Community health workers can help South African women with perinatal depression

Depression is defined by symptoms such as persistent sadness, low mood, sleep disturbances, low energy, and feelings of hopelessness. The condition is universal and can affect anyone. But certain people are more vulnerable or at risk of experiencing depression. Poverty and trauma are among the risk factors.

Pregnant women and mothers of infants are also at a higher risk of experiencing depression. This is because of the increased pressures they face economically, in their relationships, with their families and socially. And maternal depression has negative impacts on infant growth and nutrition.

Research done in Khayelitsha, a low-income township on the outskirts of Cape Town in South Africa, found that around 19% of pregnant women experienced depression and 16%–35% experienced postnatal depression. This is strongly contrasted with high-income country estimates where 9% of women experience antenatal and 10% experience postnatal depression.

The services that should be available to help these women are very scarce in South Africa. The country's mental health sector has been severely neglected and under-resourced. It receives only 5% of the total national health budget.

One way that's been proposed to help boost mental health services is "task sharing." This is defined as transferring specific tasks to community health workers with shorter training and fewer qualifications than specialists.

It has shown some promising results so far. But to be effective, it needs to consider how a person describes and understands the causes of depression, what elements of therapy are helpful, and how external factors influence the efficacy of counseling and therapy.

For part of my Ph.D., I examined these considerations in two sub-studies of depressed pregnant women in Khayelitsha.

'Thinking too much'

In the first sub-study, a sample of 34 participants were asked how they would describe depression. They responded with phrases and idioms such as "being stressed," "thinking too much," "feeling sad," and "being afraid."

The women also identified what they said were reasons for their depression. These were all related to contextual issues, such as a lack of support from partners and family, having an unwanted pregnancy, the death of a loved one, facing poverty and unemployment, thinking too much (a description and a cause), and anxiety around coping with a new baby.

The women's own descriptions of how they felt and why were an important first step in developing a way to help them. A psychosocial counseling intervention needs to acknowledge womens' context and address some of the above issues in collaboration with them. The information that the participants provided was used to help to develop a six-session counseling intervention for a randomized controlled trial testing task-sharing for pregnant women in Khayelitsha, with community health workers providing the counseling.

The second sub-study was conducted after the randomized controlled trial was completed. It examined transcripts of counseling sessions from 39 participants in the trial. Each had received six sessions of psychosocial counseling from a community health worker.

Common elements of therapy

The study investigated elements of the counseling sessions that women said had helped improve their symptoms of depression. Participants said they valued their counselors giving them information on pregnancy, birth and depression (known as psychoeducation).

The women appreciated it when counselors told them it was normal to feel depression. Counselors who expressed empathy and showed commitment to the therapeutic process were also appreciated. The women valued the experience of confidentiality and being able to share their problems with someone they trusted. They felt a sense of relief after opening up to someone, and were able to start communicating better. This led to a feeling of connection and hope.

Participants also appreciated the advice that counselors gave them about their relationships with their partners and their family members. Although this is not normally used as a therapeutic technique in counseling, it appeared to help women in this context.

Many of these factors have been identified in other studies of the counseling components and techniques that are effective in low- and middle-income countries. The study therefore validates the use of these "common elements" of therapy across a wide variety of counseling interventions.

Social determinants of mental health

The study also revealed social and economic factors that women in Khayelitsha face in their everyday lives that may have influenced how helpful counseling was for them. These included food insecurity, intimate partner violence, economic abuse and alcohol abuse by partners, lack of support from partners, HIV/AIDS, and continuously occurring traumatic events.

Although women said counseling from community health workers was helpful in many ways, these social and economic factors had a negative impact on the short- and long-term effectiveness of the counseling for them.

The study thus recommends that psychological interventions should include elements that try to address some of the social determinants of mental health. Strategies to deal with intimate partner abuse and to build economic skills would be examples.

The findings also support the provision of a basic income grant for all unemployed people. This would assist in reducing anxiety for women around obtaining food and other things they need for physical and mental wellbeing.

Looking ahead

In summary, this study highlighted the importance of addressing depression and anxiety for pregnant women and mothers of young children, using locally relevant descriptions of depression and addressing the causes identified.

Employing community health workers to provide counseling helps women to some extent and reduces the burden on specialists in the public mental health sector. But sufficient training and consistent supervision is essential to equip these health workers with appropriate counseling skills.

Interventions to assist depressed pregnant women also need to use techniques and strategies that consider the very real influences of poverty and related trauma on both depression and on counseling effectiveness.