Abstract
Integrating mental health care into well-attended health services, such as maternal-child health (MCH), offers a promising approach to increasing access to mental health care. To inform integration, we assessed the current approach to screening and treatment of perinatal mood and anxiety disorders (PMAD) in MCH facilities in Western Kenya. We conducted a cross-sectional survey among the facility managers (“in-charges”) at 20 MCH facilities in Western Kenya. Trained data collectors administered questionnaires to assess facility infrastructure and human resources, perinatal mental health screening, psychological interventions, psychiatric medication availability, and level of perinatal mental health integration into standard MCH services. Across 20 MCH facilities, the majority were located in rural areas (16,80%), 2 peri-urban (10%), and 2 urban (10%). Facilities had a median of 37.5 medical staff (IQR: 31.0, 45.5); the most common cadre was nurses (median: 9.0, IQR: 6.0, 12.5). Under half of the facilities (8, 40%) screened for PMAD using a validated tool and documented results; most (19, 95%) reported diagnosing PMAD (not necessarily through a systematic approach), yet only half (10, 53%) documented the diagnosis. The most common psychotherapy reported across the sites was supportive counseling (15, 75%). Some facilities offered evidence-based psychotherapies (e.g., cognitive behavioral therapy, problem-solving therapy, etc.), but did not report on training, supervision or guidance from the evidence-based intervention manual. Across all facilities, the availability of mental health medications was limited. Only (12, 60%) had any antidepressant available, (16, 80%) had antiepileptics, (9, 45%) had antipsychotics, and (2, 10%) had mood stabilizers available. Mental health services in MCH clinics in Western Kenya are currently not offered in a structured and systematic manner to effectively alleviate PMAD. Available infrastructure and human resources offer an opportunity to integrate an evidence-based treatment model to improve perinatal mental health in the MCH clinics in Western Kenya.
1. Introduction
Perinatal mood and anxiety disorders (PMAD) are among the most common complications that occur during pregnancy or in the first year after delivery [1]. PMAD is a public health problem, particularly in low- and middle-income countries (LMIC) [2]. Women in LMICs have an elevated risk of PMAD compared to those in higher-income settings [3,4], with women living with HIV (WLWH) being at a greater risk of experiencing PMADs during the perinatal period compared to women without HIV [5]. Recent systematic reviews found that 1 in 4 perinatal women in LMICs experience depression, and 1 in 5 experience anxiety, compared to 10–15% and 7–15% prevalence, respectively, in high-income countries [6,7]. A large prospective analysis in Kenya reported high prevalence (33%) of moderate-to-severe depressive symptoms among perinatal Kenyan women in public sector maternal-child health (MCH) care.
Disproportionately high PMAD in LMICs may be associated with exposure to stressors and risk factors like a higher likelihood of socio-economic deprivation, more severe and more chronic poverty, higher co-morbidity with chronic medical conditions, sociocultural factors such as gender inequity, and poorer levels of education among women, and persisting stigma around mental health disorders [8–10].
Further, mental illnesses during the perinatal period are underestimated, underassessed, and underdiagnosed. Consequently, perinatal mental health conditions are often untreated [11–13]. Perinatal mental disorders are highly treatable when identified early yet remain leading contributors to pregnancy and postpartum-related morbidity and mortality [14]. Untreated PMAD causes significant disability among perinatal women [1,10,15], and are associated with adverse outcomes such as preterm birth, low birth weight, insecure infant attachment, and later childhood mental health and behavioral problems [16]
Maternal child health services are well-attended in Kenya (>90%) [17], offering an opportunity to provide mental health services integrated into routinely attended health visits throughout pregnancy and postpartum. MCH in Kenya involves comprehensive health care services for pregnant women, mothers, and children from birth to 52 months post-delivery, sometimes including prenatal care. The scope of MCH facilities is broad, often integrating preventive, educational, and community-based services for both mothers and children. Mental health is increasingly recognized as part of MCH care in Kenya, though integration of mental health services into MCH has not been consistently implemented [18]. Integrating mental health services into commonly attended public healthcare represents a particularly relevant health system strengthening strategy in LMICs [1,19]. Stepped care approaches to addressing PMAD offer a feasible approach to integration in settings with limited resources for mental health overstretched health systems, such as in parts of sub-Saharan Africa [20]. Maternal child health services offer an appropriate platform for ensuring equitable, accessible, and holistic mental health services are offered to pregnant and postpartum mothers [20,21]. To expand access to perinatal mental health, the Kenya Mental Health Action Plan 2021–2025 advocates for integrating mental health care into well-attended health services such as MCH (Health, 2015).
Effective service integration requires a comprehensive understanding of the healthcare infrastructure, providers, standard procedures, and resources currently available. However, limited information is available to guide effective perinatal mental health service integration in Kenya. To address this gap, we assessed the current approach to perinatal mental health screening and treatment in maternal and child health clinics in Western Kenya and identified opportunities for leveraging current infrastructure to expand perinatal mental health services.
2. Methods
2.1 Study design, population, and setting
We conducted a cross-sectional survey among the facility managers (“in-charge”) at 20 MCH facilities in Homabay, Kisumu, and Siaya counties of Western Kenya from January 30, 2024 to April 17, 2024. The Nyanza region of Western Kenya consistently reports the highest HIV prevalence in Kenya. In 2019, Homa Bay County reported the highest prevalence at 19.6%, followed by Kisumu County at 17.5% and Siaya County at 15.3% respectively [22]. Overall, 47 facilities were evaluated for potential inclusion in the IPMH study, 20 health facilities were selected based on antenatal care (ANC) clinic attendance volume (≥30 new ANC clients per month). Selected facilities included a range of characteristics such as rural/urban location, mental healthcare model, and facility level 3 (primary care and first referral point) and level 4 (first level referral hospital). “Level” is a marker of health service provision hierarchy as stipulated in the Kenya Essential Package for Health (KEPH).
Facilities that had active research studies evaluating perinatal mental health interventions and level 5 (secondary referral hospitals, providing more specialized services) facilities with mental health specialists were excluded. All facility managers in the 20 health facilities who were approached to participate in the cross-sectional survey gave oral consent and responded to the facility checklist questionnaire. The consent process was documented in the researcher’s field notes, including the date, and confirmation that all required information was provided and understood, and that verbal consent was given.
2.2 Procedures
Trained data collectors administered tablet-based questionnaires to facility managers at each of the 20 MCH facilities. To evaluate the availability of specific perinatal mental health services, we used the WHO Special Initiative for Mental Health Facility Checklist (WHO/UCN/MSD/ODM/2023.01 2023), which our study team adapted for the Western Kenyan context to use language and terminology that was contextually aligned. Items in this checklist identify whether specific services (e.g., screening for mental health symptoms using a validated scale, documentation of mental health diagnostic results in medical records, prescription of psychiatric medication, etc.) are offered in a facility (yes/no). The questionnaire also evaluated which cadres of healthcare workers (e.g., obstetricians, social workers, etc.) provide each service. In the Kenyan context, the role of “medical officer” describes a provider who has completed undergraduate medical school and has not yet completed specialist training. The role of “clinical officer” describes a licensed provider with generalist clinical training.
We explored psychiatric medication availability within the facility, asking facility managers endorse the top three psychopharmaceuticals most frequently prescribed in each category within the survey (antipsychotics, antidepressants, anxiolytics, mood stabilizers, antiepileptics). Study nurses evaluated the availability of each drug specified on the day of data collection as “available today and not expired”, “available but expired”, “reported available but not seen”, or “not available today”.
Information about psychological treatments available at the facilities was elicited by listing types of interventions (e.g., problem-solving therapy, Problem Management Plus (PM+), cognitive behavioral therapy, etc.) and asking facility managers to indicate whether these are offered, by which cadres, and whether the target patient population includes perinatal women. If facility managers endorsed that a psychological therapy type was available, data collectors asked whether it was guided by a published manual (Yes/No), whether the published manual was reported available (Yes/No), and whether the data collectors observed the presence of the manual in the facility (Yes/No).
In Kenya, women living with HIV receive prevention of maternal to child transmission (PMTCT) services integrated into MCH care in accordance with the national guidelines, which leads to differentiation in MCH care between women living with HIV and those not living with HIV. To understand how perinatal mental health services may differ between perinatal women living with HIV versus those without HIV, we asked whether differences existed (yes/no).
Data collectors guided facility managers in determining the “Level” of integration in that facility for perinatal mental health services within routine MCH services using the “Substance Abuse and Mental Health Services Administration (SAMHSA) Framework for Integration” [23]. The levels were: 1. Minimal collaboration, 2. Basic collaboration at a distance, 3. Basic collaboration onsite, 4. Close collaboration in a partly integrated system, 5. Close collaboration in a fully integrated system.
2.3 Data analysis
We used descriptive statistics (counts and proportions for binary and categorical variables, medians and interquartile ranges for continuous variables) to summarize perinatal mental health services offered within facilities based on the aspects assessed in the facility checklist. We synthesized these data to describe current availability and gaps in perinatal mental health service provision, the similarities and differences in perinatal mental health care provided to HIV-negative women vs. women living with HIV, and to evaluate the integration level of mental health services in MCH/prevention of mother-to-child transmission of HIV (PMTCT) facilities. Statistical analyses were performed in Stata 18.0.
2.4 Ethical considerations
All the participants gave verbal consent to participate in the survey. Trained data collectors provided the participants with a standardized explanation of the study’s objectives, potential risks, and benefits. Participants had the opportunity to ask questions before participating in the study. Each instance of verbal consent was documented by the data collector in the study log and witnessed by the second member of the research team. This study was approved by the ethical review committees both at Kenyatta National Hospital/ University of Nairobi (ERC number P425/04/2023) and at the University of Washington (IRB number 00017933).
3. Results
3.1 Characteristics of maternal child health facilities assessed in Western Kenya
Characteristics of the 20 sampled facilities are presented in Table 1. The facilities included 16 rural facilities (80%), two peri-urban facilities (10%), and two urban facilities (10%). Half of the facilities were located in Siaya county (n = 10), followed by Homabay county (n = 6, 30%), and Kisumu County (n = 4, 20%). Over half of the facilities were sub-county hospitals (n = 12, 60%) and eight (40%) were health centers. Eight facilities (40%) reported a monthly antenatal care (ANC) new patient volume of between 30–40 patients, while six (30%) had between 51–60 new ANC clients per month, four (20%) had between 41–50, and two (10%) had between 61–70 new ANC patients per month.
Table 1. Characteristics of maternal child health facilities assessed in Western Kenya.
| Facility characteristics | N (%) or Median (Interquartile range) |
|---|---|
| County | |
| Homa Bay | 6 (30%) |
| Kisumu | 4 (20%) |
| Siaya | 10 (50%) |
| Location category | |
| Rural | 16 (80%) |
| Peri-urban | 2 (10%) |
| Urban | 2 (10%) |
| Health system level | |
| Level 3 | 8 (40%) |
| Level 4 | 12 (60%) |
| Monthly antenatal care new patient volume | 43.38 (35.25-51.63) |
3.2 Perinatal mental health care cascade in MCH facilities in Western Kenya
Fig 1 is a representation of perinatal mental health services offered in the MCH facilities. Out of the 20 sites assessed, eight (n = 8/20, 40%) reported screening for PMAD using a validated scale, of which all eight reported documenting PMAD screening results. In the 8 facilities that reported screening using validated scales, healthcare worker cadres conducting screening were most commonly nurses (n = 8/8, 100%), followed by clinical officers (n = 7/8, 88%). Nearly all facilities (n = 19/20, 95%) reported routinely conducting assessments for PMAD diagnosis (not necessarily through a systematic approach), among which only half (n = 10/19, 53%) reported documenting the diagnosis. Among the 19 facilities diagnosing mental health conditions, this task was primarily conducted by clinical officers (n = 17/19, 89%) followed by nurses (n = 13/19, 68%).
Fig 1. Perinatal mental health services offered in MCH facilities in Western Kenya (N = 20).
Overall, 18 (90%) facilities provided linkage to perinatal mental health services within the facility and 17 (85%) provided referral outside of the facility. Nurses were the cadre most frequently offering mental health referrals within the facility (n = 13/18, 72%), while referral outside the facility was mainly done by clinical officers (n = 15/17, 88%). Fifteen (75%) health facilities reported offering some form of psychological counseling (either evidence-based psychological interventions or general counseling), primarily by a medical officer (n = 11/15 73%) or clinical officer (n = 11/15, 73%), and 9 (45%) facilities reported offering group therapy, most commonly by medical officers (n = 7/9, 78%). Overall, a little over half (11, 55%) of facilities reported prescribing psychiatric medications, and three (15%) were visited monthly by a psychiatrist typically based outside of the facility. Clinical officers were the leading cadre prescribing psychiatric medication (n = 9/11, 82%) and the only cadre facilitating psychiatric appointments (n = 3/3, 100%) for perinatal patients with PMAD. Among facilities referring women to internal mental health services, only 44% of facilities (8/18) reported documenting perinatal mental health treatment in clinical records. Fourteen facilities (70%) reported having procedures to monitor PMAD patients over time, which was primarily conducted by clinical officers (n = 9/14, 64%), followed by nurses (n = 5/15, 36%). Across the perinatal mental health care cascade, five facilities consistently reported offering services differently among WLHIV compared to other perinatal women. These facilities differentiated care based on HIV status for perinatal mental health screening, documentation of screening and diagnosis results, provision of individual and group psychotherapy, and prescription of psychiatric medication and documentation.
3.3 Psychological intervention provision
We further explored whether evidence-based psychological therapies such as cognitive behavioral therapy (CBT), problem management plus (PM+), or interpersonal psychotherapy (IPT) were provided within MCH facilities. A high proportion of facilities initially reported providing psychological interventions (range across evidence-based psychological therapies listed in survey: 40–70%). However, in response to follow-up questions seeking more information about manuals used, none of the facilities qualified as using manualized evidence-based therapies. Therefore, none of the sites (0%) delivered evidence-based psychological interventions. Non-manualized counselling services were primarily delivered by nurses, mentor mothers (trained peers who are engaged within the healthcare system to support, educate, and empower pregnant women and new mothers living with HIV), or adherence counsellors (85% of the facilities). Less frequently, these services were delivered by psychiatrists, psychologists, or social workers (15% of the facilities).
3.4 Mental health medication available in MCH facilities in Western Kenya
Fig 2 represents the availability of unexpired mental health medication in the MCH facilities in Western Kenya. Most of the sites (n = 16/20, 80%) reported having at least one type of anxiolytic, most commonly diazepam (n = 15/20, 75%). Over half of the facilities (n = 13/20, 65%) offered antiepileptics, most commonly phenobarbitone (n = 11/20, 55%). Half of the facilities (n = 10/20, 50%) offered antidepressants, most commonly amitriptyline (n = 10/20, 50%), and half of the facilities offered carbamazepine (n = 10/20, 50%) as a mood stabilizer. Less than half of the facilities (n = 9/20, 45%) reported offering antipsychotic drugs, with chlorpromazine and olanzapine being the most commonly available (n = 4/20, 20% each). Overall, the majority (80% of facilities) only had first-generation medications available. Two facilities offered a second-generation antidepressant (fluoxetine) and four facilities offered a second-generation antipsychotic (olanzapine).
Fig 2. Mental health medication availability in MCH facilities in Western Kenya (N = 20).
3.5 Infrastructure to integrate a stepped care model for perinatal mental health services
In Table 2 we summarize the infrastructure available to support the integration of the IPMH stepped-care model for perinatal mental health services 3.5.1 Screening services
Table 2. Current status to integrate a stepped care model to deliver perinatal mental health services into MCH facilities in Western Kenya.
| Integration components | Western Kenya Overall N = 20 |
|---|---|
| N (%) or Median (Interquartile range) | |
| Screening services | |
| Screening for MH symptoms using a validated scale | 8 (40%) |
| Frequency of screening conduct | |
| Every patient encounter | 7 (88%) |
| First encounter with patient | 1 (13%) |
| No response/No screening | |
| Mental health disorders screened | |
| Depression | 8 (40%) |
| Anxiety | 3 (15%) |
| PTSD | 1 (1%) |
| Screening tools used | |
| Patient Health Questionnaire-2 | 1 (1%) |
| Patient Health Questionnaire-9 | 8 (40%) |
| Generalized Anxiety Disorder-7 | 3 (15%) |
| PTSD PCL | 1 (1%) |
| Facility infrastructure | |
| Total inpatient hospital beds | 20.0 (14.0, 29.0) |
| Maternity beds | 7.5 (5.5, 13.0) |
| Mental health/psychiatric beds | 1 (5.0%) |
| Perinatal mental health/psychiatric beds | 1 (100%) |
| Healthcare workforce | |
| Overall medical staff | 37.5 (31.0, 45.5) |
| Medical Officers | 0.0 (0.0, 0.0) |
| Psychiatrists | 0.0 (0.0, 0.0) |
| Obstetricians/gynecologists | 0.0 (0.0, 0.0) |
| Nurses | 9.0 (6.0, 12.5) |
| Psychologists | 0.0 (0.0, 0.0) |
| Mental health social workers | 0.0 (0.0, 0.0) |
| Clinical officers | 5.0 (3.0, 6.0) |
| HIV Testing Services counsellors | 3.0 (2.0, 3.0) |
| Community health workers | 17.0 (12.0, 23.5) |
| Mentor mothers | 2.0 (2.0, 3.0) |
| Psychiatric nurses | 0.0 (0.0, 0.0) |
| Counsellors (e.g., lay, behavioral) | 1.0 (1.0, 1.5) |
| Other mental health workers | 0.0 (0.0, 0.0) |
| Telemedicine infrastructure | |
| Functioning land-line phone available | 2 (10%) |
| Functioning cellular phone available | 18 (90%) |
| Functioning computer available | 18 (90%) |
| Internet access today | 15 (75%) |
| Electricity continuously available during facility working hours (past 7 days) | 17 (85%) |
| Facility working hours per day | 20 (100%) |
| Water source available in facility premises | 20 (100%) |
| Patient consultation room with auditory/visual privacy available | 20 (100%) |
| Medical records system | |
| Paper-based | 20 (100%) |
| Electronic | 19 (95%) |
| Other | 0 (0%) |
| Mental Health Integration level | |
| Level 1 | 6 (30%) |
| Level 2 | 8 (40%) |
| Level 3 | 6 (30%) |
| Level 4 | 0 (0%) |
| Level 5 | 0 (0%) |
Among the eight facilities offering screening services using a validated scale, most reported performing screening at every patient encounter (n = 7/8, 88%) while one facility reported screening at the first patient encounter only (n = 1/8, 13%). Under half of the facilities offered screening for depression, using the patient health questionnaire-9 (PHQ-9) scale (n = 8/20, 40%). Under a quarter offered screening for anxiety, using the generalized anxiety disorder-7 (GAD-7) scale (n = 3/20, 15%). One facility (5%) offered screening for post-traumatic stress disorder (PTSD), using the PTSD PCL-5.
3.5.1 Physical and telemedicine infrastructure.
Facilities reported a median of 20.0 inpatient beds (interquartile range [IQR]: 14.0-29.0) with a median of 7.5 beds designated for maternity patients (IQR: 5.5-13.0). Only one facility (5%) reported having a dedicated bed for mental health, and one facility (5%) reported a bed dedicated to perinatal mental health. Most facilities (n = 19/20, 95%) used electronic medical record systems, and all facilities also utilized paper-based medical records (n = 20/20, 100%).
All 20 (100%) facilities had a patient consultation room available with audio-visual privacy which could be utilized to facilitate telemedicine visits for perinatal mental health. The majority of facilities (n = 18/20, 90%) had a facility-owned cellular phone available, 2 (10%) had a landline telephone, 18 (90%) had a computer available, and 15 (75%) reported having internet available on the day of the survey. Most facilities (n = 17/20, 85%) reported continuous electricity during facility working hours in the prior 7 days; all 20 facilities (100%) reported water sources available on the facility premises.
3.5.2 Healthcare workforce.
The overall medical staff across the 20 facilities surveyed had a mean of 45 medical staff members (standard deviation [sd]: 19.8). Community health workers were the most common cadre with an average of about 20 community health workers per facility (mean: 19.8, sd: 10.8). Facilities had an average of 10 nurses (mean: 10.1, sd: 5.6), five clinical officers (mean: 5.1, sd: 3.0), three HIV testing services counselors (mean: 3.1, sd:1.9), and two mentor mothers (mean: 2.3, sd:1.0).
3.6 Mental health integration level in MCH facilities in Western Kenya
Using the SAMHSA Framework for Integration, we worked with facility managers to identify the level of mental health integration in MCH facilities. Approximately a third of facilities (n = 6/20, 30%) reported minimal collaboration across separate facilities with rare communication, making them “Level 1” for integration. Nearly half (n = 8/20, 40%) reported engaging in basic collaboration to provide mental health care at a distance across separate facilities with periodic collaboration (Level 2). The remaining six facilities reported basic collaboration on site within the same facility across separate systems with regular communication (Level 3). None of the facility managers felt their facility fit into levels 4 or 5 for integration of mental health services within MCH services, characterized by close collaboration within the same space and system.
4. Discussion
In this descriptive evaluation of mental health services within MCH clinics in Western Kenya, we observed that screening and referral to mental health services are currently not offered in a structured and systematic manner, which presents a serious challenge to effectively alleviating perinatal mood and anxiety disorders. However, MCH settings have existing infrastructure, resources, and personnel that offer opportunities to support integration of perinatal mental health care into these routinely attended clinics. Our findings extend the literature about the current state of perinatal mental health services in the African region and inform efforts to expand access, including our team’s “Integrated Perinatal Mental Health Program (IPMH)”. IPMH will evaluate an evidence-based treatment model to improve perinatal mental health integrated into MCH clinics in Western Kenya.
We observed that screening for PMAD using a validated scale, and documenting results was uncommon across facilities in Western Kenya. This is consistent with findings from a study on Stepped Care for Maternal Mental Health in South Africa that revealed a lack of routine screening or treatment of maternal mental disorders in primary care settings [12]. Integrating mental health screening into routine antenatal procedures in low-resource settings, where common mental disorders are often overlooked, has been found to have the potential to narrow treatment gap significantly [19–21]. There is evidence that screening alone can have some benefits by raising awareness of one’s depressive or anxiety symptoms, although initiation of treatment or referral to mental health care providers offers the maximum benefit [12,24]. In Kenya, women living with HIV receive PMTCT services integrated into MCH carein accordance with the national guidelines. Vertical HIV funding can lead to separation and differences in MCH care that may be unrelated to treating HIV. Our study assessed whether there was a difference in access to mental health screening and treatment among women living with HIV and women not living with HIV. Our evaluation identified that women living with HIV were more likely to receive PMAD screening as compared to their HIV negative counterparts in Western Kenya. Further, depression was a commonly screened mental health disorder. However, low screening rates overall observed in our survey confirm a need to implement interventions that will increase access to PMAD screening for early detection. Studies have shown that early detection of PMAD symptoms through routine screening of depression and anxiety in the obstetrics setting is key to alleviating the significant consequences of PMAD symptoms [15,21],
Despite gaps in validated PMAD screening, facility managers at most of the sites reported that mental health diagnoses occurred in that site. Our survey did not require facility managers to describe their procedures for mental health diagnosis; thus, we cannot discern whether PMAD diagnoses are conducted using a standardized clinical interview or less systematic provider judgment. Further, there was a gap in documenting and following up on diagnoses. Only three sites made psychiatric appointments, and less than half of the facilities documented treatment for perinatal mental health concerns. These findings echo results from a study in South Africa, which observed that despite high levels of antenatal and postnatal depression, there was no treatment for maternal mental disorders in primary care settings [12]. There is strong evidence from multiple studies that psychological and psychosocial interventions for perinatal depression are effective and cost-effective [25,26]. None of the sites surveyed in the present evaluation offered evidence-based psychological interventions according to the training, supervision, or guidance from published intervention manuals. However, some form of supportive talk therapy is available at a majority of MCH facilities surveyed; these talk therapies and supportive counseling approaches do not appear to be standardized, and their effectiveness has not been evaluated. There is reasonable evidence for the benefit of psychological interventions in perinatal depression and anxiety in LMICs [13]. A systematic Review of Interventions That Integrate Perinatal Mental Health Care into Routine Maternal Care in Low- and Middle-Income Countries support our finding that evidence-based psychological interventions for perinatal mental health are largely unavailable [27]
Among the facilities reporting use of psychotropic medication, the majority only had first-generation treatment available (e.g., chlorpromazine, amitriptyline), which may not be well-suited for perinatal women. Only two facilities reported offering a second-generation antidepressant, and 4 facilities reported a second-generation antipsychotic that may be more appropriate for this vulnerable population. These findings parallel those of a study that indicated limited availability of essential mental health medicines in LMICs [28]. Appropriate mental health medication for perinatal women, such as sertraline, is lacking within MCH facilities, potentially highlighting a gap in knowledge of and access to newer medications. Integration of evidence-based psychological therapies and expanded access to psychiatric medications in MCH settings would dramatically improve access to perinatal mental health support. As policy makers become more aware of the need for identification and treatment of PMAD, it is also important to highlight the urgent need to increase access to evidence based treatments in these settings.
Our study explored availability of infrastructure, resources, and personnel necessary to integrate a stepped care model for perinatal mental health services into MCH settings of Western Kenya, we observed that only one facility had a dedicated bed for perinatal mental health. Further, most health facilities lacked specialized mental health professionals. A systematic review of interventions for perinatal depression in low and middle-income countries similarly observed the sparse specialized human resources for mental health, with insufficient numbers of psychiatrists, psychologists, social workers, and mental health nurses available to meet the demand [13,29]. Despite the few mental health specialists, the study observed that there were adequate healthcare providers across the sites in other cadres, primarily nurses, whose skillsets could be leveraged to support mental health service integration and delivery. Task shifting is an evidence-based approach to strengthening and expanding the health workforce whereby responsibilities are shifted from specialized health workers to health worker or peer provider cadres with lower training and/or fewer qualifications (WHO, 2008). In the context of mental health screening and treatment, task shifting represents a shift from mental health professionals to healthcare workers who lack formalized training in mental health [20,29,30]. [31,32]Additionally, studies have shown that technology-based approaches like telephone-delivered and computer-delivered interventions can help scale mental healthcare and support [33,34]. Our study indicated that most facilities had a cellular phone available that could be used for telepsychiatry, as well as internet access, a computer, continuous electricity, and a private patient consultation room.
In terms of mental health integration level, most of the sites reported minimal collaboration to engage in basic collaboration to provide mental health care at a distance. Sites with higher existing levels of integration only showed evidence of basic onsite collaboration between MCH and mental health services. Currently, none of the facilities surveyed demonstrate close collaboration between MCH and mental health or full-service integration. Globally, evidence indicates that a multilevel, integrated approach to addressing maternal mental health problems is required [27,35]. Integrating mental health care in maternal and child health programs is an obvious next step toward ensuring equitable, accessible, and holistic mental health services are offered to pregnant and postpartum mothers [27].
4.1 Limitations
Our evaluation had several limitations. We collected data from a single facility manager at each of the surveyed facilities. The views of the facilities managers alone may not have been comprehensively reflective of the situation of perinatal mental health service delivery in the clinics. Survey responses were self-reported by facility managers, thus responses may be biased by recall or social desirability bias. Facility managers were not required to describe their procedures for mental health diagnosis, thus we cannot discern whether PMAD diagnoses were conducted using a standardized clinical interview or less systematic provider judgement. However, a strength of the study was the addition of a survey item to collect a binary indicator of physical verification of psychological intervention manuals and training materials when there were uncertainties about the accuracy of reported evidence-based interventions. Our study surveyed facility managers at a single time point, thus we were not able to report changes in mental health service provision over time.
5. Conclusions
Findings from our evaluation of perinatal mental health services within maternal child health settings in Western Kenya highlight the need to expand mental health screening, documentation of mental health diagnoses, availability of psychiatric medication, and evidence-based psychological interventions. Results from this cross-sectional survey indicate that,aternal child health settings within Western Kenya currently have human resources and infrastructure available to support integration of a stepped care model for perinatal mental health services. Our results highlight areas to address toward achieving the Kenya Mental Health Action Plan 2021–2025, which advocates for expanding access to mental health services via existing and well-attended maternal child health and HIV care programs. Future initiatives to support perinatal mental health in Kenya should leverage the existing infrastructure and resources within these care settings while systematically expanding screening, diagnosis, and treatment approaches to improve perinatal mental health.
Data Availability
Data are available through Harvard Dataverse through the following link: https://doi.org/10.7910/DVN/WN1B8I.
Funding Statement
The authors have no financial conflicts of interest to declare. This study was funded through National Institutes of Mental Health (R01MH133266 to JK). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data are available through Harvard Dataverse through the following link: https://doi.org/10.7910/DVN/WN1B8I.