Bianca was not only dealing with a pregnancy that was not planned; she had also been diagnosed HIV positive at her first antenatal clinic visit. She was in shock and did not know what to think. The problems felt insurmountable. Her boyfriend had just lost his job and had started going out drinking with his friends. She was upset at being left alone, and this caused fights between them, which had become verbally and physically abusive. Having no income, they had to move in with her mother, but the situation was uncomfortable and made her mother very stressed.
At the antenatal clinic, she was offered a mental health screening and was referred to the PMHP counsellor. In the first session she poured out her problems, and the counsellor listened attentively. Together they agreed that Bianca, and her baby’s safety was a priority, together with getting information and helping her adjust to her HIV diagnosis. They also thought about ways to tackle the conflictual relationship with her boyfriend and avoid violent encounters. Over the next few months, before Bianca’s baby was born, the help she received in the counselling relationship enabled her to approach her boyfriend differently, and their relationship became calmer.
Bianca’s conflict avoidance skills were affirmed by the counsellor and this helped to build her confidence. Since her mother was also less stressed, Bianca was able to disclose her HIV status to her, talk to her about her treatment, her worry about infecting the baby and about feeding options, and her mother provided reassuring support. Bianca’s baby was born healthy and HIV negative. Despite ongoing challenges in her life, she was able to bond with her baby as her relationships were more supportive, and she had healthy ways to approach her problems. She saw the counsellor a few times after her baby was born, until she felt confident in her adjustment to motherhood. She knew she could go back to the counsellor if she felt she was not managing.
My name is Aziza and I have just given birth to my second child. My first pregnancy was very tough as we were struggling financially and I felt unwell – I started spending days in bed, and neglected the housework. Jacob got a casual job just before I went into labour, and he could not come with me to the hospital. The nurses were impatient and angry at me because I had missed a few clinic visits. I was alone and felt scared. I felt weak and ashamed, and like a bad mother.
For the first few months of my baby’s life, I continued to feel tired, unhappy and unmotivated. Jacob didn’t understand what was happening, and our relationship went through a bad patch.
In my second pregnancy, the nurses were so gentle and they referred me to the PMHP counsellor at the clinic, who was able to settle my nerves and reassure me that many women feel anxious in pregnancy. The counsellor told me about depression and anxiety, describing some of the exact feelings I had experienced. I felt supported and understood. The counsellor helped me think about how I could talk to Jacob about what I was feeling, and our relationship really improved. It helped him to know that I was not being lazy or difficult. I felt more open after speaking with the counsellor, and I made a friend with another mother at the clinic.
The counsellor called when my baby was eight weeks old. She checked up on how I was feeling, and how things were going with my baby. I felt I was managing even though looking after two children is very challenging. She reminded me that if something changed, and I did not feel okay, I could come back to talk to her. It really helped knowing she was there.
When Sr. Matsha examined Johanna*, she noticed that Johanna was very quiet during the examination. Although everything was fine with the pregnancy, Sr. Matsha knew that something was wrong. Johanna had filled in a mental health screening questionnaire, which is routinely offered in this clinic. She had a high score. When Sr Matsha approached Johanna to offer a referral to the PMHP counsellor, Johanna started crying. When Sr Matsha asked what was wrong, Johanna said I can’t talk about it.
She did, however, want to see the counsellor. Sr Matsha arranged for Johanna to see the PMHP counsellor right away because she did not feel comfortable sending her home in such a state. Our counsellor saw Johanna immediately. Johanna had awoken that morning with a feeling of dread. Her partner had come home in a bad mood from work the night before. The atmosphere in the house was tense.
It was her appointment day at the antenatal clinic. But, before she could leave, she needed to prepare breakfast, get her 7-year-old ready for school, and arrange for her 3-year-old to stay with a neighbour. Her partner was not satisfied with the porridge she had made for him. He started yelling at her. She kept quiet and continued getting the children ready. After she had taken her younger child next door, he asked her if she had gossiped about him to the neighbour. She said no, and started walking out the house with her older child. He began hitting her on the arms and face, pushing her against the wall and calling her a liar. Her child ran away, crying.
While Johanna was telling her story to the counsellor, her partner walked into the office. He demanded to be included since he was the baby’s father. He also wanted to talk to the counsellor. The counsellor addressed the intrusion by saying that this meeting was for Johanna, but that the counsellor could talk to him afterwards. It was clear how unhappy he was to leave her alone with other people after what had happened that morning. He had not wanted to leave her side at the hospital. His behaviour had made the midwife very uncomfortable.
A number of sessions with the counsellor focussed on the ongoing cyclical nature of abuse in Johanna’s home. Eventually, Johanna felt empowered to leave her partner. She was assisted to take out a police protection order against him because he would not accept her decision and threatened to kill her if she left him. But, Johanna was able to cope with this situation. She ensured her family’s safety by arranging to stay with her cousin, who had experienced a similar situation and was supportive.
I was born, one of twins. My parents divorced when I was only two months old. Because my mother was alone she couldn’t do what she was supposed to do as a mother and I grew up with her family. There was really no one to talk to or to discipline us and I became pregnant at the age of 14. I have suffered depression since then.
Having a baby at such an early age was really hard. I had to leave school and was forced to work as a domestic worker, which I couldn’t really do because I was so young. I tried very hard, but I just couldn’t do it. So, I decided to go back to school when my baby was three years old. I passed my standard nine [penultimate year of high school], but didn’t have enough money to register for my final year. I was forced again to go back to work as a domestic worker; which I am still doing to this day.
When I was twenty-one years old, I got married to my husband. He is not the father of my first child. A couple years after being married, we had a child together. I again suffered very much from postnatal depression, although I did not know what it was called at the time. The clinic I went to in the township did not know anything about depression. So, I was unable to get help from them. Luckily, my husband was always there for me and supportive throughout my depression, even though he didn’t always understand what I was going through.
Since then, I suffered from depression until I was able to get help from the Perinatal Mental Health Project in 2004. This was the first time I heard about perinatal or postnatal depression. I had suffered from depression all these years, but I didn’t really know what it was. Finally, I was able to get help.When I was pregnant with my last baby, I was working for Linda, a psychologist. I was not at all happy to be pregnant. I was just very stressed and worried about telling her. I knew it was not the right time for me to become pregnant and I was very concerned about my job and all the things that I needed money for. But I realised that I needed to tell Linda, not only because she was my employer, but because I needed help. Everything was very hectic for me and nothing that I was experiencing seemed to be good. I knew that I was becoming more and more depressed.
I finally told Linda when I was 5 months pregnant. It turns out that she specialises in women who have perinatal and postnatal depression and when she heard my history she thought I was suffering from it. She decided to take the step to get help for me by sending me to the Mowbray Maternity Hospital which provides the Perinatal Mental Health Project.
At Mowbray, I met with a counsellor. It was very good to speak to her about how I was feeling and to just talk out about everything. That was what was killing me, having to keep all my feelings inside of me for a long time. I was so lonely and there were so many things that I needed someone to listen to. I needed to express my feelings and to be heard when I was saying something. I needed someone who could understand and who could listen when I was talking. Meeting with this counsellor gave me that chance to finally speak out, which helped so much. They also sent me to a psychiatrist to get medication for my depression. Now I am doing just fine and coping very well with motherhood. Dealing with perinatal and postnatal depression is a very difficult thing.
When you are depressed there are so many things that are affecting you. You may not be able to tell exactly what it is that is making you feel so bad, but just that you can’t get out from the fog you are in. Everything can feel like it is just falling apart, that nothing is happening right or according to plans. You may not know to take it seriously when you are first suffering from it, but it is very important to address it and to find a way out. There are so many women who are dying inside from this thing. They don’t know how to deal with it or how to cope. Everything in their lives is turning upside down. And they need someone who will understand and not judge them.
That is why I talk about this depression with everyone. I even talk to mothers I see on the bus. I want everyone to know about this problem. I want the mothers to listen. If I could have my way, each and every one of the hospitals would have these kinds of counsellors, especially the government hospitals which are for everybody. That way everyone, including women who really don’t know anything about this depression, could get help. Until that happens, I hope that all the mothers out there, who are suffering from perinatal and postnatal depression, will take care of themselves and find support. You only live once, and it does not have to be a life filled with depression!”
* Ntombombzi has given consent to tell her story and use her photo, pictured together with her daughter Liphiwe
My story begins in 2004, when I was told that I was pregnant with my first child. After extensive consideration, my husband and I decided that we would use the public healthcare facility, a Maternity Hospital, closest to our home, as private users. This facility happened to be the site of the Perinatal Mental Health Project (PMHP). Although my pregnancy was planned, and eagerly awaited, I noticed that I was not as excited and happy as I had previously anticipated. Not knowing what to expect, however, I kept these feelings to myself.
During a routine antenatal visit, I was asked to complete a questionnaire that screened for symptoms of depression. This part of the service was initiated and run by the PMHP. A high score on this questionnaire, led to a suggestion from the midwife, that I consult the PMHP counsellor, which I agreed to do. My visits to the counsellor, thereafter, coincided with my antenatal follow-up visits. During the first and follow-up session with the counsellor, I was provided with an opportunity to speak freely to someone who seemed to understand my experience, without judgement, which allowed me to process, and understand my negative and anxious response to my pregnancy. My experience of not feeling the joy others were expressing for our baby, intense emotionality, and a reluctance to leave familiar spaces, suddenly made sense, and I felt less lonely.
The level of antenatal care, including, the routine screening for a common mental health problem, depression, was excellent. Similarly, the sessions with the counsellor, which coincided with my routine antenatal visits, also worked well. During one such routine antenatal visit I was admitted after raised blood pressure and the presence of protein was detected. I started receiving medication for this as well as being monitored closely for any changes. It was decided to induce my labour after a few days. I was still being treated for hypertension, and I was given instructions to lie still and not move, through labour and birth and finally gave birth to a healthy baby girl.
After this experience of labour I was left feeling, traumatised and powerless. I had to stay in hospital for several more days for my condition to be deemed stable. I was, however, able to see the counsellor again. Through the provision of information, empathy, understanding, respect and dignity, she was able to assist me in processing, and understanding my traumatic experience. This assisted my healing and recovery emotionally.Psychosocial support can often be seen as a “nice-to-have”, add-on service. Through my traumatic experience, however, I was able to see how necessary psychosocial support is, and what a huge impact it can have on the quality of care provided to healthcare users.I would like to advocate that psychosocial support form an integral part of basic healthcare services, so that healthcare users receive holistic care. More importantly, however, as my story indicates, healthcare workers are in an ideal position to influence a patient’s experience of care. Healthcare workers need to understand that patients are more than just their illness, and “work” for them. Medical procedures that seem standard and routine to healthcare workers are often new and extremely anxiety-provoking for patients. Physical needs and wellness cannot be separated from emotional and psychological needs, and well-being. Psychosocial support should not be a specialised service running alongside healthcare services. Instead, it should be integrated into the routine treatment of patients.
This example describes how the Perinatal Mental Health Project was able to implement just such a service and it made such difference to my experience. In caring for women who are pregnant and are about to embark on the journey of labour and supporting a new life, this is especially necessary. Growing a life inside your body is a life changing experience each and every time. A mother typically will visit a health facility often during this time and receives screening and treatment for all types of preventative and pregnancy-related medical treatment. This would also, as in my experience, be an ideal opportunity to intervene with emotional as well and psychological interventions to support mothers. Mental health concerns at this time can have serious consequences to both mother and baby for the rest of both their lives. I was screened for depression and given treatment and support during this time. This enabled me to support my baby during the first few months of her life. I was also made aware of my own needs and could receive the help I needed. Without the treatment and support I was given, this would have been a far more painful time for me.As a result of my experience of having had support during a difficult time, I have a good understanding of the emotional support women need during pregnancy and birth. This understanding led to me continuing my studies and choosing to qualify as a counselling psychologist. When the opportunity came to work for an organisation focussing on pregnant women and children affected and infected by HIV, I took it. This organisation works closely with the Department of Health, which allows me to work with staff at primary health facilities and raise awareness of the importance of psychosocial support in the area of HIV, specifically for pregnant women, their children and families.
* Samantha has given consent to tell her story and use her photo.
Annie* grew up with a mother who verbally and emotionally abused her and her siblings. They moved from home to home. One of her step-fathers sexually abused Annie when she was 14. After that, Annie went to live with her aunt, dropped out of school and found a job in a factory. She started using alcohol heavily two or three nights a week and was pregnant, unplanned, at the age of 18, without a partner.
At 3 months, she booked at a Midwife Obstetric Unit, was screened for mental ill-health by one of the clinic staff and then referred to see the PMHP counsellor as her scores indicated she had symptoms of depression and anxiety.Annie was initially suspicious that she would be judged by the counsellor and that her baby would be taken away from her at birth. She arrived to the first appointment sad and reluctant to talk.
The counsellor gently developed a rapport with Annie, treating her with dignity and care. Annie, not being used to this type of relationship, broke down and was able to tell much of her life story in the first session. The counsellor was able to acknowledge and contain Annie’s anger at her mother, her fear of abandonment and her overwhelming anxiety that she would not be able to care for her baby without damaging him like what happened to me.
The counsellor was also able to identify where Annie had shown evidence of resilience and good decision making in her life – her seeking out a place of safety with her aunt, her strong work ethic at the factory which had earned her a promotion, and her courage in coming to speak with a counsellor. Over the next few sessions, together with the counsellor, Annie was able to identify a work colleague, an old school friend and her aunt as people with whom she could link more closely to be a support for her. With Annie’s improved self-esteem and a sense of agency, the counsellor was able to work with her to address her drinking problem. At birth, Annie had been sober for 4 months. Her aunt was present throughout her labour. Annie was able to breastfeed her baby for 5 months.During the first few months of her son’s life, Annie made a few appointments with the counsellor to work through some of the challenges of being a mother. She was also able to celebrate the joys in her relationship with her baby.
Jeanette* came from CAR (Central African Republic) to live in peace away from her village torn apart by war and atrocities. A teacher by profession and the breadwinner of her family, Jeanette was given in marriage by her parents to a man originally from her region, who lived in South Africa.
As in many arranged marriages, Jeanette knew very little about her husband. Soon after arriving in Cape Town her world turned upside down. Her husband was physically and emotionally abusive and incapable of supporting her. After a short while, she became pregnant and all her hopes faded. Desperate, lonely and confused, she became very anxious. The language barrier she faced in her neighbourhood and with various officials, the lack of resources and social isolation fuelled her anxiety.
At the antenatal clinic, she attended three PMHP counselling sessions with a French-speaking counsellor during pregnancy and attended two sessions with her baby. Her anxiety was acknowledged and contained. Examples of her natural resilience were drawn forward from her history and Jeanette came to feel supported and empowered.
She reconnected with her family from whom she had withdrawn in shame, she started learning English, and got to know her environment better. She made friends with a neighbour who had a toddler and in whom she found both practical and emotional support. In the counselling, she was able to disclose the abuse she was experiencing and was helped to protect herself and become more assertive. After my baby was born, I felt more hopeful about being able to care for her. I feel happy as a mother.
The baby’s father abandoned Phumza* when she became pregnant. This was also the time that she found out that she was HIV positive. She was scared that her baby might also be affected by the virus. At her first antenatal visit, Phumza was offered the PMHP mental health screening, and referred for counselling. She attended a few sessions with the PMHP counsellor.
After her baby was born, however, Phumza lost her job because her employer would not allow her to take time off work when the baby was sick. Phumza also had to take care of her older son, who was 6-years-old at the time.
I don’t know what is wrong with me. My memory is very poor. On Monday I lost money in the taxi. Yesterday, I lost my jacket. I don’t know what I’m doing these days. And I’m sad. Maybe this virus works in my mind, and I’m suffering. I’m always thinking about my future and my children. What if I can’t take care of them?
Phumza grew more desperate about her financial situation. Unemployed and receiving no support from the baby’s father, she felt hopeless about her future. She could no longer afford transport costs to attend counselling sessions at the clinic. She sent a text message to the PMHP counsellor: “I just want it all to end.”
Our counsellor began providing sessions telephonically and arranged for her to receive medication for her depression, referring her to the community clinic in her area for on-going psychiatric care. The PMHP counsellor also helped Phumza to connect with a community project for assistance with food and child grants.
Phumza’s life situation improved. She stayed in touch with our counsellor, and called to share the good news that her baby was HIV-negative. Although there are still many challenges for her, Phumza feels that she has been cared for, supported and provided with assistance. Today, she feels better able to cope. Her next text message to the PMHP counsellor read: I finished my job application today. I want to say thanks for everything you did for me. You must continue to help other people, other people who are suffering, just like I was.
Bongi* was raped by a “friend” who offered to help her with her schoolwork. She had not been sexually educated by her aunt, who had raised her from age 8, after her mother had died. Bongi didn’t know she was pregnant for several months.
I can’t get the pictures out of my mind. I wake up with my heart beating, sweating, I keep seeing his face, laughing. I hate him, and I’m so scared the baby will look like him. I wish my mother were still alive. Then I’d be okay. But right now I just want to die or kill him.
Bongi was referred to a PMHP counsellor who helped her contain her desperation and anger. The counsellor was able to affirm Bongi’s sense of self-worth and together they were able to identify a reliable source of support for her.
I couldn’t tell my aunt … I felt so ashamed. And I thought she wouldn’t believe me anyway, because I went to his house. I didn’t know what kind of person he really was. I was right. At first, she didn’t believe me. She said I was asking for it. She said she would send me back to the Eastern Cape to live with my good-for-nothing father. But now she’s not too bad with me.
Bongi then moved in with her older cousin. After she gave birth to her baby girl, she continued to attend the PMHP for counselling. Her confidence and parenting expertise grew. She began to plan for the completion of her schooling and beyond.
When Maria* was 9 years-old, her mother divorced her father, whom she was very close to. They moved to another city and Maria lost contact with him over the years. Maria was a sex worker for a while, and had a son, now 3 years-old. She used tik (methamphetamine) for 4 years before making a decision to stop. Feeling vulnerable to relapse, she met a man who seemed stable to her. They married after only knowing each other for one month. After three months, the marriage deteriorated. He became emotionally, physically and financially abusive.
But it was never okay. After hitting me, he’d apologise and be “good” for a few weeks. I always thought I wasn’t good enough and that somehow it was my fault. He would throw my past in my face. But he was good to my son. My friends tried to make me understand that I was worth more than this treatment. I was getting stronger and was planning to leave him. Then I found out I was pregnant with this baby.
After receiving counselling at the PMHP, Maria was able to anticipate and avoid violent encounters with her husband. She was equipped with skills to negotiate conflict.Although the physical abuse subsided over time, Maria felt stuck in an emotionally abusive relationship. She felt she needed to sacrifice her own happiness in order to let her children grow up in an intact family. She felt that if she left her husband, her children may choose a “wrong path in life”. She knew that she would feel responsible for this. Maria continues to see the PMHP counsellor as she works through her difficulties.
Christine* arrived in South Africa from the Democratic Republic of Congo four years ago. She struggled to get work and stay employed due to language difficulties. When Christine became pregnant for the second time, her partner did not want the child. He became verbally and emotionally abusive and was controlling with finances. She was forced to live on his meagre handouts.Eight hours after giving birth to her second daughter, Christine was discharged from hospital and returned home. Despite her pain and exhaustion, she had to continue, alone, with her domestic obligations – washing clothes, cleaning the house, and cooking for her partner and children.
Maybe it wasn’t a wise decision to bring this child into the world. I am a failure. How am I going to take care of this baby?
Christine’s relationship with her partner deteriorated, and without any friends or family to support her, Christine felt completely alone. She became increasingly sad and stressed. Feeling despondent, isolated and helpless, Christine found it difficult to bond with her new baby and had no energy to meet the demands of her 2 year old daughter. She wanted to ‘run away from it all’, but then was consumed with guilt for having such thoughts.
The baby didn’t stop crying. I couldn’t do anything to make her feel better. I felt useless as a mother and thought that it may be better if I ended my life.
Cultural norms added to Christine’s desperation. At the time of her pregnancy, her partner’s parents had not yet paid lobola (dowry) for her. She was therefore not recognised as being married. Consequently, her baby could not be named, making it more difficult to bond. Christine’s stress and depression caused her breast milk to dry up. She was referred to Charlotte, the PMHP’s French-speaking counsellor. At the time, she was 31 years old, and unemployed. Her daughters were 2 years and 2 months old.
At first, help was like a slap in my face. But with counselling I recognised that I had a problem and that it was not my fault. I now have time with my children and the milk is flowing. The heavy cloud over my head has been swept away. I now take things one step at a time.
Charlotte worked with Christine on acknowledging her feelings, and building a sense of her own self-worth and capabilities. Christine started to develop solutions to some of her problems, and felt empowered to negotiate a healthier way to communicate with her partner. She also accepted the help of a breastfeeding advisor. Today, Christine loves being a mother. She is more able to manage stress effectively and to care for her own and her children’s physical and emotional needs.
Zukiswa’s* score on the mental health screening questionnaire suggested that she was very distressed: she had not been able to get hold of her boyfriend since she found out she was pregnant, and had just learnt that she was HIV positive.
I haven’t been able to get hold of my boyfriend. He won’t take my calls. And his friends say he has gone to Joburg where the mother of his other two children is living.Worst of all, I found out two weeks ago that I am HIV positive. I’ve been going through hell. I am so worried about my baby. I am afraid the baby will get the virus. And what if I get sick? Who will support this child? I’m afraid to ask my mother because she never liked my boyfriend – said he was too old for me. I regret ever meeting him; and trusting him and not using condoms.
Zukiswa was referred to the PMHP counsellor. The first sessions focused on containing her emotions, through active listening, reflection and empathy. After a few sessions, Zukiswa’s mood started to change. She no longer felt as depressed and anxious. With the counsellor, Zukiswa worked on solutions to her problems. She identified the resources she had around her, and thought of ways to use these in the best way. The counsellor also referred Zukiswa to the HIV peer advocates at the clinic. Through the weeks of her growing pregnancy, Zukiswa learned about HIV, feeding options for her baby and how to protect her own and her baby’s health.
Eventually Zukiswa felt ready to disclose to her mother. This helped her to get more support and understanding at home, which gave her the strength to cope with her status, her pregnancy and her plans about the future.
Dipping in and out of counselling – just knowing we are there – activating referral sources
When Alice was referred for counselling after being screened early in her pregnancy by the PMHP counsellor, she declined the offer. Four months later, a midwife referred her again to the counsellor, since she had come in for pains that were understood to be stress-related. She told the counsellor that she had found out that her husband was abusing drugs.
Despite expressing a significant amount of distress, she did not want further counselling after the first session. She seemed to be managing fairly well when the counsellor contacted her 5 months later for the postnatal assessment when her baby was 8 weeks old – she was then divorced and happy about it, working from home, and getting support from her family with her baby and other children.
However, 6 months later she herself contacted the counsellor as her mood was very depressed, she was struggling to accept the divorce, and was angry at her ex-husband. The counsellor worked with Alice for 11 sessions, and made a number of referrals to community organisations for help with single parenting, mediation with her ex-husband, and also for a specific psychological problem her 6 year old had developed.
The counselling helped Alice’s mood, coping and ability to access other necessary services, significantly.
*The PMHP is committed to client confidentiality in keeping with the ethical requirements of professional mental health practice. The client stories reflect common scenarios or sets of circumstances faced by many of our clients. Pseudonyms are used and details are changed. The stories are not based on any one particular woman’s experience, unless an individual explicitly chooses to share her story with or without her name attached.