This study resulted in a number of important findings, including pervasive effects of SMI upon intimate relationships and the sexual life of women, misconceptions about family planning among women with SMI and the lack of available family planning services.
To begin with, the participants in this study perceived a reduced chance of having a lifetime partner due to stigma and discrimination. These women perceived stigmatizing attitudes from the community (29, 30) and also endorsed some of the negative stereotypes themselves (31). These findings are consistent with studies on women with SMI from other parts of the world. For instance, a study from India found that community members held negative attitudes about men marrying a woman with an SMI (32),while a study from Turkey found that women with SMI held negative perceptions about marriage, sexuality, family planning, child bearing and pregnancy, compared with women without SMI in the general population (33). As a consequence, the participants felt that they were not desirable as romantic or sexual partners. The women in this study appeared to harbor negative attitudes about their own sexual life thereby limiting the quest for partnership options.
The study participants also noted that women with SMI tend to run much higher risks of victimization and/or sexual exploitation. Some of the respondents spoke of their experiences of sexual assault, either at the hands of extended family members or strangers. Research indicates that women with SMI have a greater risk of victimization compared to women without mental illness (34–37). They have much higher risks of sexual abuse and post-traumatic experiences, which in turn can aggravate the mental illness (8, 38, 39). Exacerbations of mental illness could limit the power and ability of women to control their own sexual life (40–42), which further increases the risks of unplanned pregnancy.
Second, although women with SMI in Ethiopia felt that family planning was important, they had limited knowledge of family planning generally and a lack of understanding of the specific family planning needs relevant to having SMI. The most common reason for using family planning for women in the present study was for preventing pregnancy rather than birth spacing. This finding is similar to a study conducted in Nigeria where women with SMI reported that pregnancy prevention is the goal, even though the timing of having a baby was the most important problem faced by women in rural communities (22). Women’s lack of adequate knowledge about family planning and fear of side effects played a role in the decision to use contraceptives. This misunderstanding has implications for the uptake and discontinuation of contraception and accords with previous reports from Ethiopia (24, 43–46). In the present study, a majority of the women were aware of the existence of injectable, pills and implanted contraception. Although some of the women knew about the intrauterine contraceptive device and condoms, some related condom use with promiscuity rather than a method used in family planning. This can be partly explained by the paradoxical influence of the media in advocating condoms for prevention of sexually transmitted diseases and the cultural taboo to the disclosure of condom use (47, 48).
In terms of family planning needs specifically for women living with SMI, the participants did express fears about relapse in the context of child bearing. As evidenced by many studies, delivery appears to be one of the factors most likely to increase the risk of relapse in women with SMI (49–53). This perception in turn affected the community’s view of childbearing as risky for such women. Contrary to the evidence that discontinuing medication during pregnancy opens up the possibility for relapse in women with mental illness (54–56) participants did not mention the risk of relapse associated with drug discontinuation or special treatment needs during pregnancy. Instead women emphasized the stresses associated with child-bearing, such as inadequate sleep, nutrition and support. However, although the women in this study had access to psychiatric nurse-led out-patient care, this centralized service was unlikely to meet the needs of perinatal women with SMI adequately. Expectations of even specialist mental health services in Ethiopia have been found previously to be low (26, 57, 58) and this may be a barrier to improving care for perinatal women with SMI.
Finally, even though women of reproductive age with an SMI are vulnerable to unplanned pregnancy, are at risk for mental health relapse during child bearing and could be exposed to psychological and economic burdens if an unplanned pregnancy occurs, none of the women with SMI in the present study had received any recommendations to use family planning services while receiving mental health care services. Integrating family planning services into specialist mental health services was generally preferred by the women in this study, in keeping with the first choice of women with SMI in high income countries (46). Participants emphasized the need for specialist knowledge, for example about interactions between their medications with contraceptives, the illness and the family planning approach. They also felt more comfortable communicating with mental health professionals, with whom they had built up a relationship over a long period of time. The women in our study reported that there was a need for improved family planning advice and referral from mental health professionals. This result supports previous studies highlighting that recommendations by health professionals regarding family planning recommendation need to be modified to address specifically the needs of women with SMI (59, 60).
Family planning services in Ethiopia are usually accessed through all levels of general health care services. However, few health professionals in Ethiopia deliver a comprehensive range of family planning methods suitable for women with SMI (61). In part this reflects the low priority which has been given to mental health care in the training of general health care providers. The plan to expand mental health care by integrating into primary care may provide an opportunity to better meet the family planning needs of women with SMI. However, there may need to be modifications for women with SMI.
Several limitations affect the scope and breadth of the current study and/or the analysis of the findings. Purposive sampling was used in order to obtain in-depth information from women selected on the basis of differing family planning practices, but this means that participants may not have been representative of all women with SMI. Another potential limitation was that the sample was recruited from a cohort study in which the participants had relatively better access to mental health services and treatment. Therefore, the results of the present study are not representative of all women with SMI in the country and the findings may be difficult to generalize to other contexts in Africa. However, the Butajira cohort was community-ascertained and not liable to the strong selection bias seen in facility-based studies in this context. The findings of extremely low levels of awareness and problems of access, even in a relatively better-served population, indicate that the study is likely to be of value for service development in other areas of rural Ethiopia. The third possible limitation of this study could be that its scope includes only women with SMI. The study excluded other groups of participants who are involved in the care of women with SMI. This includes health extension workers, primary health care professionals, psychiatric nurses, their caregivers and community representatives. Future research needs to look at the views and experiences of the other stakeholders such as health extension workers. Including these participants and having their perspectives may contribute to the development of a feasible and acceptable intervention.