South African Psychiatry - November 2018

FEATURE
• Feeling detached from the infant
• Lack of interest in holding or caring for the baby
• Guilt that they are not able to enjoy the baby.
PREVALENCE AND RISK FACTORS
Rates of depression in women during the perinatal
period are reported to be around 10-15% in highincome
countries. In other low and middle-income
countries rates are 16-20%. In South Africa however,
the rates of perinatal depression are significantly
higher, ranging from 22-47%. The high rates of
perinatal depression in South Africa may be related
to the compounding nature of multiple economic,
social and psychosocial stressors.
THESE INCLUDING POVERTY AND
UNEMPLOYMENT, INTIMATE PARTNER
VIOLENCE, LACK OF PARTNER SUPPORT,
UNPLANNED PREGNANCY, AND
THE HIGH PREVALENCE OF HIV IN
PREGNANT WOMEN (39-45%), INCLUDING
DIAGNOSIS OF HIV INFECTION IN THE
COURSE OF ANTENATAL CARE. SIMILAR
ASSOCIATIONS HAVE BEEN FOUND
IN OTHER LOW AND MIDDLE-INCOME
COUNTRIES, WHERE SOCIO-ECONOMIC
DISADVANTAGES COMPRISING OF
FOOD INSECURITY, FINANCIAL DIFFICULTIES,
UNEMPLOYED PARTNERS AND LOW
INCOME WERE ASSOCIATED WITH
PERINATAL DEPRESSION.
In addition, social disadvantage comprising of
poor emotional support and lack of empathy from
partners, having hostile in-laws and having insufficient
practical and emotional support, contributed to the
risk of perinatal depression. From this, it is clear that
maternal depression has multiple etiologies, and
cannot be solely explained by women’s biological
and psychological vulnerability. Rather, social and
environmental factors are important contributing
factors and determinants of risk and socio-cultural
context impacts both prevalence and presentation
of perinatal depression. Protective factors include;
having more education, permanent job, a kind and
trustworthy intimate partner, as well as support from
friends and family.
CONSEQUENCES
Infants and children of depressed mothers have
poorer physical, cognitive and emotional outcomes.
Among women living in relative poverty, poor
maternal mental health during the antenatal period
is a risk factor for low birth weight and preterm
delivery. Postnatally, malnutrition, poor infant growth,
and increased frequency of infant diarrheal illness
are prevalent, which may be related to the early
cessation of breastfeeding in depressed mothers
living in poverty. This can lead to an increase in
child mortality. The emotional development of
infants is compromised because of a disturbed
mother-infant relationship, where mothers are less
sensitive towards their infants and infants are less
responsive towards mothers. This in turn leads to
poorer quality attachment, resulting in behavioural
and psychological difficulties that can last into
adolescence and adulthood. Compromised
cognitive functioning and delayed development
also affect infants and children of depressed
mothers, impacting on their scholastic achievement.
In the context of chronic social and economic
adversity, poor quality parenting as a result of
maternal depression is especially harmful.
THESE ADVERSE OUTCOMES FURTHER
PERPETUATE SOCIAL AND ECONOMIC
INEQUALITY IN THE NEXT GENERATION.
DEPRESSED MOTHERS ARE ALSO AT
RISK OF LOSING THEIR INCOME AND
ECONOMIC POTENTIAL AS A RESULT
OF THEIR IMPAIRED MENTAL STATE.
THESE WOMEN ALSO HAVE HIGHER
RISKS OF INTIMATE PARTNER VIOLENCE,
SUBSTANCE ABUSE AND SUICIDE.
Possible mechanisms for the above mentioned
consequences may include; poor uptake of
health and social services by depressed mothers;
increased stress hormones in utero impacting on
the developing fetus as well as a co-occurrence with
worse physical health, poor nutrition and substance
abuse. Luckily, some of the factors contributing to
these adverse consequences are modifiable and
we can prevent some of these devastating effects.
SCREENING FOR PERINATAL
MENTAL DISORDERS
Given the high rates and compounding associated
risk factors for maternal depression, its early
identification and management is vital. Screening
with referral is a valuable, strategy for mitigating the
devastating consequences of the illness on mothers
and their families. Secondary prevention consists
of early identification and treatment of a disease
to prevent potential future complications and
disabilities from the disease.
TRADITIONALLY, SCREENING PROGRAMMES
ARE A GOOD EXAMPLE OF SECONDARY
PREVENTION IN MEDICINE. THE PERINATAL
PERIOD IS AN IDEAL TIME AS PREGNANT
WOMEN ARE LIKELY TO HAVE ACCESS TO
HEALTH CARE AND THE PERINATAL PERIOD
PROVIDES MULTIPLE OPPORTUNITIES FOR
EDUCATION, PREVENTION, DETECTION
AND TREATMENT OF COMMON PERINATAL
MENTAL DISORDERS.
SOUTH AFRICAN PSYCHIATRY ISSUE 17 2018 * 19