Timely detection/treatment of perinatal/postnatal mental illnesses vital: Study
By Ruwan Laknath Jayakody
The timely detection and treatment of perinatal mental illnesses are of utmost importance in ensuring maternal mental health, and towards this end, it is essential to educate policymakers and professionals regarding such and to develop innovative research and policies that are culturally sensitive, feasible, and sustainable.
This proposal was put forward by A. Hapangama and K.A.L.A. Kuruppuarachchi in an article on “Maternal mental health services in Sri Lanka: Challenges and solutions” which was published in December 2020 in the British Journal of Psychiatry International.
With regard to demographics, in Sri Lanka, according to the Census and Statistics Department (CSD), in 2016, women in the reproductive age group of 15 to 49 years comprised 27.8% (5.6 million) of the total population. In the same year, it was found that 56.4% of the female population had completed education up to the secondary level (i.e. up to 15 years of age) and the female literacy rate was 94.5%. J. Qian noted in “Elevating Sri Lanka’s public health to the next level” that the mean (average) age at the time of marriage was 23.4 years for females. The CSD noted that in 2016, the total fertility rate was 2.4.
On the impact that culture and society have on women of child bearing age, H.E.M. Perera noted in “The changing status of women in Sri Lanka” that during most of the 20th Century and to a certain extent even at present, women who become mothers have lived with their extended family; but these traditions, including the extended family system and the obligation to live with one’s in-laws, are gradually diminishing, especially in urban areas, with most couples valuing independence by way of living apart from parents and in-laws, and with women taking on a leading role in the educational, social, and political arenas. That said, Hapangama and Kuruppuarachchi noted that dwindling support from the extended family, especially in urban settings, and the dual role of women as mothers and members of the workforce, may at times be stressful for women.
Concerning healthcare services available and provided for women of child bearing age, it is noted that combined maternal and child health services have been established in Sri Lanka since the 1920s. Qian mentioned that the Maternal and Child Health (MCH) programme, which is primarily run by medical officers of health (MOHs), concentrates on promoting antenatal care (covers 100% of the population where, the World Health Organisation [WHO] noted in the “Paradox of healthcare in Sri Lanka: A snapshot of the last decade from a partnership of 60 years” that 95% of expectant females are registered for antenatal care, prior to 12 weeks of pregnancy), delivery care (around 94% of all deliveries take place in a health facility in the public sector, including 100% deliveries in rural areas, while in urban areas, a higher proportion of births take place in private health facilities, per the Health and Statistics Department’s survey in 2016), and care for postpartum mothers (around 85% of postnatal mothers receive at least one postnatal visit from a public health midwife during the first 10 days after their delivery, per the WHO). Furthermore, P.S. Wijesinghe, K. Jayaratne, and D. Peiris observed in the “National Maternal Death Surveillance and Response (MDSR): Sri Lankan scenario” that there has been a huge decline in the maternal mortality ratio, from 92 per 100,000 live births in 1990 to 36 per 100,000 in 2017, a decline which was attributed to the improved quality of obstetric care and timely referrals to hospitals by teams in the primary healthcare setting.
Pertaining to the mental health services available and provided for women in pregnancy and who are in the postpartum period, it is noted that women who are found to have mental health problems during their pregnancy or during the postpartum period are generally referred by an MOH, obstetrician, or paediatrician to the psychiatry services in the state or the private sector, depending on the severity of the problem and the preference of the woman and/or her family. As explained in T. Agampodi, S. Agampodi, W. Wickramasinghe, A. Adhikari, and H. Chathurani’s “Postpartum depression – A problem that needs urgent attention”, the validated Sinhala translation of the Edinburgh Postnatal Depression Scale (EPDS, as noted by D. Rowel, P. Jayewardene, and N. Fernando) has been introduced into routine practice in MOH clinics, for the purpose of screening for depression in women during the first six weeks, postpartum. Moreover, a few state and private sector hospitals located in more urban areas have dedicated mother and baby beds for women with postnatal mental illnesses.
In relation to the burden of mental health problems among women during pregnancy and the postpartum period, S.B. Agampodi and T.C. Agampodi elaborated in “Antenatal depression in Anuradhapura and the factor structure of the Sinhalese version of the EPDS among pregnant women” that the maternal mental health service remains a largely neglected area. The same study conducted among antenatal women reported a prevalence of antenatal depression of 16.2%. Agampodi, Agampodi, and Wickramasinghe et al. found in their large, descriptive cross-sectional study, a 27.1% prevalence of postpartum depression, while primiparity (a condition or state in which a woman is bearing a child for the first time and/or has given birth to an offspring one time), having had three or more pregnancies, and having a lower income level were risk factors for developing postnatal depression.
The MDSR system was introduced in 1981, where deaths by suicide up to 42 days postpartum are reviewed by a team led by a consultant psychiatrist using a psychological autopsy tool, which as Wijesinghe et al. noted, helps to translate findings into policies. K. Jayaratne reported in “Maternal suicides in Sri Lanka: Lessons learnt from the review of maternal deaths over nine years (2002-2010)” that the maternal suicide rate has increased from 0.8 per 100,000 live births in 2002 to 12.1 per 100,000 live births in 2010, a situation which is explained by the improvement in the health information system in recording the cause of death.
Regardless, Hapangama and Kuruppuarachchi pointed out that such figures are a cause for significant concern as they highlight the need for the identification and addressing of the factors associated with maternal suicide. Also, S. Agampodi, K. Wickramage, T. Agampodi, U. Thennakoon, N. Jayathilaka, D. Karunarathna, and S. Alagiyawanna’s “Maternal mortality revisited: The application of the new International Classification of Diseases-Maternal Mortality classification system in reference to maternal deaths in Sri Lanka”, which was a study that was conducted in a rural district, reported that 17.8% of recorded maternal deaths were due to suicide while 79% of the women who had died by suicide were less than 30 years old.
When it comes to challenges faced in the development of such services, Hapangama and Kuruppuarachchi emphasised that policy documents on maternal and child health and documents by various funding agencies such as the WHO, do not appear to give much priority to the assessment and management of perinatal mental illnesses. They further pointed out that despite being shown to be effective in screening for antenatal depression, the EPDS is still only being used in Sinhala language to screen for postnatal depression, while a Tamil language version of the EPDS is not yet available. Also, since only a few secondary and tertiary care hospitals have dedicated mother and baby beds for women with postnatal psychiatric disorders, due to this lack of facilities, Hapangama and Kuruppuarachchi observed, at times, the mother in question is admitted to a general adult psychiatry ward to receive the required treatment during the postpartum period whilst the newborn is either admitted to a paediatric ward along with a family member, or sent home. Moreover, with regard to the relatively high prevalence of perinatal psychiatric disorders and maternal suicides, the duo noted that this situation may also be owing to the low level of identification of these illnesses due to the lack of awareness among primary healthcare workers, and the poor integration between maternal health services and mental health services. Additionally, they elaborated that culture and stigma may also play a part in the under-diagnosis and under-treatment of perinatal mental illnesses, while the demonological and astrological remedies that are at times commonly used in the treatment of postpartum mental illnesses, may in turn lead to delays in women receiving effective treatment. Connected to this issue is the fact that, as Hapangama and Kuruppuarachchi explained, there is a significant knowledge gap regarding the psychological effects of conflicts (such as the ethnic conflict), natural disasters (such as the December 2004 tsunami), and domestic violence on women during the perinatal period.
For the ways to improve these services, Hapangama and Kuruppuarachchi suggested that the education of women regarding mental health problems and their management be incorporated into the MCH programme with the screening and management of maternal mental health problems being given prominence in national health policies. Also, since all primary healthcare practitioners and grassroots level healthcare workers need to undergo regular training in the basic screening, assessment, and management of perinatal mental health problems, the duo proposed that the Sri Lanka College of Psychiatrists collaborate with the Health Ministry and the other relevant stakeholders to conduct such programmes.
The need to pay urgent attention to the unequal distribution of services for women in certain districts was also highlighted by Hapangama and Kuruppuarachchi, with the duo once again calling on the Health Ministry and the relevant colleges to proactively address such. Concentrating on aspects pertaining to education, they said that women with mental health problems in the perinatal period should be educated about their condition and offered continued care with evidence-based interventions. Hapangama and Kuruppuarachchi also urged the improvement of the integration, co-ordination, and communication between the MCH programme and the mental health teams in hospitals with regard to detecting, referring, treating, and following-up on women with perinatal mental disorders.
From the standpoint of research, it was recommended that nationwide research into the prevalence of and service-related needs be carried out with a view to formulating and influencing policies. In conclusion, Hapangama and Kuruppuarachchi called on psychiatrists to also play a proactive part in combating cultural beliefs and stigma among patients and their families by introducing maternal mental health literacy to the public and by advocating for policies to improve services for women during the perinatal period.