Characteristics of the study participants
Socio-demographic characteristic of the participants are described in table 7. A total of 13 participants were involved in this study, nine of whom were male (69%). The median age of participants was 34 years (range 26–55 years) and the median work experience was 11 years (range 4–35 years). Participants’ professional backgrounds were varied, with midwifery (6) and public health (4) being the two largest groups.
Table 1
Characteristics of the interview participants involved in a qualitative study, Gondar Town, Ethiopia (N = 13).
Participant characteristics
|
Participants(N = 13)
|
Median age (range)
|
34 (26, 55)
|
Sex
|
|
Male
|
9
|
Female
|
4
|
Median work experience in the health system (range)
|
11 (4, 35)
|
Profession
|
|
Midwifery
|
6
|
Psychiatrists
|
2
|
Psychologist
|
1
|
Master of Public Health
|
4
|
Place of work
|
|
Health offices
|
6
|
Hospitals
|
4
|
Health centres
|
3
|
Three main themes, with 13 sub-themes, emerged as barriers to, enablers of, or opportunities for perinatal depression health services implementations in Ethiopia: (i) health administrators’ and community knowledge about perinatal depression, (ii) fragmentation of health system, and (iii) enablers and opportunities. These are described in detail in Table 2.
Table 2
Summary of barriers to perinatal depression health services implementations in Ethiopia, 2018 (N = 13)
Themes
|
Sub-themes
|
Health administrators’ and community knowledge or awareness about perinatal depression
|
1. Conceptualising perinatal depression
2. Risk factors
3. Signs and symptoms
4. Onset of symptoms and screening
5. Consequences
6. Interventions
7. Community awareness and culture
|
Fragmented health system
|
8. Government capacity, readiness, and prioritisation of perinatal depression
9. Perinatal mental health policy and strategy
10. Lack of perinatal mental healthcare system
|
Enablers and opportunities
|
11. Introduction of the new mhGap action program
12. Health professionals’ commitment
13. Simplicity of screening program
|
Health administrators’ and community (public) awareness about perinatal depression
Seven key sub-themes emerged from the first theme, explaining the roles that health administrators and community mental health awareness and cultural issues played as barriers to implementing perinatal depression health services in Ethiopia.
Conceptualising perinatal depression
Proper conceptualisation of perinatal mental health or depression by health administrators is a crucial step in order for them to develop appropriate strategies to address the disorder. Some administrators related the concept of perinatal depression to the WHO definition, which proposes health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (49). Thus, the concept of health should account for mental health, which is important in keeping the psychological, spiritual, and emotional component of human health. One health administrator interviewed said:
A mother is said to be healthy as defined by the WHO: if she can use her mind properly, if she can resist for any source of stressors, if she is fruitful in any work or activity, and if she can manage or administer her family properly. In line to the WHO definition, health is not merely the absence of disease but should also include mental wellbeing. (Male, aged 32 years)
Other participants used a range of indicators to define maternal mental health. According to their perceptions, if the mother is free from depression, she would: (i) adhere to perinatal follow-up and usual activities; (ii) overcome challenges (e.g. adjust or withstand life stressors or events related to parenthood); (iii) be confident about herself and her pregnancy (e.g. she has positive thoughts, she is happy and feels healthy during pregnancy or after birth); (iv) have good social and personal interactions. These assertions are seen in the following quote.
So, if the mother is mentally healthy, she should be socially, physically, and mentally healthy. In the other way, if she can perform her usual activity, comes for follow-up services, and if she can comprehend what clinicians have said about her health, we can say she is mentally healthy. (Female, aged 50 years)
Nearly half of participants stated that they did not know about perinatal depression, or they were not sure about it. Other respondents argued that there was no literature or documents written about perinatal depression and the available working guidelines by the government did not mention perinatal depression. Some respondents did not distinguish between to perinatal and post-natal depression. One of the interviewees indicated their lack of knowledge about perinatal depression:
I do not have any idea about perinatal depression though I am a non-communicable disease officer. We are using the new non-communicable disease guideline developed by the Federal Ministry of Health and perinatal depression is not included in the guideline. (Male, aged 41 years)
Health administrators’ knowledge about risk factors for perinatal depression
Health administrators’ knowledge of risk factors for or causes of perinatal depression is important to enhance their active involvement in designing interventions that would help in prevention and management of perinatal depression. There was a range of understandings expressed about by participants, some of whom indicated relatively limited awareness about risk factors for perinatal depression.
A number of respondents proposed that individual characteristics such as female sex, younger age or older age, and personal misbehaviours such as substance use, alcoholism, drug and smoking are risk factors for depression. It was noted from the interviews that these participants did not have awareness or knowledge about perinatal depression specifically as they were focused on mentioning risk factors similar to those for depression in the general population. One of the participants mentioned,
Those who are addicted to alcohol, chat, cigarettes are more depressed. After they already immersed into it, and when they could not get these substances, they would develop depression symptoms. (Male, aged 52 years).
The reason for this (depression) might not be clear but the epidemiology showed that depression is higher in females than males. This might be because women are not emotionally strong than males. (Male, aged 29 years)
Fewer than a quarter of participants agreed that the perinatal period by itself could be a risk factor for depression. They proposed that stress associated with the physiological and hormonal changes happening during pregnancy and the postnatal period could lead to depression. Furthermore, women might start to develop psychological stress in the early stage of pregnancy, related to body image changes impending childcare responsibilities and/or other family issues. To demonstrate this, participants said:
Depression could occur during pregnancy or after birth because of some hormonal imbalances and the women would benefit from psychosocial support given by partner or any family members. (Male, aged 26 years).
...especially pregnant women, if in their early stage of pregnancy, when they feel different or start thinking about their pregnancy and the new environment after birth, they might be exposed to depression. (Male, aged 29 years)
Most participants, however, argued that the perinatal period by itself was not a risk factor for depression except for women facing additional risk factors. The proposed factors included: early age or first-time pregnancy, cultural beliefs, economic concerns, lifestyle risks such as substance misuse, poor health status during the perinatal period, sleep problems, and/or psychosocial problems related to marital relations, limited partner and social support, or unwanted or unplanned pregnancy. The following quotes illustrate the above understandings:
Sometimes it (depression) might happen to women when they are in low economic condition or financial struggle. Mostly, pregnant mothers who were pregnant for unwanted or unintended pregnancy are also stressed. If there are young to their age and very difficult for them to handle the pregnancy or they have other duties, they might start to feel depressed. However, I do not believe that pregnancy by itself is a risk factor for depression. (Female, aged 55 years).
… as a culture, when everybody comes to visit the mother, coffee should be served, and such gathering having repeated coffee ceremony might affect their (women) sleep frequency and quality as it is known that caffeine interferes with sleep. Taking care of their kids for long time in the night and their responsibility of leading family put these women not to have adequate sleep leading them to stress and depression. (Male, aged 29 years)
Further cultural risk factors for depression identified by participants included the lack of a person accompanying the mother during delivery. It was suggested that unaccompanied women immediately after delivery might be fearful or even begin to develop psychotic thoughts. It was proposed that lack of partner or family support may result in feelings of loneliness, worthlessness or feeling ignored. As one participant said:
…, for example, there is a saying after delivery called, “they leave me alone” or “she/he left me alone”. Psychosis or post psychosis might occur like this. Isn’t it? They might be tensioned for unknown reasons; can’t we say this a peripheral psychosis? (Female, aged 55 years).
While psychosocial, genetic, and biological changes related to pregnancy and childbirth were identified as risk factors, some participants stated their belief that the cause of perinatal depression is not well known. One mentioned that the disorder is mostly suspected when the mother starts ‘accidentally hating’ her baby. These participants proposed that specific causes of perinatal depression are still subject to debate in scientific literature.
The cause of depression could be related to delivery, pregnancy, genetics or natural, but this is one of the controversial issues for debate. (Male, aged 32 years).
Health administrators’ awareness about signs and symptoms of perinatal depression
Knowledge about signs and symptoms of perinatal depression is important for early identification and intervention. This sub-theme reflects health administrators’ understanding of the signs and symptoms of perinatal depression. Most participants described signs and symptoms of perinatal depression that fell into either physical or psychosocial categories. Physical symptoms included feeling tired, being sleepy, loss of appetite, weight gain, headache, disorganised speech, not responding, inability to speak, unable to accomplish daily activities, over-sleeping, mood changes, shivering and unconsciousness. Psychosocial symptoms proposed by participants included feelings of worthlessness, sadness or sorrow, hopelessness, stress or anxiety, loneliness or self-isolation, dissatisfaction with health services, agoraphobia, inappropriate clothing, suicidal ideation and even suicide attempts, Many of the proposed symptoms reflected the more severe forms of depression, rather than milder depression which is most common during pregnancy or the postnatal period, with the rare exception of psychosis which can be severe but is easily diagnosed.
Mother with depression could show signs such as lethargic, not speaking correctly, unable to give their address, I know these. For example, they might not care for themselves or their foetus or infant. if they have HIV, they might not use condoms correctly. They might not be satisfied with their routine life, they might hate to do their usual activity, or they hate to speak to you. They might show feeling of worthlessness, suicide, sad, sorrow, tiredness, and they would not dress their clothes properly. (Female, aged 55 years)
In order to be able to provide services or to develop policies that would address perinatal depression, health administrators must be aware of what perinatal depression is. For some participants, this awareness was not demonstrated. For example, one participant indicated that they were not sure whether depression symptoms were different for perinatal women than the general population and was not able to mention general signs and symptoms that everybody with depression shows.
It is not specifically to mothers, that I do not know, but I can tell you the general signs and symptoms of depression that anybody with depression could show. (Male, aged 32 years)
Health administrators’ knowledge about the onset of symptoms and screening of perinatal depression
Health administrators’ knowledge about the specific time of onset of perinatal depression symptoms could help the development of protocols to initiate and implement screening programs at its most detectable time, but participants’ knowledge or awareness about perinatal depression signs and symptoms was not specific. Their descriptions better reflected signs and symptoms of general depression. Participants commonly compared the extent of depression occurring during pregnancy and after birth. Some suggested that depression occurred more commonly during pregnancy than after birth. Another argued that depression rarely occurred during pregnancy but was more common after birth.
In some of the mothers, it might occur early like during their first trimester, but most of the time, it occurs at the end of the pregnancy. After birth, it is not common, but depression might occur in a few of the mothers. (Female, aged 32 years)
Sometimes depression might occur at the time of delivery though it was not reported in our institution. However, most of the time it occurred after delivery or during the postnatal period. (Male, aged 27 years).
Health care administrators require awareness about the timing of specific signs and symptoms of perinatal depression to detect it early and provide appropriate care for perinatal women. Concerningly, not all participants were able to identify the period by which signs and symptoms of perinatal depression might manifest:
.
Honestly speaking I do not really know the time by which these mothers start to show signs of depression or develop signs of depression. (Male, aged 32 years).
Participants’ attitudes towards a specific time of screening for perinatal depression correlated with those about the time of occurrence of depression. Those who believed that depression is a problem of pregnancy perceived that screening should be conducted during any contact made with pregnant women during pregnancy, and they proposed the ANC visit as an appropriate time. Those who believed that depression was a problem of the postnatal period stated that depression screening should take place during the postnatal visit. In general, the best time proposed by many participants was at the time of ANC and PNC visits. This is justifiable because, while perinatal women present to health facilities for pregnancy and postnatal check-ups, in Ethiopia few postnatal women attend PNC visits.
The screening should take place starting from the time of pregnancy until the postnatal period as we do not exactly know when the depression signs start to manifest. However, we give focus to postnatal depression as its prevalence is high. When we say postnatal, it includes from four to six weeks. (Male, aged 28 years).
Mainly if it (depression) should be screened, screening should be conducted during pregnancy when she comes for ANC follow up, when she comes for delivery, and thirdly after delivery when she comes for PNC follow up. (Male, aged 27 years).
Some participants indicated that screening for depression should be conducted at outpatient departments in health facilities. In the Ethiopian context, outpatient departments are areas in health facilities where patients receive immediate assessment and treatment. Most often, however, perinatal women attend maternal health clinics for issues associated with their physical health rather than visiting outpatient departments. This might suggest that participants were not adequately aware of perinatal depression.
I would be happy if screening could be done all the times. For example, in the outpatient department. Yet, we do not have psychiatry nurses in our health centre, and if we have one that can screen depression, this will help in reducing its burden. (Female, aged 55 years).
Other participants suggested that perinatal depression screening could be conducted during house to house visits. This idea was in reference to the use of health extension workers. These workers implement the Health Extension Program, which is a vertical program designed in Ethiopia in 2003 to improve access and affordability of primary health care services.
The screening of depression for mothers should be started at their home by health extension workers as the urban health extension workers’ package addresses mental health issues. (Male, aged 41 years).
Disagreeing with the above, another participant working at a higher level in the healthcare system claimed that there was no evidence clearly showing that depression during pregnancy is common or that screening should be implemented. Furthermore, the participant stressed that the specific time at which this depression should be assessed and how to assess it is unknown.
There is nothing that says pregnant mothers are at risk of depression, and they should be assessed at this point. For example, I know that a pregnant mother who has suspected to have sexually transmitted diseases should be checked and treated after three months. But there is no study that recommended time by which depression during pregnancy should be assessed and treated. There is no screening procedure for depression in pregnancy. (Male, aged 52 years).
Health administrators’ knowledge about the consequences of untreated perinatal depression
Health administrators’ knowledge or awareness about consequences of untreated perinatal depression is crucial in order to give the matter priority in government planning. Participants expressed a number of views on the consequences of perinatal depression, ranging from serious infant and maternal health effects, including suicide, to social and family disruption. This would seem to indicate that an increased health focus on perinatal depression.
Almost all participants raised concerns that untreated depression would develop into a severe mental health disorder and potentially lead to suicide. However, the type of depression referred to would appear to be a severe form. Depression that occurs during the perinatal period is more commonly mild or moderate, which can be difficult to identify and diagnose. The severe form of depression that most participants discussed was severe psychotic disorders. It is possible they felt that perinatal depression, which is usually categorised as a non-psychotic disorder, could further develop into a psychotic disorder, as they stated:
If they stop taking their drugs, this might lead them to leave and sleep on roadsides or outside their house. (Female, aged 55 years)
Unless we diagnose and treat depression at an early stage, it might develop into an irreversible psychiatric problem such as dementia, which is unwanted. (Male, aged 29 years).
Most participants also suggested that untreated depression could lead to maternal suicide and death, proposing this could be through worsening to a severe form of health disorder that affects health seeking behaviour or makes women feel lonely and hopeless. Other participants suggested that depression directly leads to death because it is reported to be a major cause of death worldwide. Interviewed hospital workers stated:
Finally, if they are not treated from depression, they start to feel hopeless and, at last, go to suicide. When they had severe thought of hopelessness, they start asking about what is living for them. As they lose the meaning of life, living in this world would be nothing for them. So, they start with the idea of suicide, then they attempt and commit suicide at the end. (Male, aged 34 years).
The end consequence is death as depression by itself is a disease that cause death. (Male, aged 27 years)
The effect of perinatal depression on foetal development and birth outcomes was discussed. Participants explained the link in several ways. (a) Not using antidepressant medication correctly could affect foetal development and birth outcome; (b) genetic transmission of depression via placenta could lead the newborn baby to foetal distress and death; (c) depression could cause high blood pressure that would complicate the pregnancy and lead to abortion; and (d) depression could affect the nutritional status of the pregnant woman and foetal development.
Her foetus might have retardation, and in our culture, it is having been believed that, if the mother has depression, it also passes to the kid genetically. Based on my information or what I have heard, your foetus is healthy if you are healthy or your foetus is active if you are active. (Female, aged 55 years)
During pregnancy, a mother in severe depression might not feed herself well; if she feels unmotivated or inactive, the foetus will not develop well, its growth would be restricted, or the pregnancy might end up in abortion. (Male, aged 26 years).
Adverse effects of perinatal depression on infant health (such as malnutrition, illnesses, and death) were suggested by the participants. Potential links between perinatal depression and infant morbidity that were proposed included reduced infant care, difficulty breastfeeding, and poor health-seeking behaviour. Perinatal depression as a cause of infant death was explained by the participants in two ways. The first is because of psychosis, which may present with sudden onset due to major hormonal imbalances after birth and lead to infanticide. This perception suggests a lack of clarity among study participants, given depression and psychosis are different conditions. The alternative theory proposed by participants was via maternal death due to depression, leaving the newborn orphaned and vulnerable to diminished care and development. There is little evidence for perinatal depression as a potential cause of mortality, which may further indicate low awareness among participants.
The mother starts to hate her infant and if she has no social support or if there is nobody around her, she might kill her infant by choking or by any other means. (Male, aged 34 years).
The mother might die from depression or other related conditions leaving the newborn orphaned, which affects cares to be given for the newborn that leads to poor growth or death. (Male, aged 27 years).
Nearly half of the participants identified the consequences of perinatal depression on social or family disruption through reduced income, disrupted relationships, and inability to work. It was suggested that mood swings and inability to communicate effectively because of depression symptoms would affect social and family interpersonal relationships. Similarly, because of decreased desire to work and perform routine activities in the home or outside, family income and relationships could be compromised. This could directly or indirectly lead to family or social disruption. Their behaviour change would also affect women’s interaction with their social circle or family.
She might not correctly work what she has been working because of the depression. So, she might affect her family income as depression affects her work interest and productivity. (Male, aged 52 years).
Depression affects health of the mother and this indirectly affects the family. For instance, the mother might be unable to handle her family or not well functioning in performing routine activities in the family. (Male, aged 41 years).
Participant's Views About Perinatal Depression Interventions
This sub-theme highlighted health care administrators’ views on how to care for perinatal women with depression. Two main views emerged from the analysis: (i) mothers with depression symptoms should be referred to hospitals because these are the only places where antipsychotic drugs are available, (ii) psychosocial support should be provided by health professionals, partners or families of mothers. Almost all participants recommended psychosocial support in the first place, with treatment for psychosis if the condition was severe.
For those who had depression, we provide social support by identifying possible sources of depression through psychological treatment or psychotherapy. If it (the depression) is severe enough, we provide them with psychotic drugs. And for mothers who have minor depression, their family should be informed or advised on how to provide them (the mothers) with support. (Male, aged 34 years)
Cultural perspectives and lack of community (public) awareness about perinatal depression
Low level of community health literacy or awareness, low health-seeking behaviours for mental health, and cultural norms about perinatal depression indirectly affected implementation of perinatal depression health services. Community awareness about perinatal depression and good health-seeking behaviour are very important to prevent and control the problem. Participants were concerned that women might seek out cultural and religious approaches to manage their depression rather than conventional health services by thinking of the disorder as evil and giving it other cultural meanings. Participants mentioned that public (community) awareness about mental health disorders, including depression, is low and people were not aware that such mental disorders are treatable. Participants raised the issue of community health literacy and poor health-seeking behaviour related to public cultural practices:
In fact, in addition to the lack of data, in our area where we are living, culturally, mothers would not prefer to go to health facilities when such disorder is happening to them. As depression is considered evil and demonic, most of the time, perinatal women prefer to go other places for service such as spiritual places to use holy water. (Female, aged 36 years)
The other barrier is community awareness on mental health condition or depression, they do not know that this condition is treatable. (Male, aged 52 years).
Fragmented Healthcare System
Three sub-themes emerged from interviews under the main theme of the fragmented healthcare system: (i) perinatal mental health policy and strategy; (ii) perinatal mental healthcare system; and (iii) government capacity, readiness, and prioritisation of perinatal depression
Perinatal Mental Health Policy And Strategy
The Ethiopian National Health Policy is an overarching document that provides guidance on how the country should address long-standing and emerging health priorities. This sub-theme assessed health administrators’ views about how Ethiopian health policy addressed the issue of maternal mental health. Most participants expressed concerns that mental health services in general were compromised. Participants tried to underline the lack of attention to mental health services in Ethiopia by highlighting the lack of mental health policies and programs that should guide government activities. The following quotes reflect these concerns:
So, I can say mental health issue and concerns are not receiving much attention from the top government. For example, if you try to contact the health bureau for issues concerning mental health, nobody gives you attention and services. Even when it is related to our ward (psychiatry ward). Generally, there is a lack of attention, starting from the policy framework, curriculum, and training. (Male, aged 34 years).
The absence of clear policy frameworks and programs might also affect appropriate training and allocation of human resources for mental health. The lack of properly organised mental health structures at different levels of the Ethiopian healthcare system may also stem from the lack of a national mental health policy and related programs. Despite being the second most populous region in the country, it does not have organised teams of mental health experts or mental health specialists able to plan and establish mental health services at the regional level. One participant said:
There is no mental health focal person at the regional level. If there is no focal person, nothing would be done. But if there is a focal person, he/she can plan, deal, arrange … (Male, aged 34 years)
The general national mental health strategy developed in 2012 (50) did not specifically address mental health need of vulnerable groups such as perinatal women, peoples with disabilities, and incarcerated people. Nearly all participants confirmed that the available national mental health strategy did not specifically focus on the diagnosis and treatment of perinatal depression. The following quote demonstrates this:
We do have a general country-level mental health strategy, but it is not specified for age, sex, or specifically designed for pregnant mothers, and it is a general approach. (Male, aged 34 years)
Perinatal Mental Healthcare System
A healthcare system is the organisation of institutions, departments, health professionals and resources that are essential to deliver all healthcare services required to meet the needs of a given population. To undertake screening and manage perinatal depression, therefore, there should be an established and clear healthcare system at all levels that can address the ‘who, how, where, when and what should be done’ questions. The main barrier, agreed by almost interviewees, was the lack of an established system to prevent, screen, and treat perinatal depression. As one participant described:
The system might be challenging; for example, it would be difficult to say that clinicians in the area of ANC can know and screen depression. If you go to other health facilities or such clinics and ask how they are screening pregnant women with depression, they would tell, we use nothing. This itself can be part of the system. So, if the mother has depression during pregnancy or after delivery, she might be missed or misdiagnosed because of the lack of provision to identify the problem. And as a psychiatry clinic leader, if I want to create a system like if I want to assign a psychiatrist in ANC or PNC department to screen depression, nobody allows me, and this is part of a system too. (male, aged 28 years)
Government Capacity, Readiness, And Prioritisation Of Perinatal Depression
This sub-theme includes healthcare administrators’ perspectives of government capacity, readiness, and priority for screening and managing perinatal depression at health service delivery points. The actual activities implemented at service delivery level to address perinatal depression were explored. All those interviewed agreed that there was no effective or adequate guidance for managing perinatal depression in health facilities at different levels of healthcare delivery. One health administrator from a health centre said:
Yes, I can say the Federal Ministry of Health (FMOH) has no initiative, plan, and readiness to screen, treat, prevent, and control perinatal depression in the healthcare system. So, if FMOH has no such initiatives, it isn’t very easy, or it is obvious that health structure beneath the FMOH would have no such initiative as every activity we are doing is based on the FMOH direction. (Female, aged 36 years)
Participants identified reasons for such little attention due to: (i) reduced priority of perinatal mental health; (ii) lack of knowledge about the burden and consequences of perinatal depression; (iii) lack of training of health professionals in screening depression; and (iv) high patient loads.
i. Reduced priority of perinatal mental health
Ethiopia is a low-income country, which means that resources are limited, and it is not possible to tackle every health problem. As such, a focus on priority health conditions is considered mandatory. Priority has been given to conditions that are the leading causes of mortality and morbidity. It has been believed that perinatal depression is not a leading cause of mortality and morbidity in Ethiopia, compared with other communicable and non-communicable diseases of pregnancy and childbirth. One participant mentioned the following to show that perinatal depression is not a priority issue for the government:
Because of many other communicable and non-communicable diseases that need fast attention, perinatal depression is not given a high priority. To reduce maternal and child mortality, hypertension, obstructed labour and infections causes higher numbers of deaths than depression. As such, if we strictly work on these issues, we might bring more changes in maternal health. We are also one of the low-income countries with limited resources, and the Ministry of Health might believe that more attention should be given for such conditions than depression. As you see, due to there being many health issues in the country, the government prioritises and focuses on interventions that benefit most of the women. (Male, aged 29 years).
ii. Lack of knowledge about the burden and consequences
As was concluded in the previous section (section 7.3.1), health administrators’ knowledge about the burden and consequences of untreated perinatal depression was generally low. More importantly, health administrators working at higher levels of the healthcare system, where policy and strategy are developed, were found to have less knowledge than those working at lower levels of the healthcare system. This would significantly affect health administrators’ motivation towards prioritising, planning, and initiating perinatal depression health services. There also appeared to be insufficient information about the consequences of perinatal depression to make perinatal depression a priority focus of the government, as one participant working at a higher level of the health care system said:
As I told you about this, there are no separate and specific activities. The primary thing about perinatal depression is that we do not consider it as a public health problem of significance, and we do not have data about it. It has not been the forefront of public health priority threats in this region. (Female, aged 50 years)
iii. Health professionals lack of training in screening for depression
The question about who should be responsible for screening needs to be clearly addressed in the healthcare system and enough personnel should be trained and made available in all health facilities that are expected to intervene in perinatal depression. This comes back to perinatal depression not being included as a priority health item in the country. Human resource development is a main issue for any perinatal mental health strategy and plan, but without such plans, attention given to human workforce development would be compromised. One participant working as a coordinator at a higher level of the health care system said:
Starting screening service is not easy. We do not have health professionals who trained in mental health. It needs a psychiatrist to screen and manage perinatal depression, and these professionals are minimal, including those who are in schools. So, we do not have trained professionals now, and it is challenging. (Male, aged 52 years)
iv. High patient load
Another barrier described by participants as a reason for government giving low priority to perinatal depression was high patient loads in health facilities because of other morbidities. As explained in a previous section, Ethiopian health facilities always are required to treat large numbers of patients with various acute and chronic health problems. At the same time, the country is placing increased demands of health professionals in health facilities. This might affect perinatal depression screening and management because of the time required for even relatively brief consultations with perinatal women. One interviewee said:
As this is a tertiary hospital, every client comes for better service. As such, due to time limitation, it is not easy to rule out additional problems like depression. (Male, aged 29 years)
Enablers for or opportunities to start perinatal depression screening services
This theme presents health system administrators’ views about the current situation of mental health services and the opportunities for perinatal depression screening services in Ethiopia. Participants described mental health services as being compromised and only focused on treating those who were presenting to health facilities with severe problems. They further added that there was no system for early detection and prevention of mental health disorders in the community. However, participants identified three potential opportunities or enablers that could help the Ethiopian healthcare system to start screening for depression in perinatal women d and to establish effective management of it. These opportunities were: the introduction of the WHO Mental Health Gap (mhGap) (51) action program; health professionals’ commitment; and simplicity of the screening program.
The mhGap action program is an international initiative developed by the WHO to fill the mental health service gap between what is available and what is urgently needed to reduce the burden of mental disorders. Participants suggested that the introduction of the mhGap initiative could potentially provide an opportunity to start and expand maternal mental health interventions in Ethiopia.
Until now, the available policy does not allow non-psychiatry health professionals to provide psychiatric services. Mental health services have been limited at the hospital level. But nowadays, because of the findings by WHO that the burden is becoming high, mental health is getting attention. One psychiatrist used to serve a population of 100,000. These days, health professionals are being trained, protocols are being under preparation, and activities have been started under MhGap initiatives to bring mental health services to health centre level. (Male, aged 52 years)
Health professionals’ commitment would also be needed to enable screening for perinatal depression in health facilities. Participants hoped that screening perinatal women for depression would not be more challenging than what they currently do for everyone visiting a health facility. Health administrators mentioned that health professionals such as themselves were highly motivated to make screening available and to manage perinatal depression if the health system could be made ready for this. One participant stated that it is possible to make screening for perinatal depression available if the environment is ready:
Simplicity of the screening activity was another potential enabler for instituting screening in health facilities. Participants suggested that screening would not be difficult relative to other clinical assessments that may require laboratory facilities, and additional skilled professionals. Using a brief screening tool, screening for depression might require a maximum of 15 minutes to implement. Similarly, additional physical space would not be required for screening because assessments could be undertaken in the same rooms where ANC and PNC services are delivered. One participant stated that health professionals are motivated and committed to undertake screening, and the only problem is lack of skill and a supportive system.
Yes, maybe we would screen and refer, this would be simple. I can see it is possible to screen pregnant and postnatal women with depression. I saw a Master’s student who did the screening in our health centre, so it is also possible as you are also doing the screening as well. (Female, aged 50 years)