ABSTRACT
Background:
Globally, maternal mental health has been recognized as a priority public health issue. While it is crucial to integrate maternal mental health into mother and child health services, research on strengthening the knowledge and skills of primary healthcare providers on maternal mental health is limited in India.
Aim:
To evaluate the effectiveness of a manual-based training program in improving auxiliary nurse midwives (ANMs) knowledge, attitudes, and skills related to maternal mental health.
Methods:
The present study adopted an experimental design among ANMs (N = 110) working at primary health centers, Karnataka, India. The participants were randomly assigned to either experimental group (n = 53) or control group (n = 57). The training program delivered interactive sessions based on a facilitator’s manual developed specifically for ANMs in India. The assessments were done in both groups at baseline, after the intervention, at three months and at six months using self-rated questionnaires and a case vignette. The descriptive and inferential statistics were used to analyze the data.
Results:
After the training program the mean knowledge, attitudes and skills scores were significantly increased in the experimental group (P < 0.001) and significant differences were found between the mean scores of the groups at 3 months and 6 months follow-up (P < 0.05).
Conclusion:
The training program was found to have a positive impact in enhancing ANMs’ knowledge, attitudes, and skills related to maternal mental health in India as there is dearth for mental health professionals in primary care settings.
Keywords: Auxiliary nurse midwives, effectiveness, India, maternal mental health, midwives
INTRODUCTION
Globally, maternal mental health has been recognized as a public health priority. Perinatal mental illness (PMI) refers to mental health problems that occur during pregnancy and postpartum period. While severe mental illnesses are rare, common mental disorders (CMDs), such as anxiety and depression, contribute significantly to maternal mortality and morbidity.[1] Psychosocial factors, such as socioeconomic deprivation, intimate partner violence, traditional confinement practices after childbirth, and women’s low status in Indian society contribute to the development of mental disorders in many women.[2] A systematic review and meta-analysis demonstrated that perinatal depression and anxiety were associated with poorer social-emotional, cognitive, language, motor, and adaptive behavior development in offspring.[3] The prevalence of perinatal mental disorders has been found to be 18.6% in low- and middle-income countries.[4] In India, the prevalence of CMDs antenatally was estimated to be 21.8%[5] and postpartum depression as 22%.[6]
In low- and middle-income countries, maternal mental health is often neglected in primary care settings due to limited or non-existent mental health specialists in peripheral healthcare facilities and lack of mental health training among primary care providers.[7] “Task shifting” or “task sharing” is found to be an effective strategy, especially in low- and middle-income countries in addressing acute shortage of mental health professionals and strengthening mental healthcare system.[8,9] The MANAS (MANashanti Sudhar Shodh, which means “project to promote mental health”) trial found that a collaborative stepped care intervention by trained lay counselors lead to an improvement in recovery of persons suffering from anxiety and depression at public primary care facilities in Goa, India.[10] Similarly, in rural Pakistan, psychological interventions provided by community-based primary health workers were found to be effective in both improving maternal depressive symptoms and infant health (e.g., decreased diarrhea and improved immunization rates).[11] Also, the PRogramme for Improving Mental Health Care (PRIME) study from Ethiopia, India, Nepal, South Africa, and Uganda found that task-sharing in mental health care was perceived as acceptable and feasible by healthcare professionals (physicians, nurses, community health workers), community members, and service users.[12] Integrating mental health into maternal and child health (MCH) programs is needed to meet the emotional needs of women in perinatal period. Therefore, healthcare professionals who offer continuous home health care for pregnant women and new mothers should be competent enough to provide mental health care. The Tropical Health and Education Trust (THET) project which was carried out in Nepal among auxiliary nurse midwives (ANMs) illustrated lack of knowledge and inadequate training related to mental health issues of women during pregnancy and postpartum period. The project also suggested the need for perinatal mental health training to improve their knowledge and practice.[13] In addition, a recent systematic review recommended that it is crucial to incorporate mental health training in midwifery curriculum to empower midwives to identify and manage women with maternal mental health issues.[14]
Published evidence from developed countries demonstrates deficits in midwives’ knowledge on perinatal mental health, and there is a need to improve midwives’ knowledge and competency in the assessment and care of women suffering from depression.[15-19] Educational interventions in perinatal mental health has shown to be effective in improving knowledge, attitudes, and confidence of midwives’[20-23] and student midwives.[24] Further, training on perinatal mental health proved to be helpful in combating stigmatizing attitudes towards maternal mental illness among midwives.[23-26] In India, while the need for training is evident, no studies have evaluated the impact of educational interventions on maternal mental health among ANMs in India. Further, Bagadia A and Chandra P.S (2017) pointed out that lack of awareness among primary care providers would be one of the challenges to integrate maternal mental health in MCH programs in India. The authors also suggested the need to upgrade the skills of community health workers in addressing this issue.[27] Therefore, in the present study a facilitator’s manual was developed specifically for ANMs to build their capacity in early identification, referral, and coordinated treatment for women with maternal mental health issues. Hence, aim of this study was to evaluate a manual based training for its efficacy in improving ANMs’ knowledge, attitudes, and skills in addressing mental health issues of women during perinatal period.
MATERIALS AND METHODS
Study design and location
An experimental design was adopted for this study. This study was carried out among ANMs working at primary health centers and subcenters of selected districts, Karnataka, South India. The data was collected from September 4, 2017, to March 18, 2018.
Participant recruitment and eligibility
The research population for the present study consisted of 2863 ANMs employed in 565 primary health centers at eight districts of Karnataka. The sample size was determined based on the pilot study and G Power analysis using the mean scores. The required power was set at 1- β = 0.90. The observed effect size from pilot study was 1.60. The level of significance was kept at α = 0.05. In order to achieve a power of 0.90, a sample size of n = 90 (45 participants in each group) was required. We have, however, included 60 participants in each group due to attrition. The study criteria included: a) should be a registered ANM, b) working at primary health centers and subcenters of Karnataka state and c) should have minimum one year of experience in providing mother and child healthcare services. Based on logistics, time, and financial constraints, participants were allocated to experimental and control groups.
Sample attrition
Over a six months period, five participants had to leave the study due to various reasons. In the experimental group, two were deputed to higher studies and two participants were on long leave. In the control group, three participants did not complete the data collection due to maternity leave. The final sample size included for the data analysis was 53 in the experimental group and 57 in the control group.
Description of the facilitator’s manual
The facilitator’s manual was developed based on extensive review of literature, the findings from focus group discussions (FGDs) carried out among ANMs as part of this project (these participants were excluded from the main study) and mental health experts’ (who had more than five years of experience in perinatal mental health) opinions. After identifying the requirements, researchers developed the training manual which consisted of 10 interactive sessions [Table 1] to educate ANMs on maternal mental health. The draft of developed manual validated by ten experts from various disciplines in NIMHANS Nursing, Psychiatry, psychiatric social work, epidemiology clinical psychology and bio-statistics. The draft of the manual was also given to the two of ANMs to give their feedback and comments. The suggestions given by experts and ANMs were incorporated, and the refined manual was piloted among group of nurses. The finalized manual was adopted for the experimental group. While we could not translate the manual in to regional language (Kannada), the training sessions were conducted in Kannada language by the research team. The facilitator’s manual outlines a three-day training program designed to help ANMs to promote maternal mental health. Each session included back ground, topic outline, objectives, duration of the session, description of the activity, facilitator’s notes, and references for further reading. The training program used a combination of teaching strategies such as brainstorming, case vignettes depicting real-life situations, small group activity, power point/audio-video presentation, role plays and also provided an opportunity for discussion and clarification of doubts.
Table 1.
Content of facilitators’ manual on maternal mental health for auxiliary nurse midwives
| Title of the session | Topics | Method of training |
|---|---|---|
| An overview of Mental Disorders | • Health, Mental Health, and Mental Disorders | • Small group activity and discussion |
| • Severe Mental Disorders | • Case vignettes and discussion | |
| • Common Mental Disorders | • Case vignettes and discussion | |
| Maternal Mental | • Concept of Maternal Mental Health | • Video presentation followed by small group activity based on case vignettes and discussion |
| Health: Key Concepts | • Impact of Maternal Mental Disorders | • Small group activity and discussion |
| Understanding risk factors for Maternal Mental Disorders | • Risk factors for Maternal mental disorders | • Small group activity based on case vignettes and discussion |
| Domestic Violence | • Concept of Domestic violence | • Small group activity and discussion |
| • Domestic violence among women during perinatal period | • Small group activity based on case vignettes and discussion | |
| • Domestic violence: Role of ANM | • Role play based on case scenario | |
| Common Maternal Mental Disorders | • Common Mental Disorders during Pregnancy | • Small group activity based on case vignettes followed by role play |
| • Common Mental Disorders during Postpartum Period | • Small group activity based on case vignettes followed by role play and video presentation | |
| Severe Maternal Mental Disorders | • Severe Mental Disorders during Pregnancy | • Small group activity based on case vignettes and discussion |
| • Severe Mental Disorders during Postpartum Period | • Role play based on case scenario | |
| Mother-Baby Bonding (MBB) | • Concept of Mother-Baby Bonding | • Small group activity and discussion |
| • Common barriers and impact of maternal mental disorders on Mother-Baby Bonding | • Small group activity based on case vignettes and discussion | |
| • ANMs role in promoting Mother-Baby Bonding | • Small group activity and discussion | |
| Maternal Mental Health Assessment | • Significance of Maternal mental health assessment | • Small group activity and discussion |
| • Process of Maternal mental health assessment | • Presentation followed by role plays based on case vignettes | |
| Maternal Mental Health: Role of | • Role of ANMs in promotion of Maternal mental health | • Role plays based on case vignettes followed by discussion |
| Auxiliary Nurse Midwives | • Role of ANMs in prevention of Maternal mental disorders | • Small group activity and discussion |
| Counseling | • Concept of Counseling skills | • Role plays based on case vignettes followed by discussion |
Tools used in this study were
Socio-demographic questionnaire elicited background information of the participants such as age, education, designation, religion, place of residence, marital status, years of professional experience. The participants were also asked if they had experience in caring for someone with a mental illness and women with maternal mental health issues.
-
Knowledge assessment questionnaire
Part 1: Knowledge questionnaire on maternal mental disorders: This was a modified version of “Perinatal Mental Health Education Evaluation Questionnaire” developed by Higgins A et al.[24] (2016) to find out the impact of perinatal mental health education on student midwives’ knowledge, skills, and attitudes. In the present study, eight items were adopted from the above said tool and two more items were added to assess ANMs’ current level of knowledge on various maternal mental disorders. The tool had a five-point Likert scale range from “1” (Poor) to 5 (Excellent), and the score for this scale ranges from 5 to 50. Higher score reflects better knowledge.
Part 2: Knowledge questionnaire on maternal mental health: This tool was developed by the research team based on findings of FGDs carried out among the ANMs and the training manual. This tool comprised of 25 multiple-choice questions focused on meaning of mental health, types of maternal mental disorders, risk factors, symptoms, mother baby bonding, baby blues, assessment scales, and role of ANMs. Each question has four responses with one correct answer. One point may be credited for the right answer and “0” for wrong answer. The maximum score for this scale was 25.
-
Attitude assessment questionnaire
This part of the scale also had two parts
Part 1: Attitudes towards women with maternal mental disorders
This scale was developed by research team and consisted of 12 items that measured participants attitudes towards women with maternal mental disorders. Participants were asked to rate their agreement on a five-point Likert scale range from “1” (strongly disagree) to 5 (strongly agree). The score for this scale ranges from 12 to 60. Higher scores indicated more positive attitudes towards women with maternal mental illness.
Part 2: ANMs’ views on their professional role in caring women with maternal mental disorders
This scale consisted of 12 items which was developed by the researcher to measure participants’ attitudes towards their role in caring women with maternal mental disorders. Participants were asked to rate their agreement on a five-point Likert scale range from “1” (strongly disagree) to 5 (strongly agree). The score for this scale ranges from 12 to 60. Higher score reflects more positive attitudes towards their role.
-
Case vignette to assess ANMs’ skills
For this purpose, a case vignette depicting a woman’s journey during pregnancy and postnatal period was used to assess ANMS’ skills in identifying and referring women with mental health issues in perinatal period. There were seven multiple-choice questions at the end of the case vignette. Each question has four responses with one correct answer. One point may be credited for the right answer and “0” for wrong answer. The maximum score would be seven and higher score reflects better skills.
Validity and reliability of the questionnaire
The steps of validation process was described in the below given Figure 1.
Figure 1.
Steps of development of the questionnaires
The follow-up assessment was done using the same pretest questionnaires and case vignette. However, the post-training questionnaire which was administered immediately after the training program additionally included few more items to obtain the participants (Experimental group) feedback on the content, teaching methods and applicability of the training program in their practice. The feedback indicated on a five-point Likert scale (1 = strongly disagree to 5 = strongly agree). Three open-ended questions were also included i.e., What did you like most about this training? What aspects of training could be improved? Do you have any additional comments? A few open-ended questions were included in the post-training questionnaire at three and six months to elicit information about the impact of the acquired knowledge on maternal mental health in their practice. For example, the number of pregnant and post-natal mothers are responsible to provide care in their respective areas; number of women identified and referred to mental health services and the ANMs were also requested to provide the important barriers in identifying and referring the women with maternal mental disorders.
Data collection procedure
On the first day of the training program, the research team welcomed the participants and briefly explained about the study including aims and procedures of the study. The pre-training questionnaires were administered to the participants in the experimental group after obtaining written informed consent. This was followed by manual-based interactive sessions which were delivered over a period of three days [Table 1]. The training program ended with administration of post-training questionnaire. Simultaneously, the researchers met the participants in the control group at their workplace (primary health centers/subcenters) and explained briefly about the study. The pre-training questionnaires were administered among the participants after obtaining written informed consent. No intervention was received by the participants in the control group, and the post-training data was collected after a week. The follow-up assessment was done among both the groups at three months and at six months after the intervention [Figure 2].
Figure 2.
Data collection process
Ethical considerations
The research proposal was approved by Institute ethical committee. The participants were explained that participation in this study was optional, anonymous and would not affect their job in any way. They were also informed that they can withdraw from the study at any point of time without giving any reason. Written informed consent was obtained from the participants.
Analysis
The data was analyzed using SPSS 21 version. Distribution of demographic variables was presented using frequencies and percentages. The data in this study were normally distributed (Shapiro–Wilk test). Hence, independent t-test and repeated measures of ANOVA were used to compare the effectiveness of the intervention in changing the ANMs’ KAP between experimental and control groups on maternal mental health. The level of significance was fixed at 0.05 level.
RESULTS
A total of 110 participants (experimental group-53 and control group-57) were included in the analysis. Mean ages of the ANMs were 41 years and 36.6 years (experimental and control groups, respectively). There was no significant difference between the two groups on any of the socio-demographic variables. However, a greater number of participants in the experimental group (98.1%) compared to control group (75.4%) had come across the individuals with mental illness than control group (χ2 = 15.72, P < 0.001) [Table 2].
Table 2.
Socio-demographic characteristics of the sample
| Variable | Group | Experimental Group (n=53) | Control Group (n=57) | χ 2 | df | P | ||
|---|---|---|---|---|---|---|---|---|
|
|
|
|||||||
| n | % | n | % | |||||
| Age (years) | <30 | 11 | 20.8 | 24 | 42.1 | 6.23 | 3 | 0.10 |
| 31-40 | 15 | 28.3 | 14 | 24.6 | ||||
| 41-50 | 10 | 18.9 | 08 | 14.0 | ||||
| >50 | 17 | 32.0 | 11 | 19.3 | ||||
| Religion | Hindu | 48 | 90.6 | 48 | 84.2 | 0.99 | 1 | 0.31 |
| Others | 05 | 9.4 | 09 | 15.8 | ||||
| Background | Rural | 33 | 62.3 | 44 | 77.2 | 2.91 | 1 | 0.08 |
| Urban | 20 | 37.7 | 13 | 22.8 | ||||
| Marital status | Married | 46 | 86.8 | 46 | 80.7 | 0.00 | 2 | 0.60 |
| Unmarried | 05 | 9.4 | 09 | 15.8 | ||||
| Widowed/divorced | 02 | 3.8 | 02 | 3.5 | ||||
| Education | SSLC | 24 | 45.3 | 19 | 33.3 | 3.40 | 2 | 0.18 |
| PUC | 24 | 45.3 | 26 | 45.6 | ||||
| Higher | 05 | 9.4 | 12 | 21.1 | ||||
| Professional experience | ≤5 | 08 | 15.1 | 19 | 33.3 | 4.94 | 2 | 0.08 |
| 6-15 | 24 | 45.3 | 20 | 35.1 | ||||
| ≥16 | 21 | 39.6 | 18 | 31.6 | ||||
| Come across persons with mental illness | Yes | 52 | 98.1 | 43 | 75.4 | 15.72 | 1 | 0.001* |
| No | 01 | 1.9 | 14 | 24.6 | ||||
| Curriculum on maternal mental illness | Never/Poor | 03 | 5.7 | 11 | 19.3 | 5.50 | 4 | 0.14 |
| Fair | 10 | 18.9 | 09 | 15.8 | ||||
| Good | 30 | 56.5 | 31 | 54.4 | ||||
| Excellent | 10 | 18.9 | 06 | 10.5 | ||||
| Come across women with maternal mental illness | Yes | 13 | 24.5 | 09 | 15.884.2 | 1.31 | 1 | 0.25 |
| No | 40 | 75.5 | 48 | |||||
*Significant at P<0.05
The two groups did not significantly differ in any of the outcome variables (knowledge, attitudes, and skills) at baseline level. After the training program the experimental groups’ mean knowledge scores on maternal mental disorders (M ± SD; 22.04 ± 3.92 to 42.96 ± 6.79) and maternal mental health (M ± SD; 12.40 ± 2.69 to 19.57 ± 3.27) significantly increased than the control group and sustained at three months and at six months (P < 0.001). The findings indicated that the mean scores of attitudes towards women with maternal mental disorders (40.83 ± 3.43 to 43.94 ± 4.50, P < 0.002) and ANMs’ role (46.72 ± 7.56 to 51.40 ± 7.40, P < 0.003) were significantly higher among participants from experimental group compared to control group. However, the positive changes in attitudes towards women with maternal mental disorders were not significant at six months between the groups. After receiving the training program on maternal mental health, the experimental groups’ skills score significantly increased from 5.15 (SD = 1.23) to 6.57 (SD = 0.63) than the control group (p < 0.001) and the improvement in skills were retained at three months and at six months (p < 0.05). Repeated measures of analysis also revealed that the mean knowledge, attitudes, and skills scores on maternal mental health in experimental group were significantly higher than control group and within the experimental group at different time points of assessment (p < 0.001) [Table 3 and Figures 3-5]. According to covariance analysis, there were no significant differences between the groups on knowledge and attitude questionnaires (experimental and control groups). Participants’ practices regarding maternal mental health, however, differed statistically significantly (F = 5.56, P < 0.01). Hence, based on the findings of the study it can be interpreted that the manual-based training was an effective intervention in improving ANMs’ knowledge, attitudes, and skills related to maternal mental health.
Table 3.
RM ANOVA results for effectiveness of training program on mean knowledge, attitude, and practice scores regarding maternal mental health
| Outcome measures | Time points | Experimental group (n=53) Mean (SD) |
Control group (n=57) Mean (SD) |
F (Group & Time) | (n=110) P |
|---|---|---|---|---|---|
|
| |||||
| Knowledge | |||||
| Maternal mental disorders | Baseline | 22.04 (3.92) | 21.35 (5.09) | 42.31 | 0.001* |
| Post-intervention | 42.96 (6.79) | 23.96 (5.42) | |||
| 3 months | 35.83 (9.98) | 23.96 (5.42) | |||
| 6 months | 35.49 (9.16) | 23.16 (6.40) | |||
| Maternal mental health | Baseline | 12.40 (2.69) | 12.58 (3.47) | 70.42 | 0.001* |
| Post-intervention | 19.57 (3.27) | 12.60 (2.65) | |||
| 3 months | 20.72 (2.66) | 12.37 (2.39) | |||
| 6 months | 18.60 (2.95) | 13.51 (3.39) | |||
|
| |||||
| Attitude | |||||
|
| |||||
| Attitudes towards women with maternal mental disorders | Baseline | 40.83 (3.43) | 39.01 (4.69) | 10.81 | 0.001* |
| Post-intervention | 43.94 (4.50) | 41.12 (4.97) | |||
| 3 months | 46.89 (5.04) | 40.77 (4.01) | |||
| 6 months | 41.89 (3.97) | 41.12 (4.17) | |||
| Attitudes towards role of ANMs | Baseline | 46.72 (7.56) | 46.60 (9.91) | 2.82 | 0.05 |
| Post-intervention | 51.40 (7.40) | 47.72 (5.40) | |||
| 3 months | 52.47 (5.34) | 47.74 (5.41) | |||
| 6 months | 50.60 (6.12) | 47.82 (6.14) | |||
|
| |||||
| Practice | |||||
|
| |||||
| Baseline | 5.15 (1.23) | 4.70 (1.39) | 9.13 | 0.001* | |
| Post-intervention | 5.84 (0.81) | 4.66 (1.38) | |||
| 3 months | 6.57 (0.63) | 3.90 (1.55) | |||
| 6 months | 5.62 (0.94) | 4.94 (1.29) | |||
SD, Standard Deviation. *Significant at P<0.05
Figure 3.
RMANOVA graph for changes in mean knowledge scores of ANMs after the Intervention on maternal mental health
Figure 5.
RMANOVA graph for changes in mean practice scores of ANMs after the Intervention on maternal mental health
Figure 4.
RMANOVA graph for changes in mean attitude scores of ANMs after the Intervention on maternal mental health
Acceptability and views on the training program
All participants strongly agreed that the training program was interesting, applicable to practice, and they would recommend the training program to other ANMs. Majority of the participants (98.2%) felt that their knowledge, attitudes, and skills related to maternal mental health was improved after the training program. They were confident in identifying (93%) and referring women with mental health issues to the appropriate services (94.7%).
Impact of the training program
The follow-up questionnaires (at 3 months and at 6 months) had an open-ended question with regard to the number of women identified and referred to the mental health services. It was found that the participants from experimental group were able to identify and refer women with maternal mental health issues (104) than the control group (39).
DISCUSSION
This study is one of the first scientific attempts to evaluate the effectiveness of a facilitator’s manual-based training program on maternal mental health in improving knowledge, attitudes, and skills of ANMs in the Indian context. This study demonstrated improvement in knowledge, attitudes, and skills related to maternal mental health after participating in the training program. Similar to other studies done[20-24,26,28] in the field, this study also found a significant increase (P < 0.001) in mean knowledge scores on maternal mental health after the training program and was sustained over a period of six months.
Earlier studies also demonstrated that negative attitudes among midwives may have an effect on the understanding of maternal mental health issues[29] and professional behavior[30] which reduces the possibility of identification of these issues among women during the perinatal period. Hence, educational interventions need to address the negative attitudes of healthcare providers. Our training program was found to be effective in changing ANMs’ attitudes positively towards women with maternal mental illness. The present study noted significant changes in attitudes of ANMs in the experimental group compared to the control group immediately after the intervention (P < 0.002) and three months (P < 0.001). These findings were similar to previous research carried out among midwives[21,22] and student midwives.[24] However, we found the change in the positive attitudes in the control group as well. This may be because the participants in this group were exposed to the baseline questionnaire, which may have stimulated interest about importance of maternal mental health and this may have accounted for these changes. However, this improvement was not sustained at six months. These findings suggest the need for continuous educational programs to sustain favorable attitudes towards women with maternal mental health issues among ANMs. Continuous medical education may be required to effect long-lasting changes. Also, we did not distribute the manual to the participants in both groups as we couldn’t translate the manual into a regional language due to financial and time constraints.
In line with earlier studies,[21,22,24] there was a significant increase in mean skills scores of ANMs in the experimental group compared to control group. The training program was found to be effective not only in improving the knowledge, but was also successful in motivating the ANMs in identifying and referring women with maternal mental health issues as more number of women with maternal mental health issues were identified and referred by the ANMs from experimental group (104) than control group (39). These findings were supportive of earlier studies that found training programs were effective in improving identification and supporting women with mental health issues in the postpartum period by midwives.[25,31] The COVID-19 pandemic affected negatively the mental health of women during pregnancy and postpartum period. Studies from India and elsewhere reported increased prevalence of anxiety and depression during COVID-19 among pregnant and new mothers.[32-34] These findings suggest the importance of educating primary care providers (ANMs) about maternal mental health to enable them in early identification and promotion of mental wellbeing of women during perinatal period.
Strengths and limitations
This study has several strengths, and to best of our knowledge, this was the first study that has focused on possible advantage of task shifting in perinatal mental health care in India. The other strengths include adequate sample size, low dropout rates, elaborate training program, and manualization. Further, this study had two follow-ups after the training which provided an opportunity to motivate the participants in identifying and supporting women with maternal mental health issues. The limitations of the study include participants were from few districts of Karnataka. Hence, the findings are not generalizable to ANMs working in other regions of India. Furthermore, no objective measures were used to assess improvement in the identification of women with maternal mental health issues and findings were relied on self-reports of practice. Also, service users’ perspectives were not included in the development of the manual. We could not translate the manual into vernacular language due to time and financial constraints. Also, we couldn’t ensure uniformity of training since the sessions were conducted by researchers in the regional language (Kannada). Additionally, we could not establish the psychometric properties of the questionnaires adopted in this study. Despite limitations, the study provides evidence that the training in perinatal mental health improves ANMs’ knowledge, attitudes, and skills in supporting women with mental health problems in perinatal period.
CONCLUSION
The training program was found to have a positive and significant impact in empowering ANMs’ with adequate knowledge, attitudes, and skills related to maternal mental health issues. However, follow-up training, ongoing clinical supervision, and clear referral pathways are urgently needed to promote sustainable changes in ANMs’ practice related to maternal mental health.
Financial support and sponsorship
This study was funded by Department of Health Research, Ministry of Health and Family Welfare, Government of India (Grant No: DHR/11/GIA-2015-16).
Conflicts of interest
Vijayalakshmi Poreddi has received research grants from Department of Health Research, Ministry of Health and Family Welfare, Government of India.
Acknowledgements
We thank all the ANMs for their valuable contribution in this study and Department of Health Research for their financial support in funding the project “Maternal mental health promotion—Efficacy of training program among ANMs” (Grant No: DHR/11/GIA-2015-16).
REFERENCES
- 1.Gelaye B, Rondon MB, Araya R, Williams MA. Epidemiology of maternal depression, risk factors, and child outcomes in low-income and middle-income countries. Lancet Psychiatry. 2016;3:973–82. doi: 10.1016/S2215-0366(16)30284-X. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Kishore MT, Satyanarayana V, Ananthanpillai ST, Desai G, Bhaskarapillai B, Thippeswamy H, et al. Life events and depressive symptoms among pregnant women in India: Moderating role of resilience and social support. Int J Soc Psychiatry. 2018;64:570–7. doi: 10.1177/0020764018789193. [DOI] [PubMed] [Google Scholar]
- 3.Rogers A, Obst S, Teague SJ, Rossen L, Spry EA, Macdonald JA, et al. Association between maternal perinatal depression and anxiety and child and adolescent development: A meta-analysis. JAMA Pediatr. 2020;174:1082–92. doi: 10.1001/jamapediatrics.2020.2910. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Fisher J, Cabral de Mello M, Patel V, Rahman A, Tran T, Holton S, et al. Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: A systematic review. Bull World Health Organ. 2012;90:139G–49G. doi: 10.2471/BLT.11.091850. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Kalra H, Tran TD, Romero L, Chandra P, Fisher J. Prevalence and determinants of antenatal common mental disorders among women in India: A systematic review and meta-analysis. Arch Womens Ment Health. 2021;24:29–53. doi: 10.1007/s00737-020-01024-0. [DOI] [PubMed] [Google Scholar]
- 6.Upadhyay RP, Chowdhury R, Aslyeh S, Sarkar K, Singh SK, Sinha B, et al. Postpartum depression in India: A systematic review and meta-analysis. Bull World Health Organ. 2017;95:706–17C. doi: 10.2471/BLT.17.192237. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Baron EC, Hanlon C, Mall S, Honikman S, Breuer E, Kathree T, et al. Maternal mental health in primary care in five low- and middle-income countries: A situational analysis. BMC Health Serv Res. 2016;16:53. doi: 10.1186/s12913-016-1291-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Eaton J, McCay L, Semrau M, Chatterjee S, Baingana F, Araya R, et al. Scale up of services for mental health in low-income and middle-income countries. Lancet. 2011;378:1592–603. doi: 10.1016/S0140-6736(11)60891-X. [DOI] [PubMed] [Google Scholar]
- 9.Kakuma R, Minas H, van Ginneken N, Dal Poz MR, Desiraju K, Morris JE, et al. Human resources for mental health care: Current situation and strategies for action. Lancet. 2011;378:1654–63. doi: 10.1016/S0140-6736(11)61093-3. [DOI] [PubMed] [Google Scholar]
- 10.Patel V, Weiss HA, Chowdhary N, Naik S, Pednekar S, Chatterjee S, et al. Effectiveness of an intervention led by lay health counsellors for depressive and anxiety disorders in primary care in Goa, India (MANAS): A cluster randomised controlled trial. Lancet. 2010;376:2086–95. doi: 10.1016/S0140-6736(10)61508-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Rahman A, Malik A, Sikander S, Roberts C, Creed F. Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: A cluster-randomised controlled trial. Lancet. 2008;372:902–9. doi: 10.1016/S0140-6736(08)61400-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Mendenhall E, De Silva MJ, Hanlon C, Petersen I, Shidhaye R, Jordans M, et al. Acceptability and feasibility of using non-specialist health workers to deliver mental health care: Stakeholder perceptions from the PRIME district sites in Ethiopia, India, Nepal, South Africa, and Uganda. Soc Sci Med. 2014;118:33–42. doi: 10.1016/j.socscimed.2014.07.057. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Simkhada B, Sharma G, Pradhan S, Van Teijlingen E, Ireland J, Simkhada P, et al. Needs assessment of mental health training for Auxiliary Nurse Midwives: A cross-sectional survey. J Manmohan Memorial Inst Health Sci. 2016;2:20–6. [Google Scholar]
- 14.Makunde B. The efficacy of training midwives in early diagnosis and management of mental health issues in women: A systematic review. MIDIRS Midwifery Digest. 2018;28:147–53. [Google Scholar]
- 15.Carroll M, Downes C, Gill A, Monahan M, Nagle U, Madden D, et al. Knowledge, confidence, skills and practices among midwives in the republic of Ireland in relation to perinatal mental health care: The mind mothers study. Midwifery. 2018;64:29–37. doi: 10.1016/j.midw.2018.05.006. [DOI] [PubMed] [Google Scholar]
- 16.Rollans M, Schmied V, Kemp L, Meade T. Digging over that old ground: An Australian perspective of women's experience of psychosocial assessment and depression screening in pregnancy and following birth. BMC Womens Health. 2013;13:18. doi: 10.1186/1472-6874-13-18. doi:10.1186/1472-6874-13-18. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Higgins A, Downes C, Monahan M, Gill A, Lamb SA, Carroll M. Barriers to midwives and nurses addressing mental health issues with women during the perinatal period: The Mind Mothers study. J Clin Nurs. 2018;27:1872–83. doi: 10.1111/jocn.14252. [DOI] [PubMed] [Google Scholar]
- 18.Jones CJ, Creedy DK, Gamble JA. Australian midwives'knowledge of antenatal and postpartum depression: A national survey. J Midwifery Womens Health. 2011;56:353–61. doi: 10.1111/j.1542-2011.2011.00039.x. [DOI] [PubMed] [Google Scholar]
- 19.Hauck YL, Kelly G, Dragovic M, Butt J, Whittaker P, Badcock JC. Australian midwives knowledge, attitude and perceived learning needs around perinatal mental health. Midwifery. 2015;31:247–55. doi: 10.1016/j.midw.2014.09.002. [DOI] [PubMed] [Google Scholar]
- 20.Lau R, McCauley K, Moss C, Miles M, Cross W. Evaluation of an advanced perinatal mental health program for midwives. Aust Nurs Midwifery J. 2015;22:44. [PubMed] [Google Scholar]
- 21.Morrell CJ, Slade P, Warner R, Paley G, Dixon S, Walters SJ, et al. Clinical effectiveness of health visitor training in psychologically informed approaches for depression in postnatal women: Pragmatic cluster randomised trial in primary care. BMJ (Clinical research ed) 2009;338:a3045. doi: 10.1136/bmj.a3045. doi:10.1136/bmj.a3045. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Jones C, Jomeen J, Glover L, Gardiner D, Garg D, Marshall C. Exploring changes in health visitors'knowledge, confidence and decision making for women with perinatal mental health difficulties following a brief training package. Eur J Pers Centred Healthc. 2015;3:384–91. [Google Scholar]
- 23.Higgins A, Carroll M, Sharek D. It opened my mind: Student midwives'views of a motherhood and mental health module. MIDIRS Midwifery Dig. 2012;2:287–92. [Google Scholar]
- 24.Higgins A, Carroll M, Sharek D. Impact of perinatal mental health education on student midwives'knowledge, skills and attitudes: A pre/post evaluation of a module of study. Nurse Educ Today. 2016;36:364–9. doi: 10.1016/j.nedt.2015.09.007. [DOI] [PubMed] [Google Scholar]
- 25.McLachlan HL, Forster DA, Collins R, Gunn J, Hegarty K. Identifying and supporting women with psychosocial issues during the postnatal period: Evaluating an educational intervention for midwives using a before-and-after survey. Midwifery. 2011;27:723–30. doi: 10.1016/j.midw.2010.01.008. [DOI] [PubMed] [Google Scholar]
- 26.Reed M, Fenwick J, Hauck Y, Gamble J, Creedy DK. Australian midwives'experience of delivering a counselling intervention for women reporting a traumatic birth. Midwifery. 2014;30:269–75. doi: 10.1016/j.midw.2013.07.009. [DOI] [PubMed] [Google Scholar]
- 27.Bagadia A, Chandra PS. Starting the conversation-Integrating mental health into maternal health care in India. Indian J Med Res. 2017;145:267–9. doi: 10.4103/ijmr.IJMR_910_16. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Jardri R, Maron M, Pelta J, Thomas P, Codaccioni X, Goudemand M, et al. Impact of midwives'training on postnatal depression screening in the first week post delivery: A quality improvement report. Midwifery. 2010;26:622–9. doi: 10.1016/j.midw.2008.12.006. [DOI] [PubMed] [Google Scholar]
- 29.McGookin A, Furber C, Smith DM. Student midwives'awareness, knowledge, and experiences of antenatal anxiety within clinical practice. J Reprod Infant Psychol. 2017;35:380–93. doi: 10.1080/02646838.2017.1337270. [DOI] [PubMed] [Google Scholar]
- 30.Noonan M, Doody O, Jomeen J, Galvin R. Midwives'perceptions and experiences of caring for women who experience perinatal mental health problems: An integrative review. Midwifery. 2017;45:56–71. doi: 10.1016/j.midw.2016.12.010. [DOI] [PubMed] [Google Scholar]
- 31.Jardri R, Maron M, Pelta J, Thomas P, Codaccioni X, Goudemand M, et al. Impact of midwives'training on postnatal depression screening in the first week post delivery: A quality improvement report. Midwifery. 2010;26:622–9. doi: 10.1016/j.midw.2008.12.006. [DOI] [PubMed] [Google Scholar]
- 32.Kawoos Y, Maqbool M, Amin R, Wani Z, Farooq Z, Margoob MA. Maternal mental health and its determinants during COVID-19, experience from Kashmir, Northern India. J Family Med Prim Care. 2022;11:2870–6. doi: 10.4103/jfmpc.jfmpc_797_21. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Berthelot N, Lemieux R, Garon-Bissonnette J, Drouin-Maziade C, Martel É, Maziade M. Uptrend in distress and psychiatric symptomatology in pregnant women during the coronavirus disease 2019 pandemic. Acta Obstet Gynecol Scand. 2020;99:848–55. doi: 10.1111/aogs.13925. [DOI] [PubMed] [Google Scholar]
- 34.Tikka SK, Parial S, Pattojoshi A, Bagadia A, Prakash C, Lahiri D, et al. Anxiety among pregnant women during the COVID-19 pandemic in India - A multicentric study. Asian J Psychiatr. 2021;66:102880. doi: 10.1016/j.ajp.2021.102880. doi:10.1016/j.ajp. 2021.102880. [DOI] [PMC free article] [PubMed] [Google Scholar]