Editorial: Focus on maternal mental health during pregnancy and after childbirth

The most common maternal mental health disorders for the women are anxiety and depression and both may range from mild to moderate or severe. The experience for women often results in not being able to follow through on their responsibilities, reduced work productivity, and decreased ability to cope with the stresses of daily living (4). Evidence shows there is a relationship between antenatal mental health problems on negative birth outcomes, but also that problematic birth outcomes like low birthweight or premature birth are related to subsequent postnatal mental health concerns. Adverse effects on infant cognitive development, nutritional status and early childhood development have been reported (5,6).Despite the importance of maternal mental health to the well-being of both mothers and infants, there remains limited evidence to inform policy regarding this serious health issue, especially in LMICs (7). Moreover, although there are programs integrated in HICs at the primary care level for pregnant and postpartum women, the availability of similar programs in LMICs remains limited to non-existent, as the focus is often more on maternal and infant physical care than psychological well-being (8). Often women are not receiving necessary psychological care.Hence, the topic area of maternal mental health disorders for pregnant and postpartum women in LMICs remains one which is in critical need of research to guide clinical care as well as to inform policy. This special issue was designed to offer researchers from LMICs an opportunity to showcase their current work in the area of mental health for pregnant and postpartum women. We are delighted to have the submissions which you will see published in this special issue. The articles offer insight into examples of current research and offer a call to action with clinical and policy recommendations.The submissions come from Rwanda (9), Nigeria (10), Ethiopia (11,12), Cameroon (13), Namibia (14), India (15), and Pakistan (16). All are projects led by researchers based in the respective country with two indicting there was an international collaboration on the project. Five are cross-sectional studies (9-13) while one is a secondary analysis ( 16) of an aspect of an intervention trial and two are qualitative designs (14,15). Three focused on depression (9,10,16) and one on both anxiety and depression (13). Other foci included mental health disorders (10,13), cognitive disorders (11), fertility desire (12), facilitating childbirth choice ( 14) and mindful parenting (15). The samples included antenatal (11,14n=2). postnatal (n=49,10,15,16), perinatal (n=113), and women living with HIV (n=112). All but one study used standardized selfreport scales while the one utilized a clinically administered measure to diagnose cognitive disorders (11).The cross-sectional studies (9-13) explored predictive factors of high risk for maternal mental health problems or factors associated with the disorders. Two of these collected their data through interviews while the others applied written questionnaires or patient medical chart extraction. The secondary analysis study explored the integration of a mental health intervention in a primary care setting. All quantitative studies employed a systematic sampling technique, described their samples well and utilized standardized measures of selected variables, which aid in being able to make comparisons between settings and over time.The two qualitative studies (14,15) utilized in-depth interviews followed by a standardized content and thematic analysis. The qualitative studies used purposive sampling to access individuals who had experienced the phenomenon and were willing to talk about their experiences. These types of studies help to gain insight into the culture and practices in the respective countries and are important to tailor future interventions which are tailored to the local context.Many results were consistent across settings, but some unique factors also emerged. Across the studies, mental disorders were cited at approximately a quarter of the respective samples. Social support emerged as an important factor across multiple studies. Umuziga et al. (9) from Rwanda reported poor perceived health status, poor partner and family support, poor social support, and negative life events (violence) as predictors of depressive symptoms while friend support was a protector. Kassaw et al. (11) from Ethiopia reported strong social support, orthodox religion follower, income level, being over 26 years, unplanned pregnancy, and rural residence dwelling as factors associated with increased cognitive impairmentsdisorders (e.g., orientation, attention, computation, recall, language). Miafo et al. (13) cited links between anxiety and depression and an absence of social support were factors associated with an increased risk of mental disorders in women from Cameroon. Tufa et al. (12) from Ethiopia described parent and community pressure, being married, having only girls, and having children who are seropositive as factors associated with the desire for fertility in women living with HIV. Desire for fertility is a psychological state whereby women have a motivation for having additional children, yet their HIV status can present challenges and bring about heightened pressures. The findings regarding both support and external pressure from others indicates that attention to mothers' interpersonal relationships is important to understanding and predicting maternal mental health outcomes.Two studies looked at the delivery of mental health care given women were not having easy access to the needed mental health care. Odufuwa et al. (10) from Nigeria described how both depressed and non-depressed women sought help for maternal mental health care. Age, family history of postpartum depression, currently feeling depressed and having children of the desired gender were associated factors for help seeking. Fear and stigma, thinking the symptoms will go away on their own, and a low perceived need for help held women back from seeking mental health care. The work by Owais and colleagues emphasized the feasibility of integrating a mental health intervention in a primary health care setting but also revealed gaps in the referral pathway (16).Of the two qualitative studies, one explored the lived experiences of mothering in an urban setting in India (15) whereas the other accessed midwives working in Namibia to explore their experiences in facilitating choice by women surrounding childbirth (14). Both studies emphasized the need for increasing awareness of the issues (e.g., emotional and physical distress, poor social support, lack of time for self, image of self as a mother) and looking atto barriers beyond the individual person. For example, fFacility and health system structural factors (e.g., access to timely care, transportation) also have an impact on the decision-making and actions of mothers.Across all studies, authors recommended clinical assessment of the mental health status of pregnant and postpartum women. Easily applied and standardized instruments are available for this purpose providing there is review for appropriateness of the tool in the local culture. They also emphasized the need to increase awareness of the reality of these disorders in the general population and for policy changes to facilitate funding to support implementation of mental health care.The authors also offered clear recommendations regarding the need for further research in this arena. In particular, the development and testing of relevant, locally appropriate, intervention strategies is needed. The need for further description of the incidence, prevalence, risk factors and impact of the disorders within larger populations, and exploration of access to mental health care would be useful.

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