OPINION: Maternal Mental Health; Uganda’s Alienated Health Field

A mother holds her newborn baby at Providence Hospital in Washington, D.C., December 2016. (Getty Images/Nikki Kahn)

Pregnancy is a normal life event and is often a happy exciting time, however, it’s a period in which a woman is more vulnerable and exposed to significant amounts of stress and anxiety. Like any other person, all pregnant women have fear for the unknown and with very many unanswered questions. Due to all this, they are at a higher risk of developing mental health disorders.

The World Health organization (WHO) recognizes World Mental Health day on 10th October every year. The theme for 2021 is “Mental Health in an equal World”. The WHO also notes that 10-16% of pregnant women experience mental health disorders, with depression (31%) and anxiety (37%) being the commonest. In many countries, Uganda inclusive, mental health disorders remain widely under-reported. These disorders are complex, could be pre-existing or pregnancy-induced, and can take many forms such as depression, anxiety, eating disorders and/or schizophrenia.

Depression in pregnancy can progress to the postnatal period or even result in postpartum psychosis which is a psychiatric emergency. These create disturbances thus disrupting the mother-infant bonding which compromises child development. In addition, they could directly translate into inability of the woman to perform basic activities of daily living. This may have an implication on her physical health as well as that of her family members.

In our society, most maternal mental health cases go unnoticed majorly due to traditional myths and beliefs surrounding mental health issues in general. This is not alien to all of us as we have at one point experienced, witnessed, or heard of a woman who suddenly “went crazy” or “became possessed” as is commonly termed, after childbirth. 

Three years ago, 19-year-old Zubedda (not real name), reported to one of the health facilities in central Uganda at 5:30 pm with labor-like pains that had started the previous day. From her records, she had attended antenatal care (ANC) five times at the very same facility, but with no evidence of mental health assessment at any of the visits or even psychiatric history taken. At 11:50 am, the following day, she delivered a live healthy baby. However, three hours later, she developed a fever, manifested urine and bowel incontinence of unexplained origin, disorientation in time and place which was associated with visual and auditory hallucinations. Later on, she became very aggressive on seeing her husband and relatives.

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Additional history revealed that Zubedda had a lot of stress throughout her pregnancy. One could hardly believe that a lady who had just delivered safely could in a blink of an eye, switch from being so calm to completely aggressive to an extent of requiring physical restraint.  Soon, this attracted a crowd of other caregivers to patients within the same facility who made a conclusion that she had been possessed by the spirit of her late father since she behaved as if there were two different people living in one body.

Despite the health worker’s efforts to link the mother to appropriate care, the family members still declined and opted to take her to the ancestral home for cleansing rituals. Follow-up efforts seemed futile as family members were unwilling to give details of what transpired after. They claimed that the mother would eventually get better.

ANC which should be an avenue for mental health assessment of pregnant women is a seriously underutilized opportunity in Uganda as this has been given less priority. Health facilities are heavily understaffed with overwhelming client numbers. Health workers now focus more on the physical wellbeing of the mother and unborn child than the psychological aspect, in a bid to cope with an already constrained, overly stretched health care system. The ideal holistic care that is meant to be availed to pregnant mothers has long been forgotten in the protocol of care. Zubedda had attended five ANC visits at the same facility but none of her mental health needs were ever addressed yet this was a chance to single out her psychological problems. 

Early identification and treatment of maternal mental disorders is imperative for the health of both mother and child. Keen interest in psychiatric risk assessment and community sensitization to dispel myths concerning mental health issues has to be taken. Many women, like Zubedda, have missed out on appropriate care and are instead taken for spiritual cleansing and traditional remedies. These could momentarily relieve symptoms.

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However, any slightest trigger could result in full-blown psychosis which is fatal for the mother and baby as well as the family members. Often times mothers become a constant threat to their families, are at risk of injuring their children through neglect like refusal to breastfeed, and command hallucinations, occasionally suicide and infanticide may also ensue.

According to the Global Alliance for Maternal Mental Health (GAMMH), mental health problems in pregnancy and following childbirth are roughly twice as common in low-income countries such as Uganda, as they are in high-income countries. Despite all this, mental health among pregnant women in Uganda is still a neglected public health concern. This continued neglect can lead to detrimental human and economic costs for this generation and the next.

Prevention and effective management of maternal mental health disorders requires a multifaceted approach consisting of;

  • The practice of self-care among women which is purposeful engagement in activities that promote healthy functioning and mental well being 
  • Unconditional partner support in all aspects especially economically and emotionally
  • family and community support of pregnant women
  • spiritual support from religious leaders
  • sensitization about maternal mental health by community leaders especially local councils
  • Media effectively informing the public about mental health
  • Health workers should aim at offering holistic care for pregnant women, 
  • The Government should promote maternal mental health through developing clear and inclusive policies that guide clinical practice to include mental health as a mandatory aspect of patient care especially for pregnant women.

Maternal mental health has been neglected for far too long, and it is high time we all woke up from our slumber and acted before it’s too late. Mental health is everyone’s responsibility. Let us prioritize maternal mental health.

The authors are BSc trained Midwives working with Sanyu Africa Research Institute as Research Midwives
Nafula Patience Ann Maria; Nambozo Brendah; Amanya Daphine; Nakate Alice and Nakyazze Monicah

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