Why we need better maternity mental health care in Malaysia
Being pregnant is a big part of a person’s life and one that we most often associate with physical health. We might think about the physical and hormonal changes someone goes through during the term of their pregnancy – but what about their mental health?
Did you know that, in Malaysia, 1 in 8 women experience depression during the peripartum period (pregnancy and after childbirth)? And yet, despite this worrying trend, our health services are inconsistent in terms of clinical management and health care is limited in treating expecting and new mothers with depression.
Alarmingly, less than 30% of maternity healthcare providers screen for peripartum depression, and few mothers are offered any form of mental health care. And yet, there are significant psychological changes experienced during and after pregnancy including “ambivalence, frequent mood changes, varying from anxiety, fatigue, exhaustion, sleepiness, depressive reactions to excitement.”1
Peripartum depression is a serious, but treatable mental illness in which pregnancy brings feelings of extreme sadness, anxiety, and changes in energy, sleep, and appetite. There’s an urgent need for adequate support and treatment in Malaysia, due to the long-term effects of the illness which, left untreated, increases risk for the child’s socioemotional and behavioral problems even during adolescence. Maternal mental health is also a moderate risk factor for paternal peripartum depression, with up to 1 in 5 fathers experiencing peripartum depression.
The issue we face in Malaysia is that the guidelines and treatment for peripartum depression are inconsistent and limited. The division responsible for developing public health, the Family Health Development Division recommends only antenatal depression screening for high risk individuals. On the other hand, the division responsible for developing medical services, the Medical Development Division, recommends repeated universal screenings for peripartum depression starting as early as practical in pregnancy, in third trimester of pregnancy, and in the first postnatal year.
Even treatment recommendations and delivery of services differ: the Medical Development Division recommends psychotherapy (Cognitive Behavioral Therapy or Interpersonal Psychotherapy) for first-line treatment of mild to moderate peripartum depression, while the Family Health Development Division recommends brief psychosocial intervention (e.g., relaxation therapy, problem solving therapy) as first-line treatment for mild to moderate peripartum depression.
Maternal mental health is crucial to child development including a child’s mental and physical health – with limited treatment options and inconsistent guidelines, Malaysia risks a public health issue that could effect generations of young people and put at risk the health and well-being of mothers in Malaysia. With adequate support and the will to invest in urgent mental health care, this potential health risk to children and their mothers is one that can be minimised, and effectively treated.
In the following sections, we outline current key policy issues, policy options, and recommendations to address the current gap in mental health care for mothers…
KEY POLICY ISSUES
1.Low awareness of peripartum depression and treatment. Despite the prevalence of peripartum depression, many primary healthcare practitioners are not familiar with symptoms and treatment of peripartum depression.
2.Lack of standardised screening for peripartum depression. Under the guidelines, midwives and nurses are responsible for administering the depression screening but less than 30% actually screen for peripartum depression. Few use the recommended questionnaires to assess for peripartum depression. This has also led mothers to perceive maternity care providers to be uninterested or unwilling to talk about their mental health.
3.The lack of peripartum depression intervention programs. Despite a number of effective psychological programs to prevent and treat peripartum depression, there are no such programs available in Malaysia. In addition, due to a shortage of mental health professionals in Malaysia, mothers often do not receive adequate care even when referred.
POLICY OPTIONS
1.Develop national guidelines. The Ministry of Health should have a national set of clinical evidence-based guidelines to identify and treat peripartum depression among mothers. The guidelines should clearly outline a process of antenatal and postpartum mental health care that can be implemented by healthcare providers. In addition, the guidelines should be written using person-centred, respectful and jargon-free language to be accessible to patients, their families and other stakeholders.
Pros: Improve mental health of expecting and new mothers, empower patients to seek and receive evidence-based care, guide healthcare practitioners to ensure they are providing evidence-based care, improve coordination between divisions of Ministry of Health and other stakeholders, improve cost effectiveness of public mental health care, and reduce health inequalities across different subgroups in the population.
Cons: Inaccessibility of guidelines due to the lack of mental health resources, inapplicability of guidelines to local settings, and low uptake of guidelines among healthcare practitioners.
2.Implement universal screening. Universal screening for peripartum depression can be implemented at selected timepoints to improve detection of peripartum depression. The Edinburgh Postnatal Depression Scale is a well-validated and reliable measure of peripartum depression and has been translated to Bahasa Malaysia, English, Chinese and Hindi.
Pros: Improved early detection and intervention of peripartum depression, which can potentially prevent the serious consequences of untreated peripartum depression.
Cons: High cost of false positives on the patient and healthcare system, and the lack of infrastructure and limited resources to provide adequate psychological care to patients who screen positive for peripartum depression.
3.Develop a population wide intervention program. As the mental health workforce is small, counsellors could be trained to deliver evidence-based preventive and treatment programs for peripartum depression (e.g., Interpersonal Psychotherapy).
Pros: This will upskill the current workforce and increase access to psychological services.
Cons: There is little research in Malaysia on the efficacy of preventive and treatment programs for peripartum depression. A population wide program is resource intensive and will take a significant number of years to implement.
RECOMENDATION
We recommend the Malaysian Government development and uptake of a national set of clinical guidelines for peripartum depression. This will help healthcare providers ensure they are providing evidence-based care and empower patients to request for the evidence-based care they need to improve their health.
The uptake of guidelines will also improve the consistency and quality of maternal mental health care. If we improve maternal mental health care, this will have a widespread impact of parents’ mental health, their child’s health, family life and ultimately the health of society.
CONCLUSION
The high prevalence of maternal peripartum depression in Malaysia is a serious health issue that must be dealt with urgency. We need clear guidelines on clinical management and service delivery which are implemented across public hospitals to ensure consistent evidence-based care is delivered to expecting and new mothers. A set of guidelines will then pave the way for a comprehensive gap analysis to be conducted to guide strategic investment and development of resources to improve maternal mental health care.
