Lack of confidentiality and feelings of shame related to experiences of domestic violence as well as service providers' discomfort in dealing with mental health issues were some of the reasons why detecting symptoms of depression, anxiety and experiences of domestic violence in Cape Town's pregnant women is limited.
Other factors revealed by the University of Cape Town (UCT) study, titled "Facilitators and barriers to detection and treatment of depression, anxiety and experiences of domestic violence in pregnant women" - recently published in Scientific Reports - were service providers' limited time available and heavy patient load.
Common mental disorders (CMDs), such as depression and anxiety, are highly prevalent during the perinatal period, with low- and middle-income countries (LMIC) carrying the greatest burden. It is estimated that in LMIC, 18% of perinatal women experience depression and 34% experience anxiety. In South Africa, the prevalence of depressive symptoms during pregnancy ranges between 27% and 39%, while symptoms of anxiety range between 15% and 23%.
The researchers investigated facilitators and barriers of service providers and service users in detecting and treating pregnant women with symptoms of CMDs and experiences of domestic violence. The study was conducted in four midwife obstetric units (MOUs) in Cape Town and the non-profit organisations providing community-based support in the communities surrounding the MOUs.
Service-provider perspectives were informed by interviews with 37 healthcare workers, while service-user perspectives were informed by interviews with 38 pregnant women attending MOUs for their first antenatal care (ANC) visit.
Findings
The study found that service providers highlighted the lack of standardised referral pathways and the poor uptake of referrals by women with symptoms of depression and anxiety, or experiences of domestic violence.
Healthcare workers reported that they did not specifically enquire about domestic violence and only detected it when a physical examination revealed signs of physical abuse or when the woman voluntarily disclosed the information.
According to the study, one ANC nurse reported detecting women who were abused "twice or thrice a month", while an MOU manager reported that detecting women who were abused was "not often, but we do". A health promotion officer admitted that if she specifically enquired about domestic violence, she would detect many women as "domestic violence is so high here in this area".
"All except for one of the facility-based healthcare workers interviewed felt that it was important to screen pregnant women for psychological distress and experiences of domestic violence."
"All except for one of the facility-based healthcare workers interviewed felt that it was important to screen pregnant women for psychological distress and experiences of domestic violence," said Dr Zulfa Abrahams, the study's lead author and research development manager at UCT's Faculty of Health Sciences.
The study also found that most pregnant women reported that they would be happy to disclose their feelings and experiences of domestic violence. However, a few women expressed their concerns regarding confidentiality. One pregnant woman was especially concerned about whether such sensitive information would remain confidential, saying: "... especially in a community where everyone knows everyone, I do not trust them [nurses]".
Dr Abrahams shared: "Many healthcare workers felt that screening should occur at all clinic visits. One ANC nurse mentioned that CMDs could occur at any point during the perinatal period, not just when women attended the MOU for the first time, as psychological distress can start any time during pregnancy."
The study found that all ANC nurses were concerned about the amount of time it took to assess patients' mental health as their heavy workload and large patient numbers allowed them limited time with each patient. One ANC nurse highlighted her heavy workload in relation to her role as a midwife: "I can't [screen all patients] because now it's gonna take me a long time ... then you worry, I need to see the next patient ... so I won't be giving much time to her."
"They thought of themselves as clinicians who were primarily responsible for the physical well-being of the pregnant woman and her foetus, and that they were not trained to address mental health issues adequately."
Abrahams said: "ANC nurses reported feeling concerned that they would not be able to provide a comprehensive consultation if they had the added responsibility of asking women about their mental health. They also felt uncomfortable discussing mental health issues with patients. They thought of themselves as clinicians who were primarily responsible for the physical well-being of the pregnant woman and her foetus, and that they were not trained to address mental health issues adequately."
Barriers
While the importance of providing a counselling service was highlighted, Abrahams noted that healthcare workers pointed out that many women who were referred for mental health counselling, declined the offer. One ANC nurse explained that mental health issues were stigmatised in the community and that patients were concerned that they would be branded as "...mad if you go for counselling".
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"Our research suggests that the system-level barriers need to be addressed at a policy level. Service-user and -provider barriers identified indicate the need to strengthen health systems by training antenatal care nurses to detect symptoms of CMDs and experiences of domestic violence in pregnant women, developing standardised referral pathways and training lay healthcare workers to provide treatment for mild symptoms of depression and anxiety," said Abrahams.
Based on these findings, Abrahams said ANC nurses could be trained to routinely enquire about their patients' feelings and anxieties while examining them, instead of completing the screening tool as a ticking exercise while completing the required documentation linked to the consultation.
"This method of assessment would address the ANC nurses' concern regarding the time needed to screen patients, as well as communicate a genuine interest in patients' emotional well-being. Standardised referral pathways and processes, specific to each facility, need to be developed and disseminated widely to ensure that both healthcare workers and patients are aware of the services available and how to access them."
