Adeona (not real name) narrates the mental breakdown she suffered when carrying and delivering her fourth and last child. She was sick throughout her pregnancy. And yet her husband expected her to function normally as a wife and mother and fully support the family. Through the morning sickness, vomiting and complications of her pregnancy she did not receive any support from her relatives. Adeona lives in Ibadan, Oyo state.
“I suffered so much; I cannot do it again. By the time I went into labour, I felt like I was alone in this world. I am done with giving birth,” Adeona says as she fights back the tears building up in her big brown eyes.
Midwife Omolara Asonibara recalls when Adeona arrived in her labour ward at University College Hospital in Ibadan, where she was working. She has delivered babies for over 20 years.
“She was alone with no caretaker. She was acting very irrational, lamenting the care of her first husband. We discovered she was not stable mentally and we had to take her for a caesarean section because she could not manage a vaginal delivery,” Asonibara says.
Her condition was diagnosed as puerperal psychosis — a severe mental illness that starts suddenly in the days, or weeks, after having a baby. Symptoms include high moods, depression, confusion, hallucinations and delusions. Adeona was referred to the psychiatry ward of the same hospital where she spent 3 months under close watch.
The ‘Why Are Women Dying While Giving Birth in Nigeria?’ Report
Findings from a community-informed maternal death review report titled ‘Why Are Women Dying While Giving Birth in Nigeria?’ reveals that many of women like Adeona suffer mental health problems in silence. It is an unrecognized contributing factor affecting quality maternal health during pregnancy and shortly after giving birth.
The 18-month community-informed maternal death review was commissioned by MSD for Mothers and implemented by Africare, Nigeria Health Watch and EpiAFRIC to provide an inquiry into the reasons pregnant women were dying in communities and to proffer a community accountability mechanism for maternal deaths.
During the baseline survey of the review, Dr Ukwori-Gisela Kalu, a clinical psychologist, assessed the mental health of pregnant women and those that had given birth to understand the mental health and wellbeing of women in selected communities in the six selected states of Niger, Bauchi, Kebbi, Lagos, Bayelsa, Ebonyi , representing each geo-political zone in Nigeria.
The report reveals that many women face mental health challenges during pregnancy and after giving birth. A mother with postpartum depression may fail to eat, bathe or care for herself, increasing the risks of ill health. Mother’s suffering might be so severe that they may even commit suicide. Prolonged or severe mental illness hampers the mother-infant attachment, breastfeeding and infant care. As a result, the children’s growth and development may be negatively affected as well.
“There is also a lot of joy, pride and wonder at the fact that she is actively involved in bringing new life to earth. This mix of emotions is what may often lead to an insatiable quest for information that health workers unwittingly term as obnoxious. By focusing primarily on the physiological needs of the mother and baby, the health system may fall short of meeting her psychological needs,” the report reveals in part.
Everyone is Affected
All women can develop mental disorders during pregnancy and in the first year after delivery, but poverty, migration, extreme stress, exposure to violence (domestic, sexual and gender-based), emergency and conflict situations, natural disasters, and low social support increase risks for specific disorders.
Asonibara, who has delivered women for over 20 years, says mental health challenges in maternity presents itself in many ways. First, pregnancy is not a normal phenomenon. A woman is vomiting, nauseated, eating everything without minding where it is from. She needs love and understanding from the people around her to go through this stage. Secondly, a woman can also experience false labour medically termed as Braxton Hicks.
“She comes and you tell her to go back. She comes again, you send her back. If her husband is not understanding, he may feel that she is playing. Women can get tired and will come and ask us to just take the baby out. She needs support to tell her that she is going through first labour, the baby will eventually come when it is ready,” Asonibara says.
The Giving Birth in Nigeria report notes that for a lot of pregnant women, the most important thing to them as regards health care is not the experience of the doctor or health worker. It is the welcoming voice of the doctor and the ability to be compassionate, listen to their concerns and patiently explain often overwhelming medical terms to them without making them feel unworthy. As regards health workers, a confident and compassionate professional will beat experience every time.
Dying in Silence
Giving birth is often described as a universal experience and many social and cultural norms are based on the assumption of a positive birth outcome. One widespread cultural belief by women in Ebonyi State is that women who have caesarean sections are weaklings. The women believe that they must deliver as the “Hebrew Woman”, revered in the pages of the Bible’s Old Testament. Negative pressures and expectations such as this can severely impact a woman’s thoughts and emotions for months or even years.
During the review, several women reported high levels of anxiety throughout pregnancy, with little to no support mechanisms or services available to them.
“Thinking is one of the problems because your blood pressure is always high and when you are with your husband you don’t seem to have rest of mind because he cares less about you as the wife, he leaves the house expecting you to sort yourself out, and by so doing, there is no other way to drown your sorrows than to keep thinking”- a pregnant woman in Kebbi State reported.
Asonibara confirms that during labour, the pain alone can cause a mental breakdown, but when you show a woman concern and speak to her, she opens up.
“Here the woman needs to understand what she is going through and what she expects during labour. You tell her about the back and abnormal pain, teach her how to breathe and how to bear the pain until the baby comes out. This helps to allay their fears and prepare them psychologically. A patient who has not been to ANC will face more difficulty because she is not prepared”, she says in support of the findings of the report.
Giving birth at home or in a community space, with little to no professional health care equipment or personnel, worsens the state of mental health. Where maternal deaths occurred in these communities, especially during labour, women generally lacked information on the causes of these deaths, which generates further fears of labour for the rest.
“Mental health problems such as anxiety disorders during pregnancy and after childbirth are serious conditions that should not be trivialised,” the report recommends.
Other forms of maternal health problems include substance abuse which puts the life of the mother and her unborn baby in danger. These women have an increased risk of obstetric complications and preterm labour. They are less likely to seek and receive antenatal or postnatal care or adhere to prescribed health regimens.
“Deaths that are caused directly or indirectly by maternal mental health disorders are not recorded or even investigated. This is a challenge that continues to hinder progress in achieving quality maternal health care globally, nationally and at community-level, down to the home,” the Giving Birth in Nigeria review concludes in its findings.
Act Now to Save Nigeria’s Mothers
The report recommends several interventions that can help arrest the mental problem in maternal health and save women in time.
First, the report recommends that mental health support should be incorporated into Antenatal Care (ANC) and Postnatal Care (PNC) for pregnant and nursing women. Routine perinatal psychosocial screenings as part of a holistic maternal health care programme would help to identify women who are in need of support and referral for further management. This plan should incorporate early antenatal and postnatal psychosocial assessments with ongoing mental health monitoring across all maternity settings.
Second, while mental health is a core course in midwifery training, there is a need for continuing professional development programs for health workers, which should include education about perinatal morbidity and mortality from mental illness. A deliberate effort should be made to ensure nurses, midwives and doctors don’t just stop at delivering women but also ensure the mental wellbeing of mothers before, during and after delivery.
Third, members of the mental health profession should be engaged in developing a standard instrument for investigating maternal deaths from indirect mental illness. PHCs must serve as lifelines for women in local communities. Support should be extended down to the community level where community members are educated about mental health support for women to ensure better maternal health outcomes. Peer-to-peer groups should also be fostered at the community level to provide mental health support for women.
If these recommendations are implemented, Nigeria will be one step closer to ensuring that its mothers stay healthy throughout their pregnancy and delivery, not only in their bodies, but also in their minds.
The “Why Are Women Dying While Giving Birth in Nigeria?” report is an analysis of findings from a community-informed maternal death review that was implemented under the Giving Birth in Nigeria project. This project is sponsored by MSD for Mothers and implemented by Africare, Nigeria Health Watch and EpiAFRIC. The “Why Are Women Dying While Giving Birth in Nigeria?” report will be launched at a virtual meeting on Monday, 30 November 2020.
I really must thank you for highlighting this issue – mental health among women during and after childbirth. I think this is the first step, creating awareness for this condition within the public, health care providers and policy makers. I like it that you highlight the role of health workers. The current shortage of qualified health workers raises a huge concern.
I absolutely agree with a holistic approach to antenatal and postnatal care. I will argue that a well organised preconception care is equally important. The social context is equally as important as the biomedical approach, hence the preconception period is important for identifying risk factors for mental health illness, identifying social support structures the woman already has, and planning for the antenatal and postnatal periods. Our care must not only be person-centred, it must be family and community oriented.