About four in 10 women in South Africa experience perinatal depression during pregnancy or postpartum depression, a condition which can have devastating effects on families.
But a new local study has revealed that despite their vulnerability to mental health disorders, many women, including those facing domestic violence, go unnoticed and untreated due to shame and fear of their condition going public.
The University of Cape Town study, which surveyed four Cape Town maternity and obstetrics units (MOUs), found not only are these women fearful of humiliation, but healthcare workers too are failing them as they neglect to investigate their depressive symptoms and other psychosocial issues.
Titled “Facilitators and barriers to detection and treatment of depression, anxiety and experiences of domestic violence in pregnant women”, the study, published in the Scientific Reports journal, revealed that healthcare workers often don’t inquire about domestic violence as it takes “too long” to screen given their heavy workload.
Signs of intimate partner violence were only detected when there were signs of physical abuse or if the women voluntarily disclosed such information. MOUs highlighted the lack of standardised referral pathways and the poor uptake of referrals by abused women or those with symptoms of depression and anxiety.
A lack of confidentiality and feelings of shame related to experiences of domestic violence kept many women from openly discussing them.
I can't screen all patients because now it’s going to take me a long time ... I need to see the next patient ... so I won’t be giving much time to her.
— Maternity and obstetrics unit nurse
Dr Zulfa Abrahams, the study’s lead author and research development manager at UCT’s faculty of health sciences, said: “All except for one of the facility-based healthcare workers interviewed felt that it was important to screen pregnant women for psychological distress and experiences of domestic violence.”
Out of the four MOUs surveyed, only one antenatal care nurse reported detecting women who were abused “twice or thrice a month”, while an MOU manager reported that detecting women who were abused was “not often, but we do”.
“A health promotion officer admitted that if she specifically inquired about domestic violence, she would detect many women as ‘domestic violence is so high here in this area’.”
The study found that many pregnant women reported being willing to disclose their feelings and experiences of domestic violence, however, some expressed concerns about confidentiality. One pregnant woman was especially concerned about whether such sensitive information would remain confidential “especially in a community where everyone knows everyone”, citing she didn’t trust nurses.
The study found that all antenatal nurses were concerned about the amount of time it took to assess patients’ mental health as a heavy workload and large patient numbers limited time with each patient.
One nurse told researchers: “I can't screen all patients because now it’s going to take me a long time ... I need to see the next patient ... so I won’t be giving much time to her.”
Common mental disorders, such as depression and anxiety, are highly prevalent during the perinatal period, with low- and middle-income countries carrying the greatest burden. In South Africa, the prevalence of depressive symptoms during pregnancy ranges between 27% and 39%, while symptoms of anxiety range between 15 and 23%.
The issue of perinatal mental disorders was thrust into the limelight this week after a South African woman, Lauren Dickason, 42, was found guilty of murdering her three young daughters Maya and Karla, and their six-year-old sister Lianè, at their home in the town of Timaru in New Zealand in 2021.
She had pleaded not guilty to murder, arguing she was suffering severe depression that could be traced back to postpartum depression.
Dickason’s parents Malcolm and Wendy Fawkes and the extended family released a statement to media after the guilty verdict this week.
“Postpartum depression is a terrible thing, as has been shown by what happened to our family on September 16 2021. This was not our daughter, but a debilitating mental illness which resulted in an awful tragedy, the details of which you are by now well aware.”
While the importance of providing a counselling service was highlighted in the Cape Town study, researchers noted that many women referred for mental health counselling, declined the offer. One nurse explained that mental health issues were stigmatised in the community and patients worried about being branded as “mad if you go for counselling”.
“Our research suggests that the system-level barriers need to be addressed at a policy level. Service-user and -provider barriers identified indicate the need to strengthen health systems by training antenatal care nurses to detect symptoms of common mental health disorders and experiences of domestic violence in pregnant women and develop standardised referral pathways.”
Abrahams said nurses could be trained to routinely inquire about their patients’ feelings and anxieties while examining them, “instead of completing the screening tool as a ticking exercise while completing the required documentation linked to the consultation”.
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