In South Africa there are many risk factors which may contribute to maternal mental illness, especially among women living in poverty.
To determine if a woman may be suffering from a mental illness during the perinatal period, it helps to assess her risk profile. A woman’s risk profile is an assessment of all the factors which may make her more vulnerable to mental illness.
Psychosocial and physical factors are considered in assessing a risk profile. Psychosocial risk factors refer to the social conditions which could influence a woman’s psychological well-being, such as poverty or violence. Physical risk factors include disease, illness or any biological factors which may predispose a woman to mental illness. Sometimes risk factors overlap, creating overwhelming circumstances for women. Key risk factors are outlined below.
25% of PMHP clients present with 3 or more risk factors, which puts them at risk for developing psychological distress during and after pregnancy.
Poverty and mental illness interact in a negative cycle that places people living in poverty at greater risk of developing mental disorders, while people living with mental disorders are at greater risk of sliding into poverty. Poverty and female gender have been statistically associated with depression and anxiety in developed countries. In low and middle-income countries, women consistently present with higher rates of anxiety and depression.
Poverty can impact on women in the following ways:
- loss of employment
- social drift
- housing problems
- social exclusion
- food insecurity
- reduced access to social capital/safety net
- obstetric risks
- violence and trauma
Adolescence is a significant risk factor for mental illness, with mental illness being associated with high rates of maternal mortality in this age group, often due to suicide. In developed countries, 26% of teen mothers develop postnatal depression. Research suggests that the rate could be twice as high in South Africa. Cognitive developmental changes and trauma are often complicating factors in adolescent mental illness requiring special mental health care. Pregnancy during adolescence can
- increase risk of maternal mortality due to suicide
- result in loss of support from family and friends
- increase likelihood of leaving school early
- increase high-risk sexual behaviour.
In addition, depressed teenage mothers are more likely to become pregnant again within 12 – 24 months of their first pregnancy, than non-depressed teen mothers. Read the PMHP brief on adolescent pregnancy.
- Nearly half of all people living with HIV/AIDS in South Africa have a diagnosable mental illness. This is significantly higher than the national prevalence of 30.3% for any mental health disorder (Freeman et al, 2008; Herman et al, 2009).
- HIV infection may predispose patients to mental distress and vice versa (Ciesla & Roberts, 2001).
- HIV-positive pregnant women are more likely to have poorer mental health than pregnant women who are HIV-negative (Bernatsky et al, 2007).
- Mental illness impacts negatively on AIDS treatment and uptake of antenatal care while being a significant factor in AIDS-related mortality among women (Stein & Rochat, 2006).
- HIV is a proven risk factor for both violence against women and mental distress, while mental distress is a risk factor for HIV infection and often a consequence of violence.
Read the PMHP brief on HIV and mental illness.
Gender and violence
- South Africa has an extraordinarily high level of violence, where women experience violence socially, in interpersonal settings such as domestic abuse, and increasingly, from health workers in an over-burdened health system.
- Violence is a significant factor in burden of disease. Women are disproportionately affected by violence.
- A large 2009 study by Jewkes found that 28% of men between 18 and 49 have perpetrated rape, almost half of whom report having done so more than once. Almost half of all men in the study report being physically violent with an intimate partner.
- This concurs with Dunkle’s 2003 Soweto study, where 56% of pregnant women were found to have experienced violence from an intimate partner. A 2003 study in Durban found 34% of pregnant women had experienced partner abuse during their pregnancy (Mbokota, 2003). Violence in personal relationships is likely to increase as the pregnancy progresses.
- Of women who have accessed PMHP counselling services, 69% experienced previous or current abuse. Experiences of rape or physical, sexual or emotional abuse are important indicators of possible risk for mental illness.
Gender-based violence increases during pregnancy, with the severity increasing as the pregnancy progresses. This contributes to the high prevalence of unwanted pregnancy, pregnancy complications and miscarriages. Mental health consequences include substance misuse, post-traumatic stress disorder, depression, and suicidality. PMHP data shows that women who experience domestic violence are at a 24 times greater risk of needing a mental health intervention.
Read the PMHP brief on abuse and mental illness.
- 40% of women counselled at the primary PMHP site are refugees.
- Women who are displaced due to conflict or economic reasons experience complex, multiple traumas.
- They are particularly vulnerable to violence, the impacts of poverty and inferior health care.
- Violent conflict, loss of loved ones, torture, rape and dispossession are just some of the traumatic experiences which can significantly affect a woman’s mental health.
- Separation from families, partners or other familiar and supportive structures can cause considerable distress. Social isolation or exclusion, discrimination and xenophobia in the countries in which they find themselves can further exacerbate existing traumas and mental anguish.
- Refugee women are therefore at increased risk of mental illness and require additional mental health support, including the need for multilingual or translation services.
Read the PMHP brief on refugee and maternal mental illness.
Mental illness is linked with substance abuse, while substance abuse contributes to onset of mental illness. A study at one Cape Town hospital found that 10% of pregnant women were using ‘tik’ (methamphetamine). Alcohol, crack/cocaine, heroin and methamphetamine are the most abused substances in South Africa, with alcohol abuse being the most significant problem. The South African Community Epidemiology Network on Drug Use (SACENDU) indicates that substance abuse is on the increase in South Africa. More people are seeking treatment and mortality rates linked to substance misuse are soaring.
A recent study of pregnant women treated at one Cape Town hospital showed a strong association between depression and substance abuse, 33% (109 women) of the sample group indicated they were depressed, 6% (20) of the 332 women studied admitted to using alcohol while pregnant, and 85% of these (17) were alcohol dependent. (MRC, 2010)
Physical risk factors
Physical factors which could contribute to a woman’s risk for mental illness include:
- thyroid disease
- chronic infection
- high-risk pregnancy
- medical complications
- substance abuse
- an infant with medical problems.
Other factors to consider
The following questions could be useful in determining a woman’s risk for mental illness.
- Does the woman have difficult or absent relationships, either with her mother, wider family or community?
- Is the pregnancy unwanted or unplanned?
- Does the woman have a history of mental illness?
- Does the woman have certain personality traits which could predispose her to mental distress, for example, perfectionism which could contribute to the onset of anxiety?
Take particular note of
- postnatal depression after a previous pregnancy – there is a 10-35% chance of postnatal depression occurring again
- Bipolar Disorder (also known as ‘manic depression’) – this condition can increase a woman’s chance of postnatal psychosis by 25%
- anxiety or depression during a previous pregnancy has high chance of occurring again.
Could she have experienced traumas which have not been resolved, for example, traumas related to
- pregnancy or childbirth (miscarriage, termination of pregnancy, death of a baby, previous difficult pregnancy and delivery)
- crime, violence, war or torture (especially among refugee women)
- interpersonal or conflictual relationships.
Has the woman recently experienced a major life event, such as
- loss of employment
- death of a loved one
- moving home.
Most prevalent presenting problems among PMHP clients:
Lack of primary support (from partner or family)
Problems in the social environment (e.g. violence, housing problems, financial issues)
Life cycle transition (e.g. teen pregnancy and unplanned pregnancy)
Approximate of PMHP clients having more than 1 presenting problem