By Lim Su Lin, Research and Advocacy Associate, SOLS Health
The perinatal period, broadly defined, refers to the period during a woman’s pregnancy from the point of conception and carrying the unborn child, to postpartum, after the infant is delivered. In the context of a timeframe, it covers the year before, to the first 18-24 months after a child is born.
This period constitutes a vulnerable time for women, as the transition to motherhood involves adapting to immense physical, emotional and social changes. Due to these changes, the risk of mothers developing mental health-related illnesses heightens, and of these, postpartum depression (PPD) numbers among the most prevalent of conditions. Across the world, PPD affects hundreds of millions annually, if all countries are accounted for. A 2011 study also found that PPD rates in Asian countries could be at 65% or more among new mothers (1).
Depression that occurs during pregnancy and postpartum can have devastating consequences for the life-long wellbeing of women, children and family members, not to mention the unborn or developing infant requiring special attention and care. For example, research shows that perinatal depression is associated with suicide and poor wellbeing of mothers; depression in fathers and family breakdown; high levels of behavioural problems as well as increased risk of young children developing psychological problems in later life.
The mental health gap in current maternal healthcare services
Over the past three decades, our government’s National Mental Health Surveys have consistently showed a higher prevalence of psychiatric morbidity among women compared to men in Malaysia. While most mental health problems are just as common during the perinatal period as at any other time in a woman’s life, it is especially important for women to have good and timely access to quality mental health care during pregnancy and postpartum.
During the perinatal period, the prevalence of perinatal psychological distress among Malaysian women in various settings ranged from 14.3 to 30.7%, according to national statistics (2). These sobering figures underscore the importance of creating prompt access to effective care pathways for women who may be struggling to cope with their new roles.
Although much progress has been made in terms of developing accessible government-based mental healthcare services, Malaysia’s public healthcare system still lacks a special programme catering specifically to women’s mental health needs during the perinatal period.
This is a serious gap, especially given the current times. The stress, isolation and economic distress brought about by Covid-19 underscores a great need for better support and care for pregnant women, who already constitute a vulnerable population group.
Pandemic-related mental health issues are likely to impact pregnant women across the country, and amplify symptoms among those who were previously struggling with anxiety and depression.
Now more than ever, measures should be adopted to ensure better mental health care and timely interventions for pregnant women who may be facing mental and psychological distress. Some short- and longer-term recommendations have been set out below for consideration:
Implement formal universal screening procedures in maternal healthcare services
First and foremost, introduce a universal screening procedure delivery of perinatal healthcare services nationwide. Currently, a major gap in Malaysia’s perinatal healthcare services is the lack of universal screening procedures to identify potential cases. Whether or not universal screening results in the desired effect of increasing women’s help-seeking behaviours, this step is likely to improve the identification of women in mental distress, who may hitherto have gone undetected despite receiving care from the system.
Increase levels of perinatal mental health literacy of medical practitioners and healthcare workers
Hand-in-hand with improving detection, ensuring that pregnant women are able to access appropriate, timely and effective help is extremely important.
There is a great need to increase and develop mental health literacy among health workers and staff who come into close and frequent contact with pregnant women and postpartum mothers. Nurses should be trained to use their routine contacts to identify mental health issues and treat the milder cases. In primary care settings, physicians should receive high quality skills training and development to detect and treat a range of perinatal mental health problems should be strengthened. Likewise, psychiatrists who provide tertiary care services must keep up to date in managing the complexity of perinatal mental health disorders. . Besides treating illnesses, these practitioners should also be trained to deliver preventive perinatal interventions to their patients, and promote strong attachment and positive parenting, so as to reduce further mental health risks for both mother and baby.
At the same time, doctors, nurses and health practitioners who work with women and families and are within the wider care system could be trained to support the referral pathways described above. At the very least, they should receive training on general knowledge and relevant skills in perinatal mental health in order to identify potential issues requiring specialist support and referral.
Study prevalence and potential risk factors influencing perinatal mental health issues
In the longer term, a national population-based survey on the prevalence of mental health disorders and potential risk factors among perinatal women would be highly valuable in helping to flesh out a clearer picture of unmet needs.
In a multicultural, ethnically diverse country like Malaysia, there will certainly be unwarranted variation in the needs of different groups, families, carers and local communities across regions. Questions on these should be included in the survey, and the information collected used to frame perinatal mental health services that are sensitive to culturally specific beliefs, needs and values.
Last but not least, in formulating these policies, the needs of all women, including the most vulnerable who are often hard to reach, must be acknowledged. These populations include, among others, women who have existing mental health needs, women with learning disabilities, women with chronic physical illness and unmarried mothers. For this, psychiatrists, obstetricians, primary care and other supporting professionals such as social medical officers, community nurses and maternal health nurses should form a multidisciplinary liaison committee to discuss and formulate efficient service protocols for these vulnerable population groups.
At the same time, the committee should not neglect working together with women, families, career and local communities- there is a high chance that input and feedback from the very people who use their services will reveal “hidden” needs that may not be possible to detect at the higher technocratic level.
Investment in perinatal mental health services has been proven to bring a significant positive cost-benefit effects in the long term, both in reducing the burden on the healthcare system as well as improving health outcomes for women, families, parents and children who use these services. It is high time that Malaysia to translate this evidence into practice, by adopting a clear mental health focus in its maternal healthcare services, and establishing good access to timely and effective mental health care for its women during the perinatal period.
References
1. Abdollahi, F., Lye, M. S., Md Zain, A., Shariff Ghazali, S., & Zarghami, M. (2011). Postnatal depression and its associated factors in women from different cultures. Iranian journal of psychiatry and behavioral sciences, 5(2), 5–11.
2. Past and present editions of the National Health and Morbidity Survey reports may be accessed through the National Health Institute’s (IKU) official website link: http://www.iku.gov.my/nhms/#clients
3. NHS England, NHS Improvement (May 2018). The Perinatal Mental Health Care Pathways- A Short Guide. National Collaborating Centre for Mental Health. (https://www.rcpsych.ac.uk/docs/default-source/improving-care/nccmh/perinatal/nccmh-the-perinatal-mental-health-care-pathways-short-guide.pdf?sfvrsn=4f52dbb3_2 )
Maternal mental health issues are significant challenges that may affect women before and during pregnancy, and after childbirth. Studies have shown that better awareness, and timely assistance, can help increase the chances of full recovery for mothers affected by these conditions.
SOLS Health is currently conducting research into how existing identification and treatment services may be improved for women affected by postpartum depression in Selangor. If you are a woman of childbearing age residing in Selangor, please do take some time to share your thoughts with us by filling up a short survey at one of the links below. It will only take less than 10 minutes, and your insights would contribute to improving the quality of services, and access to care for mothers affected by these conditions.
We are just 20 responses shy of collecting our target response numbers, and would truly value your support to help us reach our goal.
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