
Since most women in Kamuli tend to be unemployed and without any income, the support of their male partners is critical. However, the women reported that their male partners were often unwilling to support them to access health services. Men were said to not only fail to support their partners to attend antenatal care but sometimes to refuse to grant them permission to access such services at all, even on their own. This was highlighted by one pregnant woman in a group.
There are some men who don’t want to come to hospital with their wives. He tells her that if you don’t go to hospital, can’t you survive, can’t you deliver, will you die? He refuses her to go to hospital (Focus group: pregnant woman).
This reluctance to support perinatal women was believed to arise from the men’s fear that if their partners went for antenatal or postnatal services, the men themselves may be required to accompany them and to take an HIV test. Male partners are particularly encouraged to attend antenatal clinics, where there is routine testing for HIV/AIDS for the couples.
Relatedly, the practice of polygamy, which was reported to be common in Kamuli district, influences the amount of support that a male partner may give to his pregnant partner. One midwife reported:
A man of 40 years marries another woman and starts a new family. And when the first wife asks for help from the man, the man refuses and so she delivers in the village because they cannot afford anything for this woman.
Key informant: Midwife)
In addition to household related barriers, there were health facility-related challenges that were reported to affect the women’s access to maternal mental health care. Low staffing levels at the health facilities, including the district hospital was cited as a key barrier. Existing staff in the health facilities felt they did not have enough time to assess women for mental health problems, as described by one midwife.
We are only 3 midwives and for one midwife to deal with 80 patients is very hectic. And this issue of male involvement, makes our work to be too much. So we do not have enough time to handle mental health issues. (Key informant: Midwife)
As a result of the scarcity of trained midwives, and the large numbers of patients that attend the maternity units, the time spent by a mother with a midwife was reported to be very limited. Furthermore, owing to the high levels of poverty and low levels of support from their male partners, mothers seldom return for further care after childbirth, limiting the opportunity to quickly identify those at risk of mental ill health.
After normal delivery, most mothers ask to be discharged immediately, yet such problems of mental health may manifest after leaving hospital.
(Key informant: Health manager)
Exacerbating the low levels of staffing, the available midwives reported that they were not adequately trained to handle mental health problems in mothers. Furthermore, their maternity units did not even have the necessary medication to treat mental illness should this be needed. The midwives believed that the general nurses training addressed mental health better than midwifery training and yet the general nurses do not usually provide mental health care either, as one midwife elaborated.
Midwives are not well equipped with mental health knowledge and skills. If midwives were trained on mental health they could do a better job and with the issue of not having knowledge and drugs, this makes work not easy.
(Key informant: Midwife)
It was clear, therefore, that there were logistical, health organizational as well as individual health worker competency issues that needed to be addressed to make the provision of perinatal mental health care possible.
In the community it appeared that there were low levels of identification and referral of pregnant and postnatal women in need of mental health services which impeded their access to care. Although there are VHTs within communities who are expected to be a link between the community and the health facility and to mobilize and refer patients for treatment, some health workers thought that these VHTs were being underutilized. As such, there was little or no monitoring, identification or referral of mothers in need of mental health services and yet the midwives lacked the means and the time to reach out to these mothers. One midwife lamented:
VHTS are always around the health center but they have little work to do because they are not aware of what to do. Over 40 VHTS are attached to our health center! (Key informant: Midwife)
The performance of the VHTs observed by the key informants was thought to be due to little or no support or coordination by the health management in the district. These VHTs are volunteers and therefore are not paid for the work they do. Health workers believed that if VHTs are well coordinated and paid this would motivate them to do more to identify and refer mothers that need care. One general nurse said:
At times, the VHTs ask for facilitation in terms of money and if they are not given money they give up. At times due to political influence, when they ask for help, they are shut down.
Key informant: General Nurse
The existence of the informal community health system was, therefore, seen as an opportunity to be harnessed. However, there was a need to better support and utilize the VHTs to improve the identification and referral of perinatal women in need of mental health care.
Another barrier to access to maternal mental health care at the community level was reported to be negative attitudes and beliefs about the causes of mental illness in a pregnant or postpartum woman. This was believed to hamper health seeking and referral of perinatal women with mental health problems. The community was said to associate mental illness, especially during pregnancy, with witchcraft. This in turn limited the uptake of services as reported by one key informant:
Cultural influences can be a hindrance. Generally, here, people believe so much in witchcraft. Before someone is brought to hospital they are taken to the witchdoctors. (Key informant: Clinician)
This belief that mothers who are mentally ill are bewitched causes significant stigma towards the ill mother. The community was reported as viewing these ill women as useless, so that no time should be wasted on them. As such nobody took care of them, as expressed by one clinical officer:
You may find that people take such people as useless so we need to sensitize …… on this (
Key informant: Clinician)
Feasibility and acceptability of delivering perinatal mental health services in primary care settings in Kamuli district
We explored the perceived feasibility and acceptability of incorporating methods of identifying and treating perinatal women with mental health problems at both the community and health facility level. This would ensure that more women that need help are identified and referred for care. These methods included i) screening by health workers at health facilities and ii) VHT community identification and iii) counseling of mothers at the health facility.
Health workers had mixed reactions regarding the feasibility of screening for perinatal mental disorders in their clinics. While some believed that screening would be feasibly done in the same way that it is used to identify patients with tuberculosis and HIV/AIDS in the district, others had reservations. The latter feared that introducing screening for mental health problems would increase their work burden which is already unmanageable. As one general nurse reflected:
Regarding the use of questionnaires, most mothers do not know how to read. I do not think that these questionnaires will work. There is a heavy work-load. (
Key informant: General Nurse)
Furthermore, health worker key informants noted that primary health care facilities lacked people with the necessary skills to deal with perinatal mental health problems. As such they believed that treating such women in primary care facilities would not be possible. Women with mental health problems, once identified, are referred to the district or regional hospital where it is believed they can access mental health services, especially medication. One midwife voiced her concern as below:
We do not admit people with mental health problems, we just refer them. We do not have doctors. I was not trained to treat people with mental health problems. We do not have drugs for people with mental problems. (
Key informant: Midwife)
The VHTs, on the other hand, were enthusiastic about incorporating identification and referral of perinatal women with mental health problems into their routine work. The VHTs reported that detection and referrals for mental health problems was already part of their role. However, it was acknowledged by some that they are limited by the fact that they are not appropriately trained to provide community mental health care. They suggested that training would make it easier to incorporate perinatal mental health into their work in the community.
I think that as we continue doing voluntary work we need some knowledge of counseling. If we are taken through that training of counseling, I think that can be integrated in our work
(Focus group: Village Health Team member).
On the acceptability of treatment, group counseling was believed to be an acceptable modality of treatment for perinatal women, especially in rural areas. The rural women in Kamuli were reported to usually meet in groups and talk about the issues that concern them in daily life. Group counseling would therefore fit naturally into this already existing traditional way of dealing with difficult issues in their life. According to the mothers and VHTs, it would be easy to bring mothers together to share their experiences and reduce their stress.
That is the best way to do it. Some of the issues they share when they are together can help them to learn from one another; (
Focus group: Village Health Team member)
……….and you can go in that group when you are stressed and by the time you leave the group, stress is off (
Focus group: postpartum woman
For the midwives, group counseling would not only be acceptable because it is close to tradition, but also because it is convenient for them as service providers. Group counseling would be efficient in terms of saving midwives time, which is already constrained by huge workloads.
Group counseling would be better in educating mothers on mental health because you may find that most at them have similar problems. It is also less time consuming. (Key Informant: Midwife)
Services available for mental health care
A midwife reported that she was not aware of any perinatal mental health services in primary health care facilities within Kamuli district except at the district and regional referral hospitals. The latter is in a neighboring district. As a result mothers are referred away from the lower health facilities to the regional hospital for help once identified to have or to be at risk of mental illness, for fear of the mother’s mental illness becoming too complicated for the midwives to manage. She stated:
If we have someone that has had any mental problem in the previous pregnancy, we refer them to the main hospital. We do this during health education such that she does not bring us problems.
(Key Informant: Midwife)
It seemed therefore that there are no available mental health services within the community for perinatal women to access. Traditional healers appear to form the basis of mental health care for the perinatal woman in the community largely because of how the cause of such illness is understood.
Recommendations from participants
Several recommendations were made by the study participants. These included:
a) Making mental health medicines available in maternity units where they are not currently stocked; b) that there needs to be provision of food for mothers needing admission, otherwise families would opt not to bring these mothers for care. Key informants reported that mothers had difficulty getting food in case they needed to be admitted for severe mental illness due to the severe household poverty. c) The need to bridge the knowledge gaps among midwives through training them in screening, identification and treatment of maternal mental health problems was raised numerous times by a range of respondents; d) Ensuring that resources are provided to enable mental health services to be provided alongside general maternal health care; and e) empowering the VHTs through training in order to increase community sensitization, follow up and support for mothers at the community level.