Psychological interventions delivered by non-specialist health workers are effective for the treatment of perinatal depression in low- and middle-income countries. In this systematic review, we describe the content and delivery of such interventions. Nine studies were identified. The interventions shared a number of key features, such as delivery provided within the context of routine maternal and child health care beginning in the antenatal period and extending postnatally; focus of the intervention beyond the mother to include the child and involving other family members; and attention to social problems and a focus on empowerment of women. All the interventions were adapted for contextual and cultural relevance; for example, in domains of language, metaphors and content. Although the competence and quality of non-specialist health workers delivered interventions was expected to be achieved through structured training and ongoing supervision, empirical evaluations of these were scarce. Scalability of these interventions also remains a challenge and needs further attention.
Introduction
Perinatal depression is defined as an episode of depression occurring either during pregnancy, within 1 year after delivery, or both . Maternal depression is a more loosely defined term that includes perinatal depression but also depression in mothers with young children. We use the term perinatal depression in this broader context. Systematic reviews conducted in high-income countries have shown that about 10% of pregnant women and 13% of those who have given birth experience depression (or anxiety, which frequently co-occurs with depression). The prevalence of perinatal depression is higher in low- and middle-income countries (LMIC), with a mean prevalence of 15.6% (95% CI 15.4 to 15.9) antenally and 19.8% (95% CI 19.5 to 20.0) postnatally, particularly in poorer women with gender-based risks (including intimate partner violence, the bias against female babies, and role restrictions regarding housework and infant care) or a psychiatric history .
The combination of this high prevalence of perinatal depression in LMIC as well as the woman’s primary responsibility for childcare, means that, apart from its effect on maternal health, perinatal depression can have a substantial influence on child health outcomes . A recent systematic review of studies from LMIC reported that children of mothers with depression or depressive symptoms are more likely to be underweight (OR 1.5; 95% CI 1.2 to1.8) or stunted (OR 1.4; 95% CI 1.2 to1.7) ; the review estimated that between 23 and 29% fewer children would be underweight or stunted if the infant population were entirely unexposed to perinatal depressive symptoms. Perinatal depression has hence been described as a global threat to child development , and is recognised as a major public health concern, especially in LMIC .
In high income countries, evidence shows that psychosocial and psychological interventions compared with usual postpartum care are effective in reducing perinatal depression . Few LMIC have sufficient mental health professionals available to meet the population’s needs . Considering the limited availability of specialised resources, it is necessary to explore alternative delivery strategies in LMIC . Task-shifting or task-sharing to non-specialist health workers (NSHW) is emerging as an effective way to improve the access to health services and specifically services for mental disorders . These include healthcare practitioners (e.g. doctors, nurses, community health workers) and non-professionals (e.g. lay providers) . A recently conducted meta-analysis of perinatal depression interventions in LMIC included 13 (published as well as unpublished) trials with 20,092 participants . In all but one of these studies, the interventions were delivered by NSHW. Mothers and children benefitted significantly from the interventions tested compared with routine care (pooled effect size 0.38, 95% CI −0.56 to −0.21). Where assessed, benefits to the child included improved mother–infant interaction, better cognitive development, reduced diarrhoeal episodes, and increased rates of immunisation.
The aim of this review is to describe the content and delivery of such interventions. We sought to specifically address the following questions: (1) What are the types of interventions for perinatal depression in LMIC delivered by NSHW?; (2) What are the psychosocial strategies and techniques that the interventions utilise?; (3) What are the adaptations required to make these interventions culturally and contextually appropriate?; (4) What are the adaptations required to make these interventions deliverable by NSHW?; (5) What are the characteristics of the NSHWs, their training and supervision?; and (6) What are the challenges encountered in intervention delivery and how were these addressed?
Method
Studies were identified by a systematic literature search using the following strategies: (1) a database search of Ovid Medline, EMBASE and PsycINFO until December 31, 2012, was conducted to identify studies from LMIC describing interventions for perinatal depression delivered by NSHW. Search terms were adapted from another systematic review and have been listed in Appendix 1 . No start date was specified; and (2) cross-referencing of eligible articles to identify additional studies that met our inclusion criteria.
Inclusion criteria
Criteria for inclusion consisted of psychological treatments for perinatal depression in LMIC (according to the World Bank classification, July 2012) delivered by any type of NSHW. Studies involving women with perinatal depression, defined as a non-psychotic depressive episode or the presence of depressive symptoms that begins during pregnancy or in the early postnatal period (within 6 weeks of delivery) were included.
Exclusion criteria
Studies conducted with women with psychotic depression, depressive episode in a woman with bipolar disorder or other co-morbidities were excluded; studies on interventions involving provision by specialists (i.e psychiatrists, psychologists, psychiatric nurses, mental health social workers), and also studies conducted in high-income countries were excluded.
Data extraction
The titles and abstracts of each citation identified from the search were independently inspected by two reviewers (NC, NA) with reference to the inclusion and exclusion criteria. The potentially relevant full-text papers were accessed and independently reviewed by the two reviewers. Any disagreements were resolved by consensus and, when this could not be reached, a third reviewer (VP) adjudicated. Papers that referenced previous publications describing the details of the interventions and adaptations made were also retrieved. Data were summarised in a table based on the research questions identified for the review.
Data analysis
Thematic analysis was used to evaluate the strategies used in interventions, NSHW features and challenges encountered in intervention delivery. We followed the process of distillation , which is a method whereby interventions are conceptualised not as single units of analysis, but rather as composites of individual strategies, techniques, or components that can allow subsequent empirical grouping. Bernal’s framework was used for analysis of the nature of the cultural adaptations. The framework comprises eight dimensions that can be the targets of cultural adaptations: (1) language of the intervention; (2) therapist matching; (3) cultural symbols and sayings (metaphors); (4) cultural knowledge or content; (5) treatment conceptualisation; (6) treatment goals; (7) treatment methods; and (8) treatment context. Analysis was both deductive, consisting of pre-determined categories applied to data, and inductive (i.e. inferring themes from the coded data).
Method
Studies were identified by a systematic literature search using the following strategies: (1) a database search of Ovid Medline, EMBASE and PsycINFO until December 31, 2012, was conducted to identify studies from LMIC describing interventions for perinatal depression delivered by NSHW. Search terms were adapted from another systematic review and have been listed in Appendix 1 . No start date was specified; and (2) cross-referencing of eligible articles to identify additional studies that met our inclusion criteria.
Inclusion criteria
Criteria for inclusion consisted of psychological treatments for perinatal depression in LMIC (according to the World Bank classification, July 2012) delivered by any type of NSHW. Studies involving women with perinatal depression, defined as a non-psychotic depressive episode or the presence of depressive symptoms that begins during pregnancy or in the early postnatal period (within 6 weeks of delivery) were included.
Exclusion criteria
Studies conducted with women with psychotic depression, depressive episode in a woman with bipolar disorder or other co-morbidities were excluded; studies on interventions involving provision by specialists (i.e psychiatrists, psychologists, psychiatric nurses, mental health social workers), and also studies conducted in high-income countries were excluded.
Data extraction
The titles and abstracts of each citation identified from the search were independently inspected by two reviewers (NC, NA) with reference to the inclusion and exclusion criteria. The potentially relevant full-text papers were accessed and independently reviewed by the two reviewers. Any disagreements were resolved by consensus and, when this could not be reached, a third reviewer (VP) adjudicated. Papers that referenced previous publications describing the details of the interventions and adaptations made were also retrieved. Data were summarised in a table based on the research questions identified for the review.
Data analysis
Thematic analysis was used to evaluate the strategies used in interventions, NSHW features and challenges encountered in intervention delivery. We followed the process of distillation , which is a method whereby interventions are conceptualised not as single units of analysis, but rather as composites of individual strategies, techniques, or components that can allow subsequent empirical grouping. Bernal’s framework was used for analysis of the nature of the cultural adaptations. The framework comprises eight dimensions that can be the targets of cultural adaptations: (1) language of the intervention; (2) therapist matching; (3) cultural symbols and sayings (metaphors); (4) cultural knowledge or content; (5) treatment conceptualisation; (6) treatment goals; (7) treatment methods; and (8) treatment context. Analysis was both deductive, consisting of pre-determined categories applied to data, and inductive (i.e. inferring themes from the coded data).
Findings
Description of the studies
After removing duplicates, the electronic search identified 1950 potential studies. The flow chart of studies from this starting point is shown in Fig. 1 .
Nine studies were selected for final inclusion in this review The characteristics of the included studies are described in Table 1 . All the studies were written in the English language. Two studies were conducted in South Africa , two in Chile , and one each from China , Jamaica , India , Pakistan and Turkey . One study used a pilot non-randomised-controlled study design , one used a pre-test–post-test semi-experimental model , whereas the other seven studies were randomised-controlled trials. Of these, three studies used a cluster randomised-controlled design , whereas the remaining used individual level randomisation . Although studies measured perinatal depressive symptoms as an outcome, in four studies this was the primary outcome whereas, in the remaining studies, the primary outcomes were the physical health of mother and infant, quality of mother– child interaction, infant weight and height, child development and HIV knowledge.
| Author | Location | Design | Sample | Comparison group | Primary outcome | Secondary outcome | Result (Outcome – maternal depression) |
|---|---|---|---|---|---|---|---|
| Aracena M, 2009 | Chile | Experimental RCT | Adolescent mothers (14–19 years), first pregnancy. Intervention group n = 45; control group; n = 45 | Standard prenatal and well baby care at health centres | Physical health of mother and infant | Maternal mental health using the GHQ at the end of the intervention | Intervention group: average 10.94 points (SD: 5.58). Control group: average 13.85 (SD: 6.99). t (89) = 2.20; P = 0.031. |
| Baker-Henningham, 2005 | Jamaica | Cluster RCT | Mothers of under-nourished children aged 9–30 months attending 18 nutrition clinics. Intervention group n = 64; control group n = 61 | Standard health and nutrition care | Child development | Maternal depression using CES-D at end of 1 year | Effect size b = −0.98; 95% CI −1.53 to −0.41). The change was equivalent to 0.43 SD. Mothers receiving more than 40 visits and mothers receiving 25–39 visits benefited significantly from the intervention (b = −1.84, 95% CI −2.97 to −0.72, and b = −1.06; 95% CI −2.02 to −0.11, respectively), whereas mothers receiving less than 25 visits did not benefit. |
| Cooper PJ, 2009 | South Africa | Individual RCT | Women in the last trimester of pregnancy. Intervention group n = 220; control group n = 229. | Standard care provided by local infant clinic | Quality of mother–infant interactions at 6 and 12 months postpartum; infant attachment security at 18 months | Maternal depression (a dichotomous variable for depressive disorder using SCID, and a continuous variable for depressive symptoms using EPDS) assessed at 6 and 12 months. | At 6 months effect size = 2.05; P = 0.041; At 12 months effect size = 0.24, P = 0.813 . |
| Futterman D, 2013 | South Africa | Pilot non-randomised- controlled trial | Pregnant women attending maternity clinics who were HIV positive; 160 enrolled. Number followed up: intervention group n = 40; control group n = 31. | Standard PMTCT care | HIV knowledge, discomfort. Social support, satisfaction | Depression using the CES-D; 6 months after intervention. | Depression scores reduced significantly more in the intervention than in the control group (14.0 to 5.6 v 9.0 to 5.0; P = 0.008). The relatively greater decline in frequency of depression among intervention participants was not statistically significant. |
| Gao L, 2012 | China | Individual RCT | First-time pregnant women. Intervention group n = 96; control group n = 98 | Standard care consisting of childbirth education | EPDS at 6 weeks and 3-months follow up | At 6 weeks postpartum: t = −4.05, P < 0.001; at 3-month postpartum: t = 2.39, P = 0.018. | |
| Rahman A, 2008 | Pakistan | Cluster RCT | Married women, third trimester of pregnancy with perinatal depression; 40 Union Council clusters. Intervention group n = 463; control group n = 440. | Enhanced usual care consisting of equal number of visits by untrained health worker | Infant weight and height at 12 months | Maternal depression using HDRS at 6 and 12 months | Mean difference at 6 months:−5·86; 95% CI −7·92 to −3·80; P < 0·0001. At 6 months: 78% reduction in prevalence of depression in intervention arm (AOR 0.22, 95% CI 0.14 to 0.36, P < 0.0001); At 12 months: 77% reduction (AOR 0.23, 95% CI 0.15 to 0.36, P < 0.0001). |
| Rojas G, 2007 | Chile | Individual RCT | Mothers with major depression attending postnatal clinics with index children younger than 1 year. Intervention group n = 114; control group n = 116. | Usual care | Depressive symptoms using EPDS at 3 and 6 months after randomisation | Adjusted mean difference 3mo: −4.5 (−6.3 to −2.7), P < 0.0001 6mo: −2.3 (−0.50 to 0.04) | |
| Tezel A, 2006 | Turkey | A pre-test–post-test mutual controlled sem- experimental model. | Women all of whom had a risk of postpartum depression, but without exhibiting major depression symptoms. Intervention group n = 32; control group n = 30. | Nursing care | Depressive symptoms in postpartum period using the BDI after intervention | Significant difference in the prevalence of depressive symptoms before and after the intervention (McNemar test, P < 0.05). Both intervention and control (nursing care) groups showed significant reduction in mean scores from pretest to posttest (t = 10.062, P < 0.05 for control group and t = 5.462, P < 0.05 for intervention group). | |
| Tripathy P, 2010 | India | Cluster RCT | Open cohort of women 15–49 years who had just given birth from 36 clusters. Intervention group n = 6452; control group n = 5979. | Enhanced care with formation of cluster level committees. | Reduction in NMR and maternal depression score (K10) in year 2 and 3. | Secondary outcomes were stillbirths, maternal and perinatal deaths, uptake of antenatal and delivery services, home-care practices during and after delivery, and health-care-seeking behavior. | AOR: No or mild depression year 2: 0·91 (0·41–2·01) year 3: 2·33 (1·25–4·38); moderate depression year 2: 1·04 (0·50–2·16); year 3: 0·43 (0·23–0·80) Severe depression year 2: 1·53 (0·47–5·05) year 3: 0·70 (0·15–3·31) . |
Depressive symptoms were measured using six different depression scales: the Edinburgh Postnatal Depression Scale (EPDS) ( n = 3) , the Center for Epidemiological Studies Depression Scale (CES-D) ( n = 2) , Beck Depression Inventory (BDI) ( n = 1) , the General Health Questionnaire (GHQ) ( n = 1) , the Hamilton Depression Rating Scale (HDRS) ( n = 1) and the Kessler 10 ( n = 1) . Duration of the follow up ranged from 3 months to 3 years after treatment. All nine studies reported improvement in perinatal depression in the intervention compared with control groups ( Table 1 ).
Content of interventions
Content of interventions, and that of the adaptations (presented later), were extracted either from the study papers ( n = 9) or from their linked papers ( n = 3) . In four studies, the interventions were adaptations of evidence-based psychological treatments; cognitive–behavioural therapy (CBT) ( n = 2) , interpersonal psychotherapy (IPT) ( n = 1) and problem Solving therapy( n = 1) . In one study, psychoeducation was adapted for relevance to postnatal care and delivered as part of a multicomponent stepped care intervention . In another study, the intervention was an adaptation of an existing preventive mother–infant intervention programme , and, in three studies, the intervention was developed de novo for the study . The interventions as described in the studies were distilled into different strategies, and this has been presented in Table 2 .
| Author | Intervention with theoretical basis (if any) | Child health education | Activating social networks | Psychoeducation | Psychostimulation | Cognitive restructuring | Problem solving | Behaviour activation | Befriending | Addressing interpersonal triggers |
|---|---|---|---|---|---|---|---|---|---|---|
| Aracena M, 2009 | Home-visit programme | Yes | Yes | Yes | Yes | |||||
| Baker-Henningham, 2005 | Early stimulation home visit programme | Yes | Yes | Yes | Yes | |||||
| Cooper PJ, 2009 | Closely follows the principles contained in The Social Baby | Yes | Yes | |||||||
| Futterman D, 2013 | Cognitive–behavioural intervention plus peer-mentoring programme | Yes | Yes | Yes | Yes | Yes | Yes | Yes | ||
| Gao L, 2012 | Interpersonal psychotherapy-oriented childbirth education programme | Yes | Yes | Yes | Yes | |||||
| Rahman A, 2008 | Thinking healthy programme based on cognitive-behavioural therapy | Yes | Yes | Yes | Yes | Yes | Yes | Yes | ||
| Rojas G, 2007 | Psychoeducation as part of a multicomponent stepped-care intervention | Yes | Yes | Yes | Yes | |||||
| Tezel A, 2006 | Problem-solving training | Yes | Yes | Yes | ||||||
| Tripathy P, 2010 | Participatory women’s group | Yes | Yes | Yes |
Most studies used interventions that consisted of various strategies targeting the mother, the mother–child dyad , the family or both. Strategies in which the mother was the main target were psychoeducation, cognitive restructuring, problem solving, behaviour activation, and befriending. Psychoeducation was the key component in one Chilean study , in which it was delivered as part of a multicomponent intervention that included structured pharmacotherapy if needed, systematic monitoring of clinical progress and treatment compliance, further training to doctors, and specialist supervision on a regular basis. Psychoeducation consisted of information about symptoms and the likely causes, offering hope and motivating women to seek appropriate treatment. This was also described in other studies where it was delivered either in the individual or group format .
Cognitive restructuring was defined as becoming aware of one’s thoughts to identify and label those which are helpful and unhelpful, and modify the unhelpful ones into more helpful ones, thereby improving symptoms of depression. Low-intensity cognitive restructuring using culturally appropriate pictures was used in the ‘Thinking Healthy Programme’ in Pakistan, where it incorporated the additional techniques of active listening, collaboration with family, guided discovery, and home work added to the routine practice of mother and child health education . The Mamekhaya programme in South Africa too was adapted from CBT for relevance to prevention of mother-to-child transmission( PMTCT) services to focus on four broad topics: healthy living; feeling happy and strong; partnering and preventing transmission; and parenting .
Problem solving consisted of the five general stages: problem orientation, problem definition and formulation, generation of alternatives, decision making, and verification. In a Turkish study , training in problem solving was conceptualised as a form of self-control training; that is, the women ‘learns how to solve problems’ and thus discovers for herself the most effective way of responding . Problem solving was used as an important strategy in the Thinking Healthy Programme, the Chilean psychoeducation intervention, and the participatory women’s group intervention in India, where it addressed problems faced by mothers and their families .
Behavioural activation (i.e. increasing behaviours that give the woman a sense of effectiveness and pleasure leading to improvements in thoughts and emotions) was used in three studies either as part of a cognitive behaviour intervention or independently . Non-specialist health workers, who were often mothers themselves, hence peers, performed the additional role of ‘befriending’, developing positive, supportive relationships with the depressed mothers, reducing their sense of isolation and providing individual assistance .
Where the target was the mother–child dyad, the interventions focused on educating parents on the child’s physical health, and also included healthcare practices for both mother and child, child nutrition and help seeking . Apart from physical health, ‘psychostimulation’, defined as the provision of affection and warmth, responsiveness to the child, and the encouragement of autonomy and exploration, is an important aspect of perinatal care, and this is reflected in its use as the next common strategy across interventions . Psychostimulation aimed to encourage the mother in sensitive, responsive interactions with her infant and thus sensitise the mother to her infant’s individual capacities and needs. In one study , this was adapted from a preventive intervention programme by health visitors based on the principles contained in The Social Baby published by The Children’s Project. This programme was adapted by incorporating the key principles of the World Health Organization’s Improving the psychosocial development of children . Another study from Jamaica developed an early stimulation home-visit programme, which focused on improving child development by improving mothers’ knowledge and practices of child rearing and their parenting self-esteem. The NSHWs were trained to ensure that the mothers experienced success and feelings of competence. Some studies focused on discussion of parenting issues, including the importance of praise, attention, and responsiveness as well as appropriate discipline strategies.
Interventions that targeted the family and broader social milieu included strategies such as ‘activating social networks’ and ‘addressing interpersonal issues’. Activating social networks consisted of enlisting family and friends in various aspects of the intervention, including promoting adherence . It acknowledges the salience of social and family connectedness in many developing countries. A key component in a Chinese study was to address interpersonal (relationship) issues by understanding and dealing with emotional factors associated with these issues, especially where conflicts with husbands and mothers in law were frequently encountered .
Adaptations to the interventions
Details of the cultural and contextual adaptations made to the interventions were categorised using Bernal’s framework and are presented in Table 3 . Adaptations for language went beyond the literal translation to incorporate the use of colloquial expressions to replace technical terms, for example, using ‘stress’ instead of ‘depression’ and ‘thinking healthy’ instead of ‘cognitive– behaviour therapy’ . Therapist adaptations, apart from using NSHWs most of whom were already available in the clinics and were often closely connected to local neighbourhoods, also used peers (i.e. mothers with experience in child rearing). These adaptations focused on therapist-patient matching to enhance the acceptability and credibility of the counsellor by emphasising shared experiences and awareness of local customs. The NSHWs attempted to develop friendly relationships with the mothers and to empathise with their expressed concerns . The use of metaphors to increase cultural relevance took the form of using material that was culturally appropriate; for example, a health calendar to monitor homework, the use of local stories and examples with characters resembling the patient’s situation and background, and the use of idioms and symbols such as feeling cups to identify and quantify the intensity of feelings . These enabled the simplification of abstract concepts into more concrete, easy to understand terms. Cultural considerations were integrated into the content of the psychological treatment by focusing on pressing social concerns in the woman’s life and addressing local customs; for example, issues related to Chinese postpartum practice ‘Zou Yue Zi’ ie. ‘doing the month’, which refers to the traditional Chinese custom of having new mothers rest for a month at home, often under the care of their mother-in-law ; and, in Pakistan, not expecting outdoor activities during the chilla (40-day confinement of mothers after delivery) when mothers do not go out of the house . Adaptations in the dimension of concepts involved addressing cultural norms surrounding the concept of infancy and childcare practices, and focusing on relevant skill building techniques such as problem solving . Adaptations of goals involved development of client-derived treatment goals that were personally and culturally relevant, such as focusing on the health of the child and family unit rather than the mother. Goals were also extended beyond depression treatment; for example, by enhancing roles of self-help group members into community advocates and focusing on women’s empowerment . Adaptations to methods such as reducing the focus on tasks requiring literacy (i.e. reading and writing) were important for ensuring applicability to low-literacy populations. Delivery of sessions at home or over the telephone and integrating with routine healthcare visits helped to increase acceptability and feasibility of intervention delivery as well as adherence . Adaptations to ensure that the psychological treatment fits into the patient’s broader social context consisted of involving other family members in the intervention, focusing on interpersonal conflicts that may occur in joint family settings, and addressing issues related to the baby’s gender (e.g. women attributed responsibility for the baby’s gender to themselves especially in cultures that show preference for male children ) ( Table 3 ).
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