Hailed as a "watershed moment for women's health in South Africa", the release of the country's long-awaited updated National Integrated Maternal and Perinatal Care Guidelines (NIMPCG) marked an especially proud occasion for the University of Cape Town's (UCT) Perinatal Mental Health Project (PMHP), which was a key contributor to this crucial guidance for healthcare workers.
Released in October by the national Department of Health, the fifth edition of the guidelines for optimising mental healthcare among pregnant and postnatal women is a response to statistics that show that one in every three South African women experience mental health conditions during pregnancy and the postpartum period - double the rate in high-income countries.
"The release of the guidelines is a watershed moment for the women of South Africa," said Associate Professor Simone Honikman, PMHP founder and director, given that mental health issues are a major contributor to South Africa's maternal mortality rate of 109.6 per 100 000 live births, eightfold higher than in the United Kingdom.
Hard-won battle
The inclusion of the three additional chapters championed by the PMHP in the NIMPCGs has been a hard-fought victory. At 22 years in the making, Associate Professor Honikman and her team have had to overcome resistance around including certain topics - like intimate partner violence - and deal with plenty of bureaucratic delays.
Since its inception, the PMHP has shifted from offering integrated services to pregnant and postnatal women at several sites across Cape Town. Now, their work is concentrated on one demonstration site at the Hanover Park Midwife Obstetrics Unit, and they are also deeply involved in research and advocacy.
"Mental health issues are a major contributor to South Africa's maternal mortality rate."
"We have increasingly focused on systems strengthening work to ensure that health and social development organisations are capacitated to deliver maternal mental health services at scale. Our focus areas include advocacy for action, capacity building and knowledge generation, in addition to our comprehensive maternal support service, which continues to evolve and improve," Honikman said.
Along with the updated South African guidelines, the PMHP also supported the development of the World Health Organization's Guide for Perinatal Mental Health in Maternal and Child Health Services.
Social determinants of health
She attributed the divergent prevalence of mental health issues between higher- and lower-income settings to the respective social determinants of health, those non-medical factors that influence health outcomes. "The core social determinants of perinatal anxiety and depression include poverty, food insecurity, intimate partner violence, domestic violence, discrimination, social isolation and marginalisation, experiences of adverse childhood events and trauma, and a lack of safety and security," Honikman explained.
In South Africa, the interconnectedness of these determinants heightened the difficulty of addressing these issues: "We quite often find that women have three, four or even five of these risk factors. Our women are facing multiple syndemic conditions, where one reinforces the other.
"For example, if you're HIV positive, you're more likely to experience violence in the home. The reverse is also true: you're more likely to become HIV positive if you experience violence in the home. Separately, and together, HIV and being a victim of violence places women at far greater risk of experiencing mental health problems."
Honikman noted that a deep understanding of these factors had contributed to a more effective framework for managing maternal mental health issues: "What we've tried to do in the national policy is to foreground the social determinants, and then use the guidelines to show exactly what can be done by healthcare providers, and how," she said.
"This is important because the health sector doesn't traditionally work with social determinants very comfortably. However, as we have a particularly good uptake of maternity care in South Africa, we thought that if the women are coming to health services, it makes sense to optimise the opportunity to provide them with holistic care."
Optimising treatment and support
As such, the book looks at everything from how to map scarce resources and optimise referral processes, to how to engage with women in an empathetic, affirming way that improves the likelihood of them accepting these opportunities for treatment and support.
The team is hopeful that the updated guidelines will help foster a cultural shift in healthcare settings, with frontline workers better equipped and supported to address mental health issues, especially common psychosocial challenges.
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"For every R1 spent on developing mental health services for women, the return is around R4.70, so improved investment is crucial."
"Among other things, we want to see an injection of frontline workers who are dedicated or designated to working in maternal mental health so that women have access to on-site mental healthcare and psychosocial support that is integrated with the physical healthcare they receive during and after pregnancy," Honikman said.
"It would also be great to see adequate financing allocated towards this development. Our health economists have shown that for every R1 spent on developing mental health services for women, the return is around R4.70, so improved investment is crucial."
Primarily, they wanted to see a cultural shift in the healthcare landscape, to one in which compassion and respect are prioritised for healthcare workers and patients alike.
The PMHP is a self-funded project within UCT's Department of Psychiatry and Mental Health. Make a donation to support mothers in distress, and build a more positive future for women, their children and the communities in which they live.
