Barriers Preventing Women in Perinatal Period From Accessing Maternal Mental Healthcare in Rwanda

Purpose: Perinatal depression (PND) is a public health concern in Low and Middle Income Countries (LMICs) including Africa (Sawyer, 2010; WHO, 2008; Rahaman at al. 2013) and associated with consequences on general health of mothers, underutilization of antenatal services and pregnancy outcome such as low birth weight, preterm birth (Rwakarema, Premji, Nyanza & et al. 2015). PND is also associated with adverse impact on the child such as malnutrition, infant stunting, less responsive parenting, less infant stimulation resulting in developmental challenges, as well as increased infant exposure to negative life events (Patel et al. 2004; Rahman et al. 2004). Nonetheless, it is often undiagnosed and untreated (WHO, 2008; Rahaman, Fisher, Bower & et al. 2013). Few studies conducted in Rwanda report perinatal depression symptoms to be high (Umuziga et al. 2015, Hynie et al. 2017) and predicted by lower husband and social support (Hynie et al. 2017). In addition, these last authors report low levels of social support to predict infant stunting. Because of its broad impact, identifying and treating maternal mental health issues is critical to both maternal and child health.

Despite the enormous need in caring for perinatal depression, different barriers to seeking maternal mental health care have been identified by various authors. In Uganda, a study by Nakku et al. (2016) identified barriers such as poor partner support, stigma, lack of financial support and accessibility, while Lara and colleagues et al. (2014); Goodman (2009); Kopelman et al. (2008) have also reported many other barriers such as shortage of time, lack of child care, not knowing where to go, lack of transportation, cost, absence of interpersonal support, help-seeking and treatment experiences, and relationship with health professionals.

Moreover, a systematic review by Dennis (2006) reported women’s inability to disclose feelings, often reinforced by family members; and health professionals’ reluctance to respond to the mothers’ emotional and practical needs as common barriers to treatment. Additionally, Tsai et al. (2013) perceived lacking validated tools in local context for identifying symptoms of perinatal depression as a barrier to improving perinatal mental health in Africa. Furthermore, Bayrampour and colleagues (2018), identified several common barriers in addressing perinatal mental health issues and they have included lack of training, local guidelines, scope of practice and time constraints, as well as lack of clinical support and supervision for primary health care providers. However, to the best of our knowledge, there is no study conducted in Rwanda identifying barriers preventing women in perinatal period from accessing mental health care.

Interestingly, a systematic review by Dennis (2015) reported that perinatal depression can be treated through different interventions including peer support, partner support, non-directive counselling, home visits and collaborative models of care such as primary care-based screening, diagnosis, and management. Therefore, there is a need for identifying barriers preventing women in perinatal period from accessing mental health care in Rwanda.

Methods: The current study will be conducted in four health centres in Rwanda, purposively four women in perinatal period in every health centre (16 interviews) will be recruited for in-depth interviews, and 4 focus group (one in every health centre) with primary health care providers. ATLAS.ti will be used to analyse data and simple thematic coding by the investigators will be also used. All In-depth Interviews and focus groups will be recorded and transcribed. Transcripts will be de-identified before data analysis.

Results: this is an ongoing study; data will be collected in January 2019 and preliminary findings will be presented at the conference.

Conclusion: This is phase one of a PhD research project, and findings of this study would inform the implementation of maternal mental health mentorship and peer support interventions addressing perinatal depression in Rwanda.