In South Africa, mothers and pregnant women suffer from high levels of mental health issues, with at least one out of every three experiencing depression and/or anxiety during pregnancy and for at least a year after the birth.
Now, for the first time, maternal mental health is being formally recognised in the country’s official blueprint for all matters relating to pregnancy. However, write Simone Honikman and Saleha Suleman in The Conversation, without the proper resources in place, they are unlikely to translate into effective care at the clinical coalface, and there is a high probability that they will simply remain a paper exercise.
The inclusion of a chapter on mental health in the fifth edition of the Integrated Maternal and Perinatal Care Guidelines for South Africa, released by the Health Department in October 2024, means doctors, nurses and midwives will now be able to assess for mental health conditions that may present for the first time or become more severe during or after pregnancy. These include the common conditions of anxiety, depression and post-traumatic stress disorders.
They will have a clear approach to managing these at primary care level and have protocols in place for referral.
If left untreated, maternal mental health disorders can have profound and lasting effects on both mothers and infants.
Some risks greater
Mental health is strongly linked to adverse social and economic conditions, so the risk is increased for women who face violence and trauma, poverty, discrimination, chronic physical health conditions and isolation.
Those who live with these mental health problems experience extreme distress and loss of quality of life, which limits their ability to connect with helpful social networks and income-generating opportunities, exacerbating their risk of marginalisation, poverty and abuse.
Untreated, mental health conditions can cause preterm birth and low birth weight, and can interfere with breastfeeding, while children of women with mental health problems are also more likely to suffer from stunting and poor mental health themselves.
Economic toll and potential gain
Untreated maternal mental health disorders also have economic costs. A 2022 study of the lifetime costs of untreated maternal depression and anxiety for SA mothers and their newborn infants showed that this would cost a lifetime estimate of R49bn per annual group of women and infants. These calculations included losses of income, and quality of life and public sector costs.
On the other hand, the financial returns for investing in addressing perinatal depression have been estimated to be the highest for all mental health conditions affecting the wider population at R4.7 for every R1 spent.
Highly treatable
Common mental health conditions are usually highly treatable, especially when diagnosed early and managed holistically.
There is also a growing body of global evidence that non-specialist providers could make a real difference.
Community health workers and maternity healthcare workers, for example, could treat mild and moderate cases of these mental health conditions if they are adequately trained and supervised.
Resources to provide services
The new guidelines lay the foundation for the management of mental health conditions for women using maternity care services. But without the proper resources in place, they won’t translate into effective care at the clinical coalface and there is a high probability that they will remain a paper exercise.
Unfortunately, in South Africa, primary healthcare workers in maternal and child health services are under-skilled and under-supported to provide mental health services.
These staff often face an unmanageable patient load with limited time. In 2019, staffing levels (public and private sector combined) for obstetrician/gynaecologists were 36% lower than the recommended target for the country. For professional nurses and midwives, there was a 71% shortfall.
Mental health services are poorly equipped to handle the extent of the population’s needs and mostly focus on treating people with severe conditions like schizophrenia and other disorders with psychosis.
For public health service users who require mental healthcare, less than 1% receive some form of inpatient care, and only about 7% receive outpatient care – meaning there is more than a 90% treatment gap.
For the few women able to access mental health support, many experience rushed appointments or extremely long waiting times.
Co-ordinated, concerted strategy
The guidelines mark a significant milestone for women’s health, but their successful implementation requires strategic planning, adequate investment, and coordinated efforts between the Department of Health, the Department of Social Development and NGOs.
Our main suggestions are:
• Training: invest in improving and expanding existing training programmes to equip maternity health workers with the proper skills for primary level mental healthcare.
• Supervision and mentoring: establish robust clinical supervision and mentoring programmes to support these staff to provide quality mental healthcare.
• Strengthened health worker well-being: promote their well-being within the work environment to mitigate burnout and improve patient care.
• Creating and funding existing referral options for women in need of psychosocial support and/or specialised mental healthcare, while supporting mental health non-governmental organisations.
Strong governance, effective coordination and dedicated financial investment are essential to implementing these strategies. The cost of inaction – both ethically and economically – is too high.
Simone Honikman led the development of the mental health chapter in the new guidelines mentioned above. Donela Besada, senior scientist at the Medical Research Council, contributed to this article.
Honikman – Director of the Perinatal Mental Health Project; Associate Professor, University of Cape Town;
Suleman – Lecturer, University of the Western Cape.
See more from MedicalBrief archives:
Perinatal depression: mums, dads, babies all at risk – London meta-analysis
Moms’ maternal health is important for children too
Mental illness rife in new mothers, midwives warn
Psychiatrists group urges government to spend more on mental healthcare