Health in Action Stepped Care for Maternal Mental Health: A Case Study of the Perinatal Mental Health Project in South Africa

Common mental disorders such as anxiety and depression are the third leading causes of disease burden globally for women between 14 and 44 years of age [1]. By 2030, these are expected to rise to first place, ranked above heart disease and road traffic injuries [2]. A recent systematic review reveals that maternal mental disorders are approximately three times more prevalent in lowand middle-income countries (LMICs) than in high-income countries (HICs), where the related burden of disease estimates range between 5.2% and 32.9% [3,4]. In HICs, maternal suicide is the leading cause of death during the perinatal period, and while there is a relative dearth of information about maternal suicide in LMICs, the estimates are similarly high [5,6]. Untreated maternal mental illness affects infant and child growth [7] and the quality of child care [8], resulting in compromised child development [4,9]. Community-based epidemiological studies in South Africa have shown high prevalence rates of depressed mood amongst pregnant and postnatal women. In a low-income, informal settlement outside of Cape Town, 39% of pregnant women screened positive on the Edinburgh Postnatal Depression Scale (EPDS) for depressed mood [10] and 34.7% of postnatal women were diagnosed with depression [11]. In a rural area of KwaZulu-Natal province with high HIV prevalence, 47% of women were diagnosed with depression in their third trimester of pregnancy [12]. Despite high levels of antenatal and postnatal depression, there is no routine screening or treatment of maternal mental disorders in primary care settings in South Africa. Maternal care involves an average of three antenatal clinic visits with coverage of 92% of the pregnant population [13]. The antenatal care is predominantly focused on physical examination [14], whereas during the post-partum period, the health care focus is commonly on the infant for immunisation, growth monitoring, and HIV testing. The lack of integration between maternal health services, child health services, and mental health services in primary care creates a large gap in the screening and treatment of maternal mental disorders [15]. If women are referred for mental health services, they are often required to incur additional costs related to transport and child care, and loss of income to attend appointments. Women may also be referred to services at a different site, which exacerbates these costs and frequently results in poor uptake [16]. There is a lack of routine programmatic maternal mental health care in South Africa. This is despite evidence that such interventions may be successfully implemented in primary care settings [17,18].