Interventions for common perinatal mental disorders in women in low- and middle-income countries: a systematic review and meta-analysis

Interventions sur les troubles mentaux périnataux communs des femmes dans les pays à faible et moyen revenus: une étude systématique et une méta-analyse

Las intervenciones para los trastornos mentales perinatales frecuentes en mujeres de países de ingresos bajos y medios: revisión sistemática y metaanálisis

التدخلات من أجل الاضطرابات النفسية الشائعة في الفترة المحيطة بالولادة لدى النساء في البلدان المنخفضة والمتوسطة الدخل: استعراض منهجي وتحليل وصفي

中低收入国家妇女围产期常见精神障碍的干预措施:系统评价和元分析

Вмешательства при общих перинатальных психических расстройствах у женщин в странах с низким и средним уровнем доходов: систематический обзор и мета-анализ

Atif Rahman Jane Fisher Peter Bower Stanley Luchters Thach Tran M Taghi Yasamy Shekhar Saxena Waquas Waheed About the authors

Abstract

Objective

To assess the effectiveness of interventions to improve the mental health of women in the perinatal period and to evaluate any effect on the health, growth and development of their offspring, in low- and middle-income (LAMI) countries.

Methods

Seven electronic bibliographic databases were systematically searched for papers published up to May 2012 describing controlled trials of interventions designed to improve mental health outcomes in women who were pregnant or had recently given birth. The main outcomes of interest were rates of common perinatal mental disorders (CPMDs), primarily postpartum depression or anxiety; measures of the quality of the mother–infant relationship; and measures of infant or child health, growth and cognitive development. Meta-analysis was conducted to obtain a summary measure of the clinical effectiveness of the interventions.

Findings

Thirteen trials representing 20 092 participants were identified. In all studies, supervised, non-specialist health and community workers delivered the interventions, which proved more beneficial than routine care for both mothers and children. The pooled effect size for maternal depression was −0.38 (95% confidence interval: −0.56 to −0.21; I 2 = 79.9%). Where assessed, benefits to the child included improved mother–infant interaction, better cognitive development and growth, reduced diarrhoeal episodes and increased immunization rates.

Conclusion

In LAMI countries, the burden of CPMDs can be reduced through mental health interventions delivered by supervised non-specialists. Such interventions benefit both women and their children, but further studies are needed to understand how they can be scaled up in the highly diverse settings that exist in LAMI countries.

Résumé

Objectif

Estimer l'efficacité des interventions visant à améliorer la santé mentale des femmes dans la période périnatale et évaluer tout effet sur la santé, la croissance et le développement de leur progéniture, dans les pays à faible et moyen revenus (PFMR).

Méthodes

On a étudié de manière systématique sept bases de données bibliographiques électroniques pour y trouver les articles, publiés jusqu'en mai 2012, décrivant les essais contrôlés d'interventions visant à améliorer la santé mentale des femmes enceintes ou ayant récemment accouché. Les principaux résultats intéressants étaient les taux des troubles mentaux périnataux communs (TMPC), la dépression ou l'anxiété, essentiellement après l'accouchement, les mesures de la qualité de la relation mère-nourrisson, ainsi que la mesure de la santé, de la croissance et du développement cognitif du nourrisson ou de l'enfant. Une méta-analyse a été effectuée pour obtenir une mesure synthétique de l'efficacité clinique des interventions.

Résultats

On a identifié treize essais représentant 20 092 participants. Dans toutes les études, des agents de la santé et des travailleurs communautaires non spécialistes supervisés ont effectué les interventions qui se sont avérées plus bénéfiques que les soins de routine pour les mères et les enfants. La taille de l'effet groupé de la dépression maternelle était de −0,38 (intervalle de confiance de 95%: −0,56 à −0,21; I 2 = 79,9%). Dans les cas où ils étaient évalués, les avantages pour l'enfant comprenaient une meilleure interaction mère-enfant, un meilleur développement cognitif, une croissance supérieure, des épisodes diarrhéiques réduits et des taux accrus de vaccination.

Conclusion

Dans les PFMR, la charge des TMPC peut être réduite par des interventions de santé mentale prises en charge par des non-spécialistes supervisés. Ces interventions bénéficient à la fois aux femmes et à leurs enfants, mais d'autres études sont nécessaires pour comprendre comment elles peuvent être élargies aux paramètres très divers qui existent dans les PFMR.

Resumen

Objetivo

Determinar la efectividad de las intervenciones destinadas a mejorar la salud mental de las mujeres en el periodo perinatal y evaluar los efectos en la salud, el crecimiento y el desarrollo de sus hijos en los países de ingresos bajos y medios (PIBM).

Métodos

Se realizaron búsquedas sistemáticas en siete bases de datos bibliográficas electrónicas a fin de hallar trabajos, publicados antes de mayo de 2012, que describieran ensayos controlados de intervenciones diseñadas para mejorar el estado de salud mental de mujeres embarazadas o que habían dado a luz recientemente. Los resultados de mayor interés fueron: las tasas de trastornos mentales perinatales frecuentes (TMPF); la depresión o la ansiedad principalmente después del parto; las medidas de la calidad de la relación madre–hijo; así como la medida de la salud, el crecimiento y el desarrollo cognitivo de bebés y niños. Se realizó un metaanálisis para obtener una medida sinóptica sobre la efectividad clínica de las intervenciones.

Resultados

Se identificaron trece ensayos que representaron a un total de 20 092 participantes. En todos los estudios, las intervenciones se llevaron a cabo por personal de salud no especializado y por trabajadores comunitarios bajo supervisión, lo cual resultó ser más beneficioso que la atención rutinaria para madres y niños. El tamaño del efecto combinado de la depresión materna fue −0,38 (intervalo de confianza del 95 %: −0,56 a −0,21; l 2 = 79,9 %). En las zonas donde se realizó la evaluación, los beneficios para el niño incluían una mejora en la interacción madre-hijo, en el desarrollo cognitivo y el crecimiento, una reducción en los episodios de diarrea, así como un aumento en las tasas de inmunización.

Conclusión

En países de ingresos bajos o medios es posible reducir la carga por los trastornos mentales perinatales frecuentes mediante intervenciones de salud mental prestadas por personal no especializado bajo supervisión. Estas intervenciones benefician tanto a las mujeres como a sus hijos, pero se necesitan más estudios para averiguar cómo pueden ampliarse dentro de la gran diversidad de los países de ingresos bajos y medios.

ملخص

الغرض

تقييم فعالية التدخلات من أجل تحسين الصحة النفسية للنساء في الفترة المحيطة بالولادة وتقييم أي تأثير على صحة أطفالهن ونموهم وتطورهم، في البلدان المنخفضة والمتوسطة الدخل.

الطريقة

تم إجراء بحث في سبع قواعد بيانات بيبليوغرافية إلكترونية على نحو منهجي للحصول على الأبحاث المنشورة حتى أيار/ مايو 2012 التي تصف التجارب التي أجريت في بيئة خاضعة للمراقبة خاصة بالتدخلات المصممة لتحسين حصائل الصحة النفسية لدى النساء اللاتي حملن أو ولدن مؤخراً. وكانت الحصائل المهمة الرئيسية هي معدلات الاضطرابات النفسية الشائعة في الفترة المحيطة بالولادة، أو اكتئاب أو قلق ما بعد الولادة؛ وقياسات جودة العلاقة بين الأم والرضيع؛ وقياس صحة الرضيع أو الطفل والنمو والنمو الإدراكي. وتم إجراء تحليل وصفي للحصول على قياس موجز للفعالية السريرية للتدخلات.

النتائج

تم تحديد 13 تجربة تمثل 20092 مشاركاً. وفي جميع الدراسات، قام العاملون الصحيون والمجتمعيون غير المتخصصين الذين يعملون تحت الإشراف بإيتاء التدخلات، التي أثبتت فائدتها عن الرعاية الروتينية لكل من الأمهات والأطفال. وكان حجم الأثر المجمع لاكتئاب الأم -0.38 (فاصل الثقة 95 %: من -0.56 إلى -00.21؛ I 2 = 79.9 %). شملت الفوائد التي تعود على الطفل، عند تقييمها، تحسين تفاعل الأم مع الرضيع وتحسين النمو والنمو الإدراكي وتقليل نوبات الإسهال وازدياد معدلات التمنيع.

الاستنتاج

في البلدان المنخفضة والمتوسطة الدخل، يمكن تقليل عبء الاضطرابات النفسية الشائعة في الفترة المحيطة الولادة من خلال تدخلات الصحة النفسية التي يقدمها عاملون غير متخصصين يعملون تحت إشراف. وتفيد هذه التدخلات كلاً من النساء وأطفالهن، ولكن لابد من إجراء مزيد من الدراسات لفهم الكيفية التي يمكن من خلالها دعم هذه التدخلات في البيئات شديدة التنوع، التي توجد في البلدان المنخفضة والمتوسطة الدخل.

摘要

目的

评估中低收入(LAMI)国家旨在改善围产期妇女心理健康状况的干预措施的有效性,并评估对其后代的健康、成长和发育的任何影响。

方法

对七个电子文献数据库进行系统检索,查找描述旨在改善怀孕或者刚刚分娩的妇女精神健康效果的干预措施对照试验的论文,发表时间截至2012 年5 月。 关注的主要成果是围产期常见精神障碍(CPMD)率,主要是产后抑郁症或焦虑;母婴关系质量的衡量;以及婴儿或儿童健康、成长和认知发展的衡量。执行元分析获得干预措施临床效果的总体衡量。

结果

确定了十三个代表20092 名参与者的试验。在所有研究中,受监督的非专业卫生和社区工作者提供了干预措施,经证明这些措施比常规护理更有利于母亲和儿童。孕产妇抑郁症汇总效应大小是-0.38(95%置信区间:-0.56 至-0.21;I 2 = 79.9%)。评估方面,对孩子的益处包括改善母婴互动、更好的认知发展和成长、更低的腹泻发作率和更高的免疫率。

结论

在LAMI国家,可通过由受监督的非专业人员提供精神健康干预措施,降低CPMD负担。这种干预措施对妇女及其孩子都有益处,但是要理解如何在LAMI国家高度多样化的环境中推广这些措施还需要进一步的研究。

Резюме

Цель

Оценить эффективность вмешательств для улучшения психического здоровья женщин в перинатальный период и оценить влияние на здоровье, рост и развитие их плода в странах с низким и средним уровнем доходов.

Методы

По семи электронным библиографическим базам данных проводился систематический поиск работ, опубликованных до мая 2012 года, в которых описывались контролируемые испытания вмешательств, направленных на улучшение психического здоровья беременных или недавно родивших женщин. Главными результатами исследования являлись уровни общих перинатальных психических расстройств (ОППР) (в основном послеродовой депрессии или беспокойства), оценки качества отношений между матерью и младенцем и оценка здоровья, роста и когнитивного развития младенцев и детей. Проводился мета-анализ для получения итоговой оценки клинической эффективности вмешательств.

Результаты

Было исследовано 13 испытаний, представляющих 20 092 участников. Во всех исследованиях вмешательства проводились контролируемыми медико-санитарными работниками-неспециалистами и они оказались более благотворными, чем система регулярного ухода как за матерями, так и за детьми. Общая величина эффекта при материнской депрессии составила −0,38 (доверительный интервал: от −0,56 до −0,21; I 2 = 79,9%). Там, где проводилась оценка, благотворные воздействия на ребенка включали улучшение взаимодействия матери и младенца, лучшее когнитивное развитие и рост, уменьшенную частоту развития диареи и повышенный уровень иммунизации.

Вывод

В странах с низким и средним уровнем доходов бремя ОППР может быть уменьшено посредством проводимых контролируемыми неспециалистами вмешательств в области психического здоровья. Подобные вмешательства оказывают благотворное воздействие как на женщин, так и на детей, однако необходимо проведение дальнейших исследований для понимания того, как они могут быть увеличены в весьма различных условиях, имеющихся в странах с низким и средним уровнем доходов.

Introduction

Perinatal mental health problems are common worldwide.1Prince M, Patel V, Saxena S, Maj M, Maselko J, Phillips MR et al. No health without mental health. Lancet 2007;370:859–77. doi: http://dx.doi.org/10.1016/S0140-6736(07)61238-0 PMID:17804063
http://dx.doi.org/10.1016/S0140-6736(07)...
In high-income countries, about 10% of pregnant women and 13% of women who have just given birth experience a mental disorder, primarily depression or anxiety.2O’hara MW, Swain AM. Rates and risk of postpartum depression: a meta-analysis. Int Rev Psychiatry 1996;8:37–54. doi: http://dx.doi.org/10.3109/09540269609037816
http://dx.doi.org/10.3109/09540269609037...
, 3Hendrick V, Altshuler L, Cohen L, Stowe Z. Evaluation of mental health and depression during pregnancy: position paper. Psychopharmacol Bull 1998;34:297–9. PMID:9803758 A recent systematic review showed higher rates of common perinatal mental disorders (CPMDs) among women from low- and lower-middle-income countries, where the weighted mean prevalence of these disorders was found to be 15.6% (95% confidence interval, CI: 15.4–15.9) in pregnant women and 19.8% (95% CI: 19.5–20.0) in women who had recently given birth.4Fisher J, Cabral de Mello M, Patel V, Rahman A, Tran T, Holton S et al. Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review. Bull World Health Organ 2012;90:139G–49G. doi: http://dx.doi.org/10.2471/BLT.11.091850 PMID:22423165
http://dx.doi.org/10.2471/BLT.11.091850...
The review identified several risk factors for CPMDs among women: having a partner lacking in empathy or openly antagonistic; being a victim of gender-based violence; having belligerent in-laws; being socially disadvantaged; having no reproductive autonomy; having an unintended or unwanted pregnancy; having pregnancy-related illness or disability; receiving neither emotional nor practical support from one's mother, and giving birth to a female infant.4Fisher J, Cabral de Mello M, Patel V, Rahman A, Tran T, Holton S et al. Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review. Bull World Health Organ 2012;90:139G–49G. doi: http://dx.doi.org/10.2471/BLT.11.091850 PMID:22423165
http://dx.doi.org/10.2471/BLT.11.091850...
The day-to-day interactions between neonates and their primary caregivers influence neurological, cognitive, emotional and social development throughout childhood. Maternal mental health problems are not only detrimental to a woman's health; they have also been linked to reduced sensitivity and responsiveness in caregiving and to higher rates of behavioural problems in young children. There is growing evidence that, in low- and middle-income (LAMI) countries, the negative effects of maternal mental disorders on the growth and development of infants and young children are independent of the influence of poverty, malnutrition and chronic social adversity.5Stewart RC. Maternal depression and infant growth: a review of recent evidence. Matern Child Nutr 2007;3:94–107. doi: http://dx.doi.org/10.1111/j.1740-8709.2007.00088.x PMID:17355442
http://dx.doi.org/10.1111/j.1740-8709.20...
, 6Engle PL. Maternal mental health: program and policy implications. Am J Clin Nutr 2009;89:963S–6S. doi: http://dx.doi.org/10.3945/ajcn.2008.26692G PMID:19176734
http://dx.doi.org/10.3945/ajcn.2008.2669...
In low-income settings, maternal depression has been linked directly to low birth weight and undernutrition during the first year of life, as well as to higher rates of diarrhoeal diseases, incomplete immunization and poor cognitive development in young children.7Patel V, DeSouza N, Rodrigues M. Postnatal depression and infant growth and development in low income countries: a cohort study from Goa, India. Arch Dis Child 2003;88:34–7. doi: http://dx.doi.org/10.1136/adc.88.1.34 PMID:12495957
http://dx.doi.org/10.1136/adc.88.1.34...
1010 Rahman A, Bunn J, Lovel H, Creed F. Maternal depression increases infant risk of diarrhoeal illness: a cohort study. Arch Dis Child 2007;92:24–8. doi: http://dx.doi.org/10.1136/adc.2005.086579 PMID:16966339
http://dx.doi.org/10.1136/adc.2005.08657...

In some high-income countries, including England and Australia, the detection and treatment of CPMDs are prioritized.1111 Australian Government Department of Health and Ageing [Internet]. National Perinatal Depression Initiative. Canberra: AGDHA; 2013. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/mental-perinat [accessed 11 May 2013].
http://www.health.gov.au/internet/main/p...
However, this is not so in most LAMI countries, where many other health problems compete for attention.4Fisher J, Cabral de Mello M, Patel V, Rahman A, Tran T, Holton S et al. Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review. Bull World Health Organ 2012;90:139G–49G. doi: http://dx.doi.org/10.2471/BLT.11.091850 PMID:22423165
http://dx.doi.org/10.2471/BLT.11.091850...
Psycho-educational interventions that promote problem solving and a sense of personal agency and help to reframe unhelpful thinking patterns, including cognitive behaviour therapy and interpersonal therapy, have consistently proven effective in the management of CPMDs.1212 National Collaborating Centre for Mental Health. Antenatal and postnatal mental health: the NICE guideline on clinical management and service guidance. London: The British Psychological Society & The Royal College of Psychiatrists; 2007. , 1313 Dennis C, Hodnett E. Psychosocial and psychological interventions for treating postpartum depression (review). London: JohnWiley & Sons Ltd; 2009. Although few LAMI countries have sufficient mental health professionals to meet their populations' mental health needs,1414  Mental health atlas. Geneva: WHO Department of Mental Health and Substance Abuse; 2005. several have tried to deliver acceptable, feasible and affordable interventions based on evidence generated locally.1515 Patel V, Kirkwood B. Perinatal depression treated by community health workers. Lancet 2008;372:868–9. doi: http://dx.doi.org/10.1016/S0140-6736(08)61374-4 PMID:18790294
http://dx.doi.org/10.1016/S0140-6736(08)...
The aims of this study were to investigate systematically the evidence surrounding the impact of such interventions on women and their infants and on the mother–infant relationship, and to understand the feasibility of applying them in LAMI countries.

Methods

Search strategy

We conducted a systematic search, without language restrictions, of seven electronic bibliographic databases: MEDLINE, EMBASE, CINAHL, PsycINFO, the British Nursing Index, the Allied and Complementary Medicine database and the Cochrane Central Register. The search terms were: depression, maternal depression, perinatal depression, postnatal depression, postpartum depression, common mental disorders, mental health and postpartum psychosis. These terms were individually combined with the terms randomized controlled trial, controlled clinical trial, clinical trials, evaluation studies, cross over studies AND with the names of countries classified as LAMI countries by the World Bank.1616 World Bank [Internet]. World Bank development indicators. Washington: World Bank; 2005. Available from: http://data.worldbank.org/about/country-classifications/country-and-lending-groups [accessed 15 May 2013].
http://data.worldbank.org/about/country-...
China is a middle-income country. Despite ambiguity in its economic status, we included Taiwan, China, in the middle-income category. We hand-searched the reference lists of all included articles. When necessary, we also approached experts to identify unpublished studies.

We included all controlled trials from LAMI countries, published up to May 2012,1717 Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009;6:e1000097. doi: http://dx.doi.org/10.1371/journal.pmed.1000097 PMID:19621072
http://dx.doi.org/10.1371/journal.pmed.1...
that involved structured mental health interventions targeting women during pregnancy and after childbirth, or that measured maternal mental health outcomes up to 36 months postpartum. Two reviewers scanned the abstracts of all identified sources to determine eligibility independently. Disagreements were resolved consensually. Using a standard form, we extracted information on the following for all eligible studies: study design, study setting, sample characteristics, recruitment strategies, measures of mental health, main outcomes of interest and follow-up intervals. We also summarized the details of each intervention, including its acceptability to patients and providers, if assessed.

Data analysis

We undertook a meta-analysis of selected outcomes. We translated continuous outcomes to a standardized effect size (mean of intervention group minus mean of control group, divided by the pooled standard deviation); we translated dichotomous outcomes to a standardized effect size using conventional procedures.1818 Lipsey MW, Wilson DB. Practical meta-analysis. Thousand Oaks: Sage Publications; 2001. To maximize consistency, we chose the outcomes reported in the review a priori according to an algorithm. Thus, in studies that had more than one follow-up assessment, we chose the outcome for the assessment closest to 6 months after the intervention. If both categorical and continuous data were reported, we used the continuous data for the meta-analysis. To adjust for the precision of cluster trials, we used the methods recommended by the Cochrane Collaboration1919 Alderson P, Bero L, Eccles M. Effective Practice and Organisation of Care Group (Cochrane Collaborative Review Groups). London: John Wiley and Sons; 2005. and assumed an intra-class correlation of 0.02. We conducted meta-analysis using random effects modelling to assess the pooled effect of maternal mental health interventions. The I 2 statistic was used to quantify heterogeneity.2020 Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ 2003;327:557–60. doi: http://dx.doi.org/10.1136/bmj.327.7414.557 PMID:12958120
http://dx.doi.org/10.1136/bmj.327.7414.5...
To assess possible publication bias, we conducted the Egger test and generated a funnel plot.

Studies were heterogeneous in terms of the setting, nature and content of the interventions, as well as outcomes and outcome measures, so we also undertook a realist review using Pawson et al.'s method.2121 Pawson R, Greenhalgh T, Harvey G, Walshe K. Realist review–a new method of systematic review designed for complex policy interventions. J Health Serv Res Policy 2005;10(Suppl 1):21–34. doi: http://dx.doi.org/10.1258/1355819054308530 PMID:16053581
http://dx.doi.org/10.1258/13558190543085...
With this method, similarities and differences between studies are considered on the basis of study design, methodological quality, intervention characteristics and delivery, presumed mode of action, fidelity of implementation, acceptability to participants, recognition of the sociocultural context and appropriateness of the outcome measures for the particular setting.

Results

Of the 52 records we retrieved, we retained 15 after screening. We excluded one study because it lacked a comparison group. The 13 eligible trials, described in 13 papers and a thesis, represented 20 092 participants. Their findings were used for the meta-analysis (Fig. 1).2222 Baker-Henningham H, Powell C, Walker S, Grantham-McGregor S. The effect of early stimulation on maternal depression: a cluster randomised controlled trial. Arch Dis Child 2005;90:1230–4. doi: http://dx.doi.org/10.1136/adc.2005.073015 PMID:16159905
http://dx.doi.org/10.1136/adc.2005.07301...
3535 Morris J, Jones L, Berrino A, Jordans MJ, Okema L, Crow C. Does combining infant stimulation with emergency feeding improve psychosocial outcomes for displaced mothers and babies? A controlled evaluation from northern Uganda. Am J Orthopsychiatry 2012;82:349–57. doi: http://dx.doi.org/10.1111/j.1939-0025.2012.01168.x PMID:22880973
http://dx.doi.org/10.1111/j.1939-0025.20...
China contributed three trials; India, Pakistan and South Africa contributed two trials each, and Chile, Jamaica, Mexico and Uganda contributed one each. Twelve studies were controlled and randomized either at the individual or the cluster level and one study2828 Cooper PJ, Landman M, Tomlinson M, Molteno C, Swartz L, Murray L. Impact of a mother-infant intervention in an indigent peri-urban South African context: pilot study. Br J Psychiatry 2002;180:76–81. doi: http://dx.doi.org/10.1192/bjp.180.1.76 PMID:11772856
http://dx.doi.org/10.1192/bjp.180.1.76...
used a historical matched control from another epidemiological study. The main outcomes assessed were maternal mental health, the mother–infant relationship, and infant or child cognitive development and health.

Fig. 1
Flowchart showing selection of studies on interventions for common perinatal mental disorders among women in low- and middle-income countries

Study characteristics and quality

In the trials, outcomes were assessed at one or more points from 3 weeks to 3 years after childbirth. The following self-reported symptom checklists were used in the different studies to assess maternal depression: the World Health Organization's 20-item Self-reporting Questionnaire (SRQ-20),3636 A user's guide to the Self Reporting Questionnaire (SRQ). Geneva: World Health Organization; 1994. the Edinburgh Postnatal Depression Scale (EPDS),3737 Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987;150:782–6. doi: http://dx.doi.org/10.1192/bjp.150.6.782 PMID:3651732
http://dx.doi.org/10.1192/bjp.150.6.782...
the 12-item General Health Questionnaire (GHQ-12),3838 Goldberg D, Williams P. A user's guide to the General Health Questionnaire. Oxford: NFER-Nelson Publishing Company Ltd; 1988. the nine-item Patient Health Questionnaire (PHQ-9),3939 Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001;16:606–13. doi: http://dx.doi.org/10.1046/j.1525-1497.2001.016009606.x PMID:11556941
http://dx.doi.org/10.1046/j.1525-1497.20...
the Centre for Epidemiologic Studies Depression Scale (CES-D),4040 Radloff L. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas 1977;1:385–401. doi: http://dx.doi.org/10.1177/014662167700100306
http://dx.doi.org/10.1177/01466216770010...
the interviewer-administered Structured Clinical Interview for DSM-IV Axis 1 Disorders (SCID-I),4141 First M, Spitzer R, Gibbon M, Williams J. Structured clinical interview for Axis I DSM-IV disorders. New York: Biometrics Research; 1994. the Mini International Neuropsychiatric Interview (MINI),4242 Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E et al. The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 1998;59(Suppl 20):22–33,quiz 34-57. PMID:9881538 the Hamilton Depression Rating Scale (HDRS),4343 Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry 1960;23:56–62. doi: http://dx.doi.org/10.1136/jnnp.23.1.56 PMID:14399272
http://dx.doi.org/10.1136/jnnp.23.1.56...
the Revised Clinical Interview Schedule (CIS-R),4444 Lewis G, Pelosi AJ, Araya R, Dunn G. Measuring psychiatric disorder in the community: a standardized assessment for use by lay interviewers. Psychol Med 1992;22:465–86. doi: http://dx.doi.org/10.1017/S0033291700030415 PMID:1615114
http://dx.doi.org/10.1017/S0033291700030...
the 10-item Kessler Psychological Distress Scale (K10),4545 Kessler RC, Andrews G, Colpe LJ, Hiripi E, Mroczek DK, Normand SLT et al. Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychol Med 2002;32:959–76. doi: http://dx.doi.org/10.1017/S0033291702006074 PMID:12214795
http://dx.doi.org/10.1017/S0033291702006...
the Short Form (36) Health Survey (SF-36),4646 Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36): conceptual framework and item selection. Med Care 1992;30:473–83. doi: http://dx.doi.org/10.1097/00005650-199206000-00002 PMID:1593914
http://dx.doi.org/10.1097/00005650-19920...
the Symptom Checklist-90-R (SCL-90-R)4747 Derogatis LR. SCL-90-R: Symptom Checklist-90-R: administration, scoring, and procedures manual. Bloomington: NCS Pearson, Inc.; 1996. and the Beck Depression Inventory–II (BDI-II).4848 Beck A, Steer R, Brown G. Manual for beck depression inventory II (BDI-II). San Antonio: Psychology Corporation; 1996. In nine studies, the self-report measure was supplemented by a psychiatric interview (Table 1, available at: http://www.who.int/bulletin/volumes/91/8/12-109819).

Table 1
Design, methods and main findings of 13 trials of interventions for common perinatal mental disorders in women in low- and middle-income countries

Intervention characteristics

The interventions varied in content and structure, mode of implementation and method of assessing acceptability to providers and participants (Table 2, available at: http://www.who.int/bulletin/volumes/91/8/12-109819). Four studies addressed maternal depression directly. Rahman et al.'s2525 Rahman A, Malik A, Sikander S, Roberts C, Creed F. Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial. Lancet 2008;372:902–9. doi: http://dx.doi.org/10.1016/S0140-6736(08)61400-2 PMID:18790313
http://dx.doi.org/10.1016/S0140-6736(08)...
multimodal approach in the Thinking Healthy Programme (THP) included specific cognitive behaviour therapy methods to identify and modify maladaptive thinking styles – e.g. fatalism, inability to act, superstitious explanations and somatization – and replace them with more adaptive ways of thinking.4949 Rahman A. Challenges and opportunities in developing a psychological intervention for perinatal depression in rural Pakistan–a multi-method study. Arch Womens Ment Health 2007;10:211–9. doi: http://dx.doi.org/10.1007/s00737-007-0193-9 PMID:17676431
http://dx.doi.org/10.1007/s00737-007-019...
It aimed to improve women's social status by using the family's shared commitment to the infant's well-being as an entry point. Mao et al.3232 Mao HJ, Li HJ, Chiu H, Chan WC, Chen SL. Effectiveness of antenatal emotional self-management training program in prevention of postnatal depression in Chinese women. Perspect Psychiatr Care 2012;48:218–24. doi: http://dx.doi.org/10.1111/j.1744-6163.2012.00331.x PMID:23005589
http://dx.doi.org/10.1111/j.1744-6163.20...
also used a culturally adapted approach based on cognitive behaviour therapy to teach emotional self-management, including problem-solving and cognitive re-framing, in a facilitated group programme. Rojas et al.2323 Rojas G, Fritsch R, Solis J, Jadresic E, Castillo C, González M et al. Treatment of postnatal depression in low-income mothers in primary-care clinics in Santiago, Chile: a randomised controlled trial. Lancet 2007;370:1629–37. doi: http://dx.doi.org/10.1016/S0140-6736(07)61685-7 PMID:17993363
http://dx.doi.org/10.1016/S0140-6736(07)...
sought to maximize the uptake of antidepressant pharmacotherapy and treatment compliance. Their intervention also involved professionally-led, structured psycho-educational groups that focused on symptom recognition and management, including problem-solving and behavioural strategies. Hughes et al.2727 Hughes MWA. Randomised, controlled trial of a perinatal psycho-social intervention for postnatal depression in Goa, India [thesis]. London: University of London & King's College London Institute of Psychiatry; 2009. focused on a specific social determinant that had been identified in their study site, namely, the “male child fixation” in pregnant women whose older children were all female.5050 Patel V, Rodrigues M, DeSouza N. Gender, poverty, and postnatal depression: a study of mothers in Goa, India. Am J Psychiatry 2002;159:43–7. doi: http://dx.doi.org/10.1176/appi.ajp.159.1.43 PMID:11772688
http://dx.doi.org/10.1176/appi.ajp.159.1...
This problem was addressed through specific education about sex determination and strategies to empower women to challenge ill-informed reactions devaluing the birth of a female child.

Table 2
Nature of interventions for common perinatal mental disorders in low- and middle-income countries and acceptability to consumers and providers

Two studies in China2929 Gao LL, Chan SW, Li X, Chen S, Hao Y. Evaluation of an interpersonal-psychotherapy-oriented childbirth education programme for Chinese first-time childbearing women: a randomised controlled trial. Int J Nurs Stud 2010;47:1208–16. doi: http://dx.doi.org/10.1016/j.ijnurstu.2010.03.002 PMID:20362992
http://dx.doi.org/10.1016/j.ijnurstu.201...
, 3333 Ho SM, Heh SS, Jevitt CM, Huang LH, Fu YY, Wang LL. Effectiveness of a discharge education program in reducing the severity of postpartum depression: a randomized controlled evaluation study. Patient Educ Couns 2009;77:68–71. doi: http://dx.doi.org/10.1016/j.pec.2009.01.009 PMID:19376677
http://dx.doi.org/10.1016/j.pec.2009.01....
and one in Mexico3131 Lara MA, Navarro C, Navarrete L. Outcome results of a psycho-educational intervention in pregnancy to prevent PPD: a randomized control trial. J Affect Disord 2010;122:109–17. doi: http://dx.doi.org/10.1016/j.jad.2009.06.024 PMID:19596446
http://dx.doi.org/10.1016/j.jad.2009.06....
addressed adjustment to motherhood through programmes integrated into existing hospital-based antenatal education or postpartum health care. These studies also took a psycho-educational approach, with structured content provided in a psychologically supportive context. Gao et al.'s programme2929 Gao LL, Chan SW, Li X, Chen S, Hao Y. Evaluation of an interpersonal-psychotherapy-oriented childbirth education programme for Chinese first-time childbearing women: a randomised controlled trial. Int J Nurs Stud 2010;47:1208–16. doi: http://dx.doi.org/10.1016/j.ijnurstu.2010.03.002 PMID:20362992
http://dx.doi.org/10.1016/j.ijnurstu.201...
was derived from interpersonal therapy and used learning activities and the social support of a group process to promote a problem-solving approach, including ways to manage interpersonal conflict in intimate relationships. Ho et al.3333 Ho SM, Heh SS, Jevitt CM, Huang LH, Fu YY, Wang LL. Effectiveness of a discharge education program in reducing the severity of postpartum depression: a randomized controlled evaluation study. Patient Educ Couns 2009;77:68–71. doi: http://dx.doi.org/10.1016/j.pec.2009.01.009 PMID:19376677
http://dx.doi.org/10.1016/j.pec.2009.01....
and Lara et al.3131 Lara MA, Navarro C, Navarrete L. Outcome results of a psycho-educational intervention in pregnancy to prevent PPD: a randomized control trial. J Affect Disord 2010;122:109–17. doi: http://dx.doi.org/10.1016/j.jad.2009.06.024 PMID:19596446
http://dx.doi.org/10.1016/j.jad.2009.06....
provided information about the symptoms and causes of postpartum depression in an information booklet and supplemented this with either supportive discussion with a primary care nurse to encourage early help-seeking behaviour,3333 Ho SM, Heh SS, Jevitt CM, Huang LH, Fu YY, Wang LL. Effectiveness of a discharge education program in reducing the severity of postpartum depression: a randomized controlled evaluation study. Patient Educ Couns 2009;77:68–71. doi: http://dx.doi.org/10.1016/j.pec.2009.01.009 PMID:19376677
http://dx.doi.org/10.1016/j.pec.2009.01....
or participation in a series of group discussions facilitated by professionals.3131 Lara MA, Navarro C, Navarrete L. Outcome results of a psycho-educational intervention in pregnancy to prevent PPD: a randomized control trial. J Affect Disord 2010;122:109–17. doi: http://dx.doi.org/10.1016/j.jad.2009.06.024 PMID:19596446
http://dx.doi.org/10.1016/j.jad.2009.06....

Five studies2222 Baker-Henningham H, Powell C, Walker S, Grantham-McGregor S. The effect of early stimulation on maternal depression: a cluster randomised controlled trial. Arch Dis Child 2005;90:1230–4. doi: http://dx.doi.org/10.1136/adc.2005.073015 PMID:16159905
http://dx.doi.org/10.1136/adc.2005.07301...
, 2424 Rahman A, Iqbal Z, Roberts C, Husain N. Cluster randomized trial of a parent-based intervention to support early development of children in a low-income country. Child Care Health Dev 2009;35:56–62. doi: http://dx.doi.org/10.1111/j.1365-2214.2008.00897.x PMID:18991970
http://dx.doi.org/10.1111/j.1365-2214.20...
, 2626 Cooper PJ, Tomlinson M, Swartz L, Landman M, Molteno C, Stein A et al. Improving quality of mother–infant relationship and infant attachment in socioeconomically deprived community in South Africa: randomised controlled trial. BMJ 2009;338:b974. doi: http://dx.doi.org/10.1136/bmj.b974 PMID:19366752
http://dx.doi.org/10.1136/bmj.b974...
, 2828 Cooper PJ, Landman M, Tomlinson M, Molteno C, Swartz L, Murray L. Impact of a mother-infant intervention in an indigent peri-urban South African context: pilot study. Br J Psychiatry 2002;180:76–81. doi: http://dx.doi.org/10.1192/bjp.180.1.76 PMID:11772856
http://dx.doi.org/10.1192/bjp.180.1.76...
, 3535 Morris J, Jones L, Berrino A, Jordans MJ, Okema L, Crow C. Does combining infant stimulation with emergency feeding improve psychosocial outcomes for displaced mothers and babies? A controlled evaluation from northern Uganda. Am J Orthopsychiatry 2012;82:349–57. doi: http://dx.doi.org/10.1111/j.1939-0025.2012.01168.x PMID:22880973
http://dx.doi.org/10.1111/j.1939-0025.20...
did not address maternal mental health directly. However, the researchers hypothesized that individual parenting education provided by a supportive home visitor or within the context of a mother's group might also improve maternal depression and improve infant health and development. In South Africa, Cooper et al.2626 Cooper PJ, Tomlinson M, Swartz L, Landman M, Molteno C, Stein A et al. Improving quality of mother–infant relationship and infant attachment in socioeconomically deprived community in South Africa: randomised controlled trial. BMJ 2009;338:b974. doi: http://dx.doi.org/10.1136/bmj.b974 PMID:19366752
http://dx.doi.org/10.1136/bmj.b974...
, 2828 Cooper PJ, Landman M, Tomlinson M, Molteno C, Swartz L, Murray L. Impact of a mother-infant intervention in an indigent peri-urban South African context: pilot study. Br J Psychiatry 2002;180:76–81. doi: http://dx.doi.org/10.1192/bjp.180.1.76 PMID:11772856
http://dx.doi.org/10.1192/bjp.180.1.76...
demonstrated what neonates could do using a neonatal assessment scale. In a study conducted by Baker-Henningham et al.2222 Baker-Henningham H, Powell C, Walker S, Grantham-McGregor S. The effect of early stimulation on maternal depression: a cluster randomised controlled trial. Arch Dis Child 2005;90:1230–4. doi: http://dx.doi.org/10.1136/adc.2005.073015 PMID:16159905
http://dx.doi.org/10.1136/adc.2005.07301...
in Jamaica and in the adapted Learning Through Play (LTP) programmes implemented in Pakistan2424 Rahman A, Iqbal Z, Roberts C, Husain N. Cluster randomized trial of a parent-based intervention to support early development of children in a low-income country. Child Care Health Dev 2009;35:56–62. doi: http://dx.doi.org/10.1111/j.1365-2214.2008.00897.x PMID:18991970
http://dx.doi.org/10.1111/j.1365-2214.20...
and northern Uganda,3535 Morris J, Jones L, Berrino A, Jordans MJ, Okema L, Crow C. Does combining infant stimulation with emergency feeding improve psychosocial outcomes for displaced mothers and babies? A controlled evaluation from northern Uganda. Am J Orthopsychiatry 2012;82:349–57. doi: http://dx.doi.org/10.1111/j.1939-0025.2012.01168.x PMID:22880973
http://dx.doi.org/10.1111/j.1939-0025.20...
mothers were shown age-appropriate play activities and how to craft toys out of affordable, accessible materials to stimulate infant cognitive development. In broad terms, the theoretical rationale underpinning these approaches was that optimal child development requires maternal caregiving that attends explicitly to development in the physical, social, emotional and cognitive domains. The interventions carried out in these five studies aimed to enhance mothers' knowledge about normal child development, improve maternal sensitivity and responsiveness towards infants and, through group programmes,2424 Rahman A, Iqbal Z, Roberts C, Husain N. Cluster randomized trial of a parent-based intervention to support early development of children in a low-income country. Child Care Health Dev 2009;35:56–62. doi: http://dx.doi.org/10.1111/j.1365-2214.2008.00897.x PMID:18991970
http://dx.doi.org/10.1111/j.1365-2214.20...
, 3535 Morris J, Jones L, Berrino A, Jordans MJ, Okema L, Crow C. Does combining infant stimulation with emergency feeding improve psychosocial outcomes for displaced mothers and babies? A controlled evaluation from northern Uganda. Am J Orthopsychiatry 2012;82:349–57. doi: http://dx.doi.org/10.1111/j.1939-0025.2012.01168.x PMID:22880973
http://dx.doi.org/10.1111/j.1939-0025.20...
reduce social isolation and improve maternal mood by means of peer support.

Tripathy et al.'s intervention3434 Tripathy P, Nair N, Barnett S, Mahapatra R, Borghi J, Rath S et al. Effect of a participatory intervention with women’s groups on birth outcomes and maternal depression in Jharkhand and Orissa, India: a cluster-randomised controlled trial. Lancet 2010;375:1182–92. doi: http://dx.doi.org/10.1016/S0140-6736(09)62042-0 PMID:20207411
http://dx.doi.org/10.1016/S0140-6736(09)...
also addressed maternal depression indirectly. It focused on educating mothers about pregnancy, birth, neonatal health and health-care seeking through locally designed illustrative case studies and stories. With the help of a trained local woman, community participatory action groups devised local interventions designed to reduce maternal and neonatal morbidity, with potential flow-on benefits for maternal mental health.

All studies except those from China and Mexico were conducted with participants of low socioeconomic status who experienced difficulties that could have contributed to their mental health problems. In these studies, the social determinants of perinatal depression in women were either reported as relevant by participants or explicitly recognized on a theoretical level.2424 Rahman A, Iqbal Z, Roberts C, Husain N. Cluster randomized trial of a parent-based intervention to support early development of children in a low-income country. Child Care Health Dev 2009;35:56–62. doi: http://dx.doi.org/10.1111/j.1365-2214.2008.00897.x PMID:18991970
http://dx.doi.org/10.1111/j.1365-2214.20...
2828 Cooper PJ, Landman M, Tomlinson M, Molteno C, Swartz L, Murray L. Impact of a mother-infant intervention in an indigent peri-urban South African context: pilot study. Br J Psychiatry 2002;180:76–81. doi: http://dx.doi.org/10.1192/bjp.180.1.76 PMID:11772856
http://dx.doi.org/10.1192/bjp.180.1.76...
, 3535 Morris J, Jones L, Berrino A, Jordans MJ, Okema L, Crow C. Does combining infant stimulation with emergency feeding improve psychosocial outcomes for displaced mothers and babies? A controlled evaluation from northern Uganda. Am J Orthopsychiatry 2012;82:349–57. doi: http://dx.doi.org/10.1111/j.1939-0025.2012.01168.x PMID:22880973
http://dx.doi.org/10.1111/j.1939-0025.20...
Such determinants include, for example, living in poor and overcrowded housing, suffering social exclusion as a result of illiteracy and unemployment, being a victim of the gender stereotypes that restrict women's social participation or underpin hostility towards women, and experiencing social instability and neighbourhood violence.2222 Baker-Henningham H, Powell C, Walker S, Grantham-McGregor S. The effect of early stimulation on maternal depression: a cluster randomised controlled trial. Arch Dis Child 2005;90:1230–4. doi: http://dx.doi.org/10.1136/adc.2005.073015 PMID:16159905
http://dx.doi.org/10.1136/adc.2005.07301...
No study addressed these determinants directly.

All the studies drew on evidence generated in high-income countries. However, authors acknowledged that such evidence could not be transferred directly to resource-constrained settings and that, before being adopted, the interventions had to be supported by local evidence about effectiveness, affordability, acceptability and cultural appropriateness. The study interventions were all assessed in settings with very few specialists in mental health. Chile, China and Mexico were the only countries where the interventions were implemented by mental health professionals.2323 Rojas G, Fritsch R, Solis J, Jadresic E, Castillo C, González M et al. Treatment of postnatal depression in low-income mothers in primary-care clinics in Santiago, Chile: a randomised controlled trial. Lancet 2007;370:1629–37. doi: http://dx.doi.org/10.1016/S0140-6736(07)61685-7 PMID:17993363
http://dx.doi.org/10.1016/S0140-6736(07)...
, 2929 Gao LL, Chan SW, Li X, Chen S, Hao Y. Evaluation of an interpersonal-psychotherapy-oriented childbirth education programme for Chinese first-time childbearing women: a randomised controlled trial. Int J Nurs Stud 2010;47:1208–16. doi: http://dx.doi.org/10.1016/j.ijnurstu.2010.03.002 PMID:20362992
http://dx.doi.org/10.1016/j.ijnurstu.201...
, 3131 Lara MA, Navarro C, Navarrete L. Outcome results of a psycho-educational intervention in pregnancy to prevent PPD: a randomized control trial. J Affect Disord 2010;122:109–17. doi: http://dx.doi.org/10.1016/j.jad.2009.06.024 PMID:19596446
http://dx.doi.org/10.1016/j.jad.2009.06....
, 3333 Ho SM, Heh SS, Jevitt CM, Huang LH, Fu YY, Wang LL. Effectiveness of a discharge education program in reducing the severity of postpartum depression: a randomized controlled evaluation study. Patient Educ Couns 2009;77:68–71. doi: http://dx.doi.org/10.1016/j.pec.2009.01.009 PMID:19376677
http://dx.doi.org/10.1016/j.pec.2009.01....
In all other studies they were implemented by local trained community health workers under professional supervision. In seven interventions involving individual home visits,2222 Baker-Henningham H, Powell C, Walker S, Grantham-McGregor S. The effect of early stimulation on maternal depression: a cluster randomised controlled trial. Arch Dis Child 2005;90:1230–4. doi: http://dx.doi.org/10.1136/adc.2005.073015 PMID:16159905
http://dx.doi.org/10.1136/adc.2005.07301...
, 2424 Rahman A, Iqbal Z, Roberts C, Husain N. Cluster randomized trial of a parent-based intervention to support early development of children in a low-income country. Child Care Health Dev 2009;35:56–62. doi: http://dx.doi.org/10.1111/j.1365-2214.2008.00897.x PMID:18991970
http://dx.doi.org/10.1111/j.1365-2214.20...
2828 Cooper PJ, Landman M, Tomlinson M, Molteno C, Swartz L, Murray L. Impact of a mother-infant intervention in an indigent peri-urban South African context: pilot study. Br J Psychiatry 2002;180:76–81. doi: http://dx.doi.org/10.1192/bjp.180.1.76 PMID:11772856
http://dx.doi.org/10.1192/bjp.180.1.76...
, 3535 Morris J, Jones L, Berrino A, Jordans MJ, Okema L, Crow C. Does combining infant stimulation with emergency feeding improve psychosocial outcomes for displaced mothers and babies? A controlled evaluation from northern Uganda. Am J Orthopsychiatry 2012;82:349–57. doi: http://dx.doi.org/10.1111/j.1939-0025.2012.01168.x PMID:22880973
http://dx.doi.org/10.1111/j.1939-0025.20...
the therapeutic relationship between the health worker and the study participant was regarded as an important determinant of improvements in mental health. In this relationship, trust was of utmost importance. Equally important was the selection of local health workers who understood their clients' sociocultural circumstances and who possessed basic psychological counselling skills, including knowing how to listen and to be non-judgmental, empathic and supportive. In settings where many women lived in multigenerational households, members of the extended family were engaged during home visits to reduce women's reticence and encourage long-term behaviour change.2222 Baker-Henningham H, Powell C, Walker S, Grantham-McGregor S. The effect of early stimulation on maternal depression: a cluster randomised controlled trial. Arch Dis Child 2005;90:1230–4. doi: http://dx.doi.org/10.1136/adc.2005.073015 PMID:16159905
http://dx.doi.org/10.1136/adc.2005.07301...
, 2424 Rahman A, Iqbal Z, Roberts C, Husain N. Cluster randomized trial of a parent-based intervention to support early development of children in a low-income country. Child Care Health Dev 2009;35:56–62. doi: http://dx.doi.org/10.1111/j.1365-2214.2008.00897.x PMID:18991970
http://dx.doi.org/10.1111/j.1365-2214.20...

Effects on maternal mental health

Psychiatric labels and the conceptualization of illness differed widely among studies. In Rojas et al.'s intervention,2323 Rojas G, Fritsch R, Solis J, Jadresic E, Castillo C, González M et al. Treatment of postnatal depression in low-income mothers in primary-care clinics in Santiago, Chile: a randomised controlled trial. Lancet 2007;370:1629–37. doi: http://dx.doi.org/10.1016/S0140-6736(07)61685-7 PMID:17993363
http://dx.doi.org/10.1016/S0140-6736(07)...
participants were assessed for depression and received education about symptom recognition and the importance of compliance with psychotropic medication. Some interventions were applied to women in the general community;2222 Baker-Henningham H, Powell C, Walker S, Grantham-McGregor S. The effect of early stimulation on maternal depression: a cluster randomised controlled trial. Arch Dis Child 2005;90:1230–4. doi: http://dx.doi.org/10.1136/adc.2005.073015 PMID:16159905
http://dx.doi.org/10.1136/adc.2005.07301...
, 2424 Rahman A, Iqbal Z, Roberts C, Husain N. Cluster randomized trial of a parent-based intervention to support early development of children in a low-income country. Child Care Health Dev 2009;35:56–62. doi: http://dx.doi.org/10.1111/j.1365-2214.2008.00897.x PMID:18991970
http://dx.doi.org/10.1111/j.1365-2214.20...
, 2929 Gao LL, Chan SW, Li X, Chen S, Hao Y. Evaluation of an interpersonal-psychotherapy-oriented childbirth education programme for Chinese first-time childbearing women: a randomised controlled trial. Int J Nurs Stud 2010;47:1208–16. doi: http://dx.doi.org/10.1016/j.ijnurstu.2010.03.002 PMID:20362992
http://dx.doi.org/10.1016/j.ijnurstu.201...
, 3434 Tripathy P, Nair N, Barnett S, Mahapatra R, Borghi J, Rath S et al. Effect of a participatory intervention with women’s groups on birth outcomes and maternal depression in Jharkhand and Orissa, India: a cluster-randomised controlled trial. Lancet 2010;375:1182–92. doi: http://dx.doi.org/10.1016/S0140-6736(09)62042-0 PMID:20207411
http://dx.doi.org/10.1016/S0140-6736(09)...
, 3535 Morris J, Jones L, Berrino A, Jordans MJ, Okema L, Crow C. Does combining infant stimulation with emergency feeding improve psychosocial outcomes for displaced mothers and babies? A controlled evaluation from northern Uganda. Am J Orthopsychiatry 2012;82:349–57. doi: http://dx.doi.org/10.1111/j.1939-0025.2012.01168.x PMID:22880973
http://dx.doi.org/10.1111/j.1939-0025.20...
others were applied only to women who were attending programmes not specifically dealing with mental health.2929 Gao LL, Chan SW, Li X, Chen S, Hao Y. Evaluation of an interpersonal-psychotherapy-oriented childbirth education programme for Chinese first-time childbearing women: a randomised controlled trial. Int J Nurs Stud 2010;47:1208–16. doi: http://dx.doi.org/10.1016/j.ijnurstu.2010.03.002 PMID:20362992
http://dx.doi.org/10.1016/j.ijnurstu.201...
, 3333 Ho SM, Heh SS, Jevitt CM, Huang LH, Fu YY, Wang LL. Effectiveness of a discharge education program in reducing the severity of postpartum depression: a randomized controlled evaluation study. Patient Educ Couns 2009;77:68–71. doi: http://dx.doi.org/10.1016/j.pec.2009.01.009 PMID:19376677
http://dx.doi.org/10.1016/j.pec.2009.01....
In these interventions, mental health was assessed by means of symptom checklists rather than diagnoses or psychiatric assessment. Although all participants in the THP met the diagnostic criteria for depression, the intervention was positioned as a maternal and child health promotion strategy in which the use of psychopathological labelling was likely to have increased stigma and reduced compliance.2525 Rahman A, Malik A, Sikander S, Roberts C, Creed F. Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial. Lancet 2008;372:902–9. doi: http://dx.doi.org/10.1016/S0140-6736(08)61400-2 PMID:18790313
http://dx.doi.org/10.1016/S0140-6736(08)...

All 13 studies reported outcome data on maternal depression that was sufficiently detailed to be included in a meta-analysis. The resulting pooled effect size was −0.38 (95% CI: –0.56 to −0.21; I 2 = 79.9%) (Fig. 2). The funnel plots were symmetrical (Fig. 3). Egger test statistics confirmed the lack of asymmetry indicative of publication bias (P = 0.97).

Fig. 2
Forest plot presenting the standardized effect size (and 95% confidence intervals, CI) for 13 interventions for common perinatal mental disorders among women in low- and middle-income countries
Fig. 3
Funnel plot showing the standardized effect sizea and pseudo 95% confidence limits for 13 interventions for common perinatal mental disorders among women in low- and middle-income countries

Two trials assessed secondary maternal psychological outcomes. Rojas et al.2323 Rojas G, Fritsch R, Solis J, Jadresic E, Castillo C, González M et al. Treatment of postnatal depression in low-income mothers in primary-care clinics in Santiago, Chile: a randomised controlled trial. Lancet 2007;370:1629–37. doi: http://dx.doi.org/10.1016/S0140-6736(07)61685-7 PMID:17993363
http://dx.doi.org/10.1016/S0140-6736(07)...
reported that women who received multi-component group therapy were more compliant with their antidepressant drug schedules, attended primary care more frequently and had better functioning, as measured by the SF-36, than those in the usual care group. Women in the THP intervention clusters in Pakistan2525 Rahman A, Malik A, Sikander S, Roberts C, Creed F. Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial. Lancet 2008;372:902–9. doi: http://dx.doi.org/10.1016/S0140-6736(08)61400-2 PMID:18790313
http://dx.doi.org/10.1016/S0140-6736(08)...
had less disability, better overall functioning and greater perceived social support at their two follow-up assessments than women in the control group.

Child health and development

Direct, between-study comparisons of the effects of the various interventions on infant health and development are limited by differences in design, intervention content, the age at which outcomes were measured and the parameters that were assessed. Six of the 13 interventions2222 Baker-Henningham H, Powell C, Walker S, Grantham-McGregor S. The effect of early stimulation on maternal depression: a cluster randomised controlled trial. Arch Dis Child 2005;90:1230–4. doi: http://dx.doi.org/10.1136/adc.2005.073015 PMID:16159905
http://dx.doi.org/10.1136/adc.2005.07301...
, 2424 Rahman A, Iqbal Z, Roberts C, Husain N. Cluster randomized trial of a parent-based intervention to support early development of children in a low-income country. Child Care Health Dev 2009;35:56–62. doi: http://dx.doi.org/10.1111/j.1365-2214.2008.00897.x PMID:18991970
http://dx.doi.org/10.1111/j.1365-2214.20...
, 2525 Rahman A, Malik A, Sikander S, Roberts C, Creed F. Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial. Lancet 2008;372:902–9. doi: http://dx.doi.org/10.1016/S0140-6736(08)61400-2 PMID:18790313
http://dx.doi.org/10.1016/S0140-6736(08)...
, 2727 Hughes MWA. Randomised, controlled trial of a perinatal psycho-social intervention for postnatal depression in Goa, India [thesis]. London: University of London & King's College London Institute of Psychiatry; 2009. , 2828 Cooper PJ, Landman M, Tomlinson M, Molteno C, Swartz L, Murray L. Impact of a mother-infant intervention in an indigent peri-urban South African context: pilot study. Br J Psychiatry 2002;180:76–81. doi: http://dx.doi.org/10.1192/bjp.180.1.76 PMID:11772856
http://dx.doi.org/10.1192/bjp.180.1.76...
, 3434 Tripathy P, Nair N, Barnett S, Mahapatra R, Borghi J, Rath S et al. Effect of a participatory intervention with women’s groups on birth outcomes and maternal depression in Jharkhand and Orissa, India: a cluster-randomised controlled trial. Lancet 2010;375:1182–92. doi: http://dx.doi.org/10.1016/S0140-6736(09)62042-0 PMID:20207411
http://dx.doi.org/10.1016/S0140-6736(09)...
aimed specifically to enhance infant health and development either by improving maternal knowledge, sensitivity, responsiveness or caregiving skills, or, less directly, by improving maternal mood (Table 2).

In three studies that focused specifically on child health and development, information on the benefits of age-appropriate activities for stimulating cognitive capacity and of structured parent–infant play was provided during home visits by community health workers.2222 Baker-Henningham H, Powell C, Walker S, Grantham-McGregor S. The effect of early stimulation on maternal depression: a cluster randomised controlled trial. Arch Dis Child 2005;90:1230–4. doi: http://dx.doi.org/10.1136/adc.2005.073015 PMID:16159905
http://dx.doi.org/10.1136/adc.2005.07301...
, 2424 Rahman A, Iqbal Z, Roberts C, Husain N. Cluster randomized trial of a parent-based intervention to support early development of children in a low-income country. Child Care Health Dev 2009;35:56–62. doi: http://dx.doi.org/10.1111/j.1365-2214.2008.00897.x PMID:18991970
http://dx.doi.org/10.1111/j.1365-2214.20...
, 3535 Morris J, Jones L, Berrino A, Jordans MJ, Okema L, Crow C. Does combining infant stimulation with emergency feeding improve psychosocial outcomes for displaced mothers and babies? A controlled evaluation from northern Uganda. Am J Orthopsychiatry 2012;82:349–57. doi: http://dx.doi.org/10.1111/j.1939-0025.2012.01168.x PMID:22880973
http://dx.doi.org/10.1111/j.1939-0025.20...
Women who participated in the LTP programme in Pakistan showed significantly better knowledge about their infants' needs and development than those who had received standard care.2424 Rahman A, Iqbal Z, Roberts C, Husain N. Cluster randomized trial of a parent-based intervention to support early development of children in a low-income country. Child Care Health Dev 2009;35:56–62. doi: http://dx.doi.org/10.1111/j.1365-2214.2008.00897.x PMID:18991970
http://dx.doi.org/10.1111/j.1365-2214.20...
Even under crisis conditions in Uganda, there was a notable improvement in mothers' use of play materials to stimulate their infants in the Acholi adaptation of the LTP programme.3535 Morris J, Jones L, Berrino A, Jordans MJ, Okema L, Crow C. Does combining infant stimulation with emergency feeding improve psychosocial outcomes for displaced mothers and babies? A controlled evaluation from northern Uganda. Am J Orthopsychiatry 2012;82:349–57. doi: http://dx.doi.org/10.1111/j.1939-0025.2012.01168.x PMID:22880973
http://dx.doi.org/10.1111/j.1939-0025.20...
In a Jamaican programme, mothers were shown how to engage their infants' interest with affordable toys, picture books and household materials,2222 Baker-Henningham H, Powell C, Walker S, Grantham-McGregor S. The effect of early stimulation on maternal depression: a cluster randomised controlled trial. Arch Dis Child 2005;90:1230–4. doi: http://dx.doi.org/10.1136/adc.2005.073015 PMID:16159905
http://dx.doi.org/10.1136/adc.2005.07301...
and the results showed a negative association between the development quotient in boys – not girls – and the number of depressive symptoms found in the mother. None of these studies reported specifically on child health or physical development.

In an intervention conducted by Hughes,2727 Hughes MWA. Randomised, controlled trial of a perinatal psycho-social intervention for postnatal depression in Goa, India [thesis]. London: University of London & King's College London Institute of Psychiatry; 2009. anganwadi workers explained to mothers, using dolls, how massaging their infants could improve child development. No differences were noted in child health and development outcomes, but average weight was significantly lower in infants whose mothers were at high risk of becoming depressed. The THP study aimed to improve child health by reducing maternal depression. Although infant stunting and low weight were not improved, infants experienced fewer episodes of diarrhoea and rates of completion of the recommended immunization schedule improved.2525 Rahman A, Malik A, Sikander S, Roberts C, Creed F. Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial. Lancet 2008;372:902–9. doi: http://dx.doi.org/10.1016/S0140-6736(08)61400-2 PMID:18790313
http://dx.doi.org/10.1016/S0140-6736(08)...

The mother–infant relationship

Six interventions sought to improve the relationship between mother and infant as a primary2626 Cooper PJ, Tomlinson M, Swartz L, Landman M, Molteno C, Stein A et al. Improving quality of mother–infant relationship and infant attachment in socioeconomically deprived community in South Africa: randomised controlled trial. BMJ 2009;338:b974. doi: http://dx.doi.org/10.1136/bmj.b974 PMID:19366752
http://dx.doi.org/10.1136/bmj.b974...
, 2828 Cooper PJ, Landman M, Tomlinson M, Molteno C, Swartz L, Murray L. Impact of a mother-infant intervention in an indigent peri-urban South African context: pilot study. Br J Psychiatry 2002;180:76–81. doi: http://dx.doi.org/10.1192/bjp.180.1.76 PMID:11772856
http://dx.doi.org/10.1192/bjp.180.1.76...
, 3535 Morris J, Jones L, Berrino A, Jordans MJ, Okema L, Crow C. Does combining infant stimulation with emergency feeding improve psychosocial outcomes for displaced mothers and babies? A controlled evaluation from northern Uganda. Am J Orthopsychiatry 2012;82:349–57. doi: http://dx.doi.org/10.1111/j.1939-0025.2012.01168.x PMID:22880973
http://dx.doi.org/10.1111/j.1939-0025.20...
or subsidiary2222 Baker-Henningham H, Powell C, Walker S, Grantham-McGregor S. The effect of early stimulation on maternal depression: a cluster randomised controlled trial. Arch Dis Child 2005;90:1230–4. doi: http://dx.doi.org/10.1136/adc.2005.073015 PMID:16159905
http://dx.doi.org/10.1136/adc.2005.07301...
, 2525 Rahman A, Malik A, Sikander S, Roberts C, Creed F. Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial. Lancet 2008;372:902–9. doi: http://dx.doi.org/10.1016/S0140-6736(08)61400-2 PMID:18790313
http://dx.doi.org/10.1016/S0140-6736(08)...
goal (Table 1). The pooled effect size of the corresponding interventions was 0.36 (95% CI: 0.22–0.51).

In Cooper et al.'s studies,2626 Cooper PJ, Tomlinson M, Swartz L, Landman M, Molteno C, Stein A et al. Improving quality of mother–infant relationship and infant attachment in socioeconomically deprived community in South Africa: randomised controlled trial. BMJ 2009;338:b974. doi: http://dx.doi.org/10.1136/bmj.b974 PMID:19366752
http://dx.doi.org/10.1136/bmj.b974...
, 2828 Cooper PJ, Landman M, Tomlinson M, Molteno C, Swartz L, Murray L. Impact of a mother-infant intervention in an indigent peri-urban South African context: pilot study. Br J Psychiatry 2002;180:76–81. doi: http://dx.doi.org/10.1192/bjp.180.1.76 PMID:11772856
http://dx.doi.org/10.1192/bjp.180.1.76...
which focused on the mother–infant relationship, behavioural assessment items were used to show mothers what their infants could do (e.g. tracking objects with their eyes or imitating others' facial expressions) and the reciprocal influence of the infant–child interaction. In one of the two studies, mothers were given direct, tailored advice about how to recognize and respond to normal infant needs in a manner intended to make the mother–infant interaction more gratifying and to enhance maternal competence and self-confidence.2828 Cooper PJ, Landman M, Tomlinson M, Molteno C, Swartz L, Murray L. Impact of a mother-infant intervention in an indigent peri-urban South African context: pilot study. Br J Psychiatry 2002;180:76–81. doi: http://dx.doi.org/10.1192/bjp.180.1.76 PMID:11772856
http://dx.doi.org/10.1192/bjp.180.1.76...
The pilot intervention led to improved infant weight and length.2828 Cooper PJ, Landman M, Tomlinson M, Molteno C, Swartz L, Murray L. Impact of a mother-infant intervention in an indigent peri-urban South African context: pilot study. Br J Psychiatry 2002;180:76–81. doi: http://dx.doi.org/10.1192/bjp.180.1.76 PMID:11772856
http://dx.doi.org/10.1192/bjp.180.1.76...
Cooper et al.'s studies were the only ones that assessed the quality of the mother–infant relationship through independent scoring of videotaped interactions. Mothers' sensitivity and expressions of affection towards their infants improved, and, in one trial, rates of secure infant–mother attachment increased.2626 Cooper PJ, Tomlinson M, Swartz L, Landman M, Molteno C, Stein A et al. Improving quality of mother–infant relationship and infant attachment in socioeconomically deprived community in South Africa: randomised controlled trial. BMJ 2009;338:b974. doi: http://dx.doi.org/10.1136/bmj.b974 PMID:19366752
http://dx.doi.org/10.1136/bmj.b974...

The interventions conducted by Baker-Henningham et al.2222 Baker-Henningham H, Powell C, Walker S, Grantham-McGregor S. The effect of early stimulation on maternal depression: a cluster randomised controlled trial. Arch Dis Child 2005;90:1230–4. doi: http://dx.doi.org/10.1136/adc.2005.073015 PMID:16159905
http://dx.doi.org/10.1136/adc.2005.07301...
were manifold. They included demonstrations of activities for stimulating infants' cognitive development; praise for mothers who showed sensitivity and imagination in their interactions with their infants, and facilitator-initiated discussions about infant nutrition. A less direct but explicit approach was used in two Pakistani studies that focused specifically on the mother–infant relationship. In these studies,2525 Rahman A, Malik A, Sikander S, Roberts C, Creed F. Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial. Lancet 2008;372:902–9. doi: http://dx.doi.org/10.1016/S0140-6736(08)61400-2 PMID:18790313
http://dx.doi.org/10.1016/S0140-6736(08)...
the THP sought to help mothers become more aware of their infants' needs and replace “unhealthy” thoughts about their infants with more productive thinking based on improved knowledge. In LTP programmes in Pakistan and Northern Uganda, as a way to stimulate discussion mothers were shown educational images illustrating activities that they could engage in with their infants.2424 Rahman A, Iqbal Z, Roberts C, Husain N. Cluster randomized trial of a parent-based intervention to support early development of children in a low-income country. Child Care Health Dev 2009;35:56–62. doi: http://dx.doi.org/10.1111/j.1365-2214.2008.00897.x PMID:18991970
http://dx.doi.org/10.1111/j.1365-2214.20...
, 3535 Morris J, Jones L, Berrino A, Jordans MJ, Okema L, Crow C. Does combining infant stimulation with emergency feeding improve psychosocial outcomes for displaced mothers and babies? A controlled evaluation from northern Uganda. Am J Orthopsychiatry 2012;82:349–57. doi: http://dx.doi.org/10.1111/j.1939-0025.2012.01168.x PMID:22880973
http://dx.doi.org/10.1111/j.1939-0025.20...

In the two Pakistani studies, the interventions' beneficial effect on maternal depression and on the mother–infant relationship was assumed to be attributable to a common pathway: that improving maternal knowledge, caregiving skills, sensitivity and responsiveness towards infants enhances the mother–infant interaction and maternal self-efficacy and satisfaction. Mood lifting effects were demonstrated to some degree. Morris et al.3535 Morris J, Jones L, Berrino A, Jordans MJ, Okema L, Crow C. Does combining infant stimulation with emergency feeding improve psychosocial outcomes for displaced mothers and babies? A controlled evaluation from northern Uganda. Am J Orthopsychiatry 2012;82:349–57. doi: http://dx.doi.org/10.1111/j.1939-0025.2012.01168.x PMID:22880973
http://dx.doi.org/10.1111/j.1939-0025.20...
found no improvement in maternal sadness or irritability when they controlled for the effects of interview site and baseline scores, but Baker-Henningham et al.2222 Baker-Henningham H, Powell C, Walker S, Grantham-McGregor S. The effect of early stimulation on maternal depression: a cluster randomised controlled trial. Arch Dis Child 2005;90:1230–4. doi: http://dx.doi.org/10.1136/adc.2005.073015 PMID:16159905
http://dx.doi.org/10.1136/adc.2005.07301...
and Rahman et al.2525 Rahman A, Malik A, Sikander S, Roberts C, Creed F. Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial. Lancet 2008;372:902–9. doi: http://dx.doi.org/10.1016/S0140-6736(08)61400-2 PMID:18790313
http://dx.doi.org/10.1016/S0140-6736(08)...
did note improvements in maternal depression. In Rahman et al.'s study, knowledge about infant care improved not just among mothers, but also among fathers; as a result of the THP, both parents became more playful with their infants, with potential flow-on benefits in terms of the parent–infant relationship and the infants' cognitive, social and emotional development.2525 Rahman A, Malik A, Sikander S, Roberts C, Creed F. Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial. Lancet 2008;372:902–9. doi: http://dx.doi.org/10.1016/S0140-6736(08)61400-2 PMID:18790313
http://dx.doi.org/10.1016/S0140-6736(08)...
Overall the interventions had significant positive effects on growth, development and rates of infectious diseases among infants, and they resulted in lower neonatal mortality (Table 3).

Table 3
Outcomes of interest, effect measures and effect sizes from studies of interventions for common perinatal mental disorders among women in low- and middle-income countries

Discussion

This is the first systematic review of the evidence surrounding interventions for the relief of CPMDs. Its findings show that such interventions can be effectively implemented in LAMI countries by trained and supervised health workers in primary care and community settings. The results are concordant with the findings of meta-analyses of psychological and psychosocial intervention studies for perinatal depression from high-income countries, which report a summary relative risk of 0.70 (95% CI: 0.60–0.81) for women in the intervention arm versus controls receiving standard care.1313 Dennis C, Hodnett E. Psychosocial and psychological interventions for treating postpartum depression (review). London: JohnWiley & Sons Ltd; 2009.

There was substantial heterogeneity in estimated treatment effects, but the small number of studies precludes a meaningful assessment of the reasons for the variation. The psychotherapeutic content of the interventions, the number of therapy sessions, and staff training and supervision practices may have differed across studies. This is true of the THP in Pakistan2525 Rahman A, Malik A, Sikander S, Roberts C, Creed F. Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial. Lancet 2008;372:902–9. doi: http://dx.doi.org/10.1016/S0140-6736(08)61400-2 PMID:18790313
http://dx.doi.org/10.1016/S0140-6736(08)...
and of the anganwadi intervention in India conducted by Hughes et al.,2727 Hughes MWA. Randomised, controlled trial of a perinatal psycho-social intervention for postnatal depression in Goa, India [thesis]. London: University of London & King's College London Institute of Psychiatry; 2009. which had the largest and the smallest impact, respectively. The THP in Pakistan was based on cognitive behaviour therapy combined with active listening, measures for strengthening the mother–infant relationship and mobilization of family support. The anganwadi intervention, on the other hand, was based on a more general supportive psycho-educational approach. The interventions also differed in intensity: 162525 Rahman A, Malik A, Sikander S, Roberts C, Creed F. Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial. Lancet 2008;372:902–9. doi: http://dx.doi.org/10.1016/S0140-6736(08)61400-2 PMID:18790313
http://dx.doi.org/10.1016/S0140-6736(08)...
sessions as opposed to 5, respectively.2727 Hughes MWA. Randomised, controlled trial of a perinatal psycho-social intervention for postnatal depression in Goa, India [thesis]. London: University of London & King's College London Institute of Psychiatry; 2009. Although the THP had a shorter training period (3 days compared with 1 month for the anganwadi workers), the Lady Health Workers in Pakistan had monthly half-day supervision throughout the intervention. This suggests that continuous supervision is more effective than one-off training.

Our findings suggest that the relationship between maternal mood and infant health and development is not unidirectional. Interventions in which mothers are taught about infant development and are shown how to engage and stimulate their infants and to be more responsive and affectionate towards them appear to improve maternal mood, in addition to strengthening the mother–infant relationship and leading to better infant health and development outcomes. Similarly, interventions expressly designed to improve maternal mental health have a positive impact on infant health and development. An intervention's effect on infant health and development appears to be stronger when the maternal and infant components are integrated and infant health is a direct, rather than an incidental focus of the intervention.

Collectively, the studies in this review provide important lessons in terms of service development. First, approaches that are culturally adapted and grounded in cognitive, problem-solving and educational techniques can be applied effectively to groups or individuals. Most of the interventions described in the studies targeted mothers and infants and were conducted in women's homes. In settings where women live in multigenerational households, this approach makes it possible to engage the whole family in the common pursuit of caring for the new infant. In all the studies, except for Lara et al.'s in Mexico, the interventions were delivered by supervised, non-specialist health and community workers without any training in mental health care. Thus, the studies provide evidence of the feasibility of training such workers to deliver mental health interventions effectively in a relatively short time. For low-income countries, where mental health professionals are scarce and tend to concentrate in big cities, this has important implications.5151 Jacob KS, Sharan P, Mirza I, Garrido-Cumbrera M, Seedat S, Mari JJ et al. Mental health systems in countries: where are we now? Lancet 2007;370:1061–77. doi: http://dx.doi.org/10.1016/S0140-6736(07)61241-0 PMID:17804052
http://dx.doi.org/10.1016/S0140-6736(07)...
, 5252 Saxena S, Thornicroft G, Knapp M, Whiteford H. Resources for mental health: scarcity, inequity, and inefficiency. Lancet 2007;370:878–89. doi: http://dx.doi.org/10.1016/S0140-6736(07)61239-2 PMID:17804062
http://dx.doi.org/10.1016/S0140-6736(07)...

A second lesson learnt is that the psychological and educational components of the interventions must be adapted to the circumstances in which women in LAMI countries live. In places where women live in densely populated communities and crowded households, involving the entire family and community in their care tends to be more beneficial than an individualistic approach. Interventions that engage the family can mitigate some important risk factors for depression in women: a poor sense of personal agency, pejorative and limiting gender stereotypes, lack of financial autonomy and intimate partner coercion and violence.

Common perinatal mental disorders are difficult to recognize. Furthermore, the fear of stigma can make women and their families reluctant to seek care. In the studies included in this review, health workers integrated the mental health interventions into their regular work activities, which may prove less stigmatizing to women. Maternal mental health and infant development interventions appear to act synergistically and the perinatal period provides an opportunity to deliver them in an integrated fashion. These data indicate that community-based approaches are beneficial and might be preferable to stand-alone vertical programmes. They may also be relevant to high-income countries, where providing equitable mental health services is becoming increasingly costly.1515 Patel V, Kirkwood B. Perinatal depression treated by community health workers. Lancet 2008;372:868–9. doi: http://dx.doi.org/10.1016/S0140-6736(08)61374-4 PMID:18790294
http://dx.doi.org/10.1016/S0140-6736(08)...

No interventions targeting the more severe perinatal mental disorders, such as postpartum psychosis or suicidal behaviour, were found in this review. Future studies should address this gap. Nevertheless, our meta-analysis provides grounds for believing that the large global burden of CPMDs, particularly perinatal depression in women, can be addressed in resource-constrained settings through appropriate interventions. District-level primary care programmes providing integrated training and supervision and outcomes assessed in the general community are required to inform strategies for taking such interventions to scale.

Acknowledgements

We thank the authors of trials who provided additional information for our review and meta-analysis.

Funding:

  • The study was sponsored by the Department of Mental Health and Substance Abuse of the World Health Organization, the United Nations Population Fund (UNFPA) and Compass, the Women's and Children's Health Knowledge Hub funded by the Australian Agency for International Development (AusAID) and the Victorian Operational Infrastructure Support Programme. The views expressed in this article do not necessarily represent the decisions, policy or views of WHO, the UNPFA or AusAID. The authors had full control over the analysis and reporting of the results.

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History

  • Received
    09 July 2012
  • Reviewed
    26 Mar 2013
  • Accepted
    28 Apr 2013
  • Issue publication
    Aug 2013
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