McCauley et al. BMC Psychiatry          (2019) 19:279 
https://doi.org/10.1186/s12888-019-2261-x
RESEARCH ARTICLE Open Access
“I just wish it becomes part of routine
care”: healthcare providers’ knowledge,
attitudes and perceptions of screening for
maternal mental health during and after
pregnancy: a qualitative study
Mary McCauley1* , Abigail Brown1, Bernice Ofosu2 and Nynke van den Broek1
Abstract
Background: Maternal mental health is an international public health concern. Many women experience mental ill-
health during and after pregnancy, but assessment is not part of routine maternity care in many low- and middle-
income countries. Healthcare providers are in a position to identify and support women who experience mental
health disorders during and after pregnancy. We sought to investigate the knowledge, attitudes and perceptions of
routine screening for maternal mental health during and after pregnancy among healthcare providers providing
routine maternity care in Accra, Ghana. Enabling factors, barriers and potential management options to routinely
screen maternal mental health during and after pregnancy were explored.
Methods: Semi-structured key informant interviews (n = 20) and one focus group discussion (n = 4) were
conducted with healthcare providers working in one public hospital in Accra, Ghana. Transcribed interviews were
coded by topic and then grouped into categories. Thematic framework analysis was undertaken to identify
emerging themes.
Results: Most healthcare providers are aware of the importance of maternal mental health and would be keen to
help women who experience mental ill-health during and after pregnancy, if resources were available to do so. An
enabling factor was the suggestion of introducing a culturally appropriate mental health screening tool. However,
compromised mental health was often considered a ‘spiritual issue’ and not routinely screened for by healthcare
providers, nor requested by women. Barriers to the provision of quality maternal mental health care included lack
of trained staff and lack of time.
Conclusions: Healthcare providers are aware of the problem of the lack of maternal mental health provision during
and after pregnancy and are open to developing protocols to improve care. Currently, screening for maternal
mental ill-health is not part of routine maternity care. The establishment of such a service requires the
reprioritisation of workloads, further training, and a change in the attitudes and practices of healthcare providers.
Education to change the attitudes of healthcare providers, women and the wider community towards mental
health is needed. The development and implementation of culturally appropriate guidelines would be beneficial
and result in better quality of maternity care.
Keywords: Maternal mental health, Healthcare providers, Quality of care, Antenatal care, Postnatal care,
Psychological ill-health
* Correspondence: mary.mccauley@lstmed.ac.uk
1Centre for Maternal and Newborn Health, Liverpool School of Tropical
Medicine, Pembroke Place, Liverpool L3 5QA, UK
Full list of author information is available at the end of the article
© The Author(s). 2019, corrected publication 2019. Open Access This article is distributed under the terms of the Creative
Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use,
distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.
McCauley et al. BMC Psychiatry          (2019) 19:279 Page 2 of 8
Background women suffering from maternal mental health disorders
Maternal mental health is an international public health is unknown [15]. General mental health services in
concern [1]. Many women experience mental health dis- Ghana are provided through specialized psychiatric hos-
orders during and after pregnancy that are often not pitals in the capital, with little government funding for
recognised or treated [1, 2]. Health has previously been general hospital and primary healthcare level services
described as ‘a state of complete (physical, psychological [15]. Ghana has recently developed a comprehensive
and social) well-being and not merely the absence of Mental Health Bill which aims to protects the rights of
disease or infirmity’ [3]. The updated Sustainable Devel- people with mental disorders in accordance with inter-
opment Goal 3 (SDG) aims to improve the health and national human rights standards [15].
well-being for all at all ages by 2030, and the Global There are international policies and guidelines to im-
Strategy for Women’s, Children’s and Adolescent’s prove maternal mental health but, at present, there is little
Health emphasises that all women have the right to, and practical implementation across many LMIC, including
should obtain, the highest attainable standard of health, Ghana [15, 16]. Globally, 85% of women attend for ante-
including physical and psychological care [4, 5]. In many natal care (ANC) at least once and this provides an oppor-
low- and middle-income countries (LMIC) maternal tunity for healthcare providers to improve the quality of
mental health has been ignored and not part of the over- care women receive [17]. It is therefore essential that
all routine wellbeing and assessment of women. As a healthcare providers are enabled to provide comprehen-
component of health, there is a need to focus on mater- sive and holistic maternity care that goes beyond the
nal mental health [2]. provision of basic emergency care and includes mental
Maternal mental health is defined as ‘a state of well- health assessment and management during and after preg-
being in which a mother realises her own abilities, can nancy [2, 4, 5].
cope with the normal stresses of life, can work product- This study sought to investigate the knowledge, atti-
ively and fruitfully and is able to contribute to her com- tudes and perceptions of healthcare providers who pro-
munity’ [6]. Common mental disorders (depression, vide routine maternity care, regarding maternal mental
anxiety) rank third in the list of the burden of disease health during and after pregnancy in Accra, Ghana. In
globally and are expected to rank number one by 2030, addition, enabling factors and barriers to the provision
overtaking road accidents and heart disease [7]. Globally, of mental health assessment were explored and potential
mental health disorders affect up to 10% of women dur- management options, and how to translate these recom-
ing pregnancy and 13% of women following childbirth mendations into clinical practice were considered.
[6]. In LMIC, these figures are estimated to be as high as
15.6% of women during pregnancy and 19.8% of women
following childbirth [6]. However, maternal mental Methods
health is often not reported, infrequently recognised and Study design and setting
under-treated in many LMIC [8]. It is estimated that 1 Data collection used a qualitative descriptive approach,
in 4 women in LMIC report antepartum depression and and semi-structured key informant interviews (KII) and a
1 in 5 report postpartum depression; twice the rate of focus group discussion (FGD) were conducted with
women in high income countries [9]. Women in LMIC healthcare providers working in the obstetric department
are more vulnerable to contributing risk factors such as of the largest teaching hospital in Accra, Ghana in May
low socioeconomic status, unplanned pregnancies, low and June 2017. All interviews were held in a private loca-
social support and domestic violence, all of which can tion (an office in the healthcare facility) that would ensure
increase the likelihood of a woman developing a mental privacy and that was convenient for the participants.
disorder during or after pregnancy [10, 11].
Compromised maternal mental health is associated with
adverse consequences for the mother and the baby, both Participants
short and long term [12, 13]. Many high-income countries Healthcare providers (mainly doctors) were included
such as the United Kingdom (UK), recognise the detri- if they provided routine maternity care in the chosen
mental impact of maternal mental health disorders on the study site. All participants were aged 21 years or
overall well-being of mothers and their newborn babies more. Nurse-midwives were included to enable the
during and after pregnancy, and have implemented rou- triangulation of the data and broadened the scope of
tine screening of mental health during and after preg- the topic. Snowballing and opportunistic techniques
nancy by a trained healthcare provider [14]. were employed to identify the participants. Partici-
In Ghana, it is estimated that 650,000 people suffer pants were chosen purposively, based on their ability
from a severe mental disorder, 2,166,000 suffer from a to speak English, and were recruited sequentially until
moderate to mild mental disorder; but the number of saturation was met.
McCauley et al. BMC Psychiatry          (2019) 19:279 Page 3 of 8
Topic guide Ethics
The topic guide was designed by the primary researcher Ethical approval was granted by the Liverpool School of
(AB) and piloted by two Obstetricians who were based Tropical Medicine, UK (LSTM14.025) and by the Korle-
in the study site. The topic guide was a flexible tool that Bu Teaching Hospital, Accra, Ghana (KBTH-STC
enabled the interviewer to capture the healthcare pro- 00055/2017). Written informed consent was obtained
viders’ responses as well as acting as a cue to probe fur- from all participants of the study.
ther to develop an understanding of the participants
perceptions and beliefs. Following the pilot of the topic Results
guide it was amended and refined; for example, informa- Participants’ characteristics
tion related to the type of information that was being A total of 24 healthcare providers participated in the
collected was clarified so that participants were aware study (20 doctors and 4 nurse-midwives; of whom 13
that their general views were being sought and not first- were female and 11 male). Two other participants who
hand experiences of mental health disorders during or were approached refused to take part due to time con-
after pregnancy. In addition to sociodemographic ques- straints. Twenty doctors with varying levels of experi-
tions, the topic guide included five main subject areas: ence (junior doctor, specialist registrar, consultant) were
(1) overall understanding of mental health; (2) cultural interviewed using KII and four nurse-midwives took part
perception of mental health disorders; (3) current ex- in one FGD. Participants were aged between 25 and 65
perience and views on maternal mental health; (4) years of age, with the majority between 25 and 35 years.
current management for women who experience mental Most participants were junior doctors and had between
disorders; and (5) suggestions for change to provide ma- one to five years of experience of providing routine ma-
ternal mental healthcare. ternity care. All participants were interviewed in English.
Data collection Emerging themes
The data collection was undertaken by a female student The main emerging themes derived from the data in-
undertaking a Master’s in International Public Health. cluded (1) enabling factors, (2) barriers and challenges
The data collector had completed training in qualitative and (3) healthcare providers’ suggestions on improving
research methods and was supported during the inter- maternal mental health assessment. The variation in type
view process by a second researcher (BO). Participants of interview, age, gender or cadre of healthcare provider
were approached by the data collector (AB) face-to-face did not impact the response patterns.
prior to the interview and were given written and verbal
information about the study. The information included Enablers
an overview of the research aims, objectives and ques- Key enabling themes to improve the quality of routine
tions. An appointment was then scheduled in a conveni- maternity care included healthcare providers’ awareness
ent place and time for each participant. All participants of mental health in general and the understanding that
were interviewed in English and the interviews and the women were at high risk of mental health disorders dur-
focus group discussion lasted on average 30 mins. Inter- ing and after pregnancy. Most healthcare providers
views and the focus group discussion were conducted expressed awareness that mental health covered a
face-to-face, recorded on a digital recording device and spectrum of disorders varying in severity (Table 1: Q1,
transcribed upon completion. Triangulation data from Q2) and that women were at risk of poor mental health
the nurse-midwives’ interviews established credibility. By during and after pregnancy (Table 1: Q3, Q4, Q5). Many
emphasising anonymity and confidentiality we increased healthcare providers appreciated that poor maternal
participants confidence in providing honest answers. mental health can have negative consequences for the
woman, her baby and the wider family (Table 1: Q6, Q7,
Analysis Q8, Q9). Within these themes, there was an underlying
The interviews and focus group discussion were transcribed willingness of the healthcare providers to provide better
and manually coded by the first researcher (AB). The second care. However, there were significant barriers in place.
reviewer (BO) independently coded 50% of all transcripts.
The identified codes were grouped into categories and Barriers
reviewed by three researchers (AB, BO, MMC) to ensure Reported challenges to the assessment of maternal men-
consistency and to check for interrater reliability. This en- tal health included a lack of time, healthcare staff short-
abled the first extraction of data [18]. Key themes were then ages, staff not trained to assess and manage maternal
discussed and checked by all three researchers together to mental health and cultural stigmas surrounding mental
reach consensus (AB, BO, MMC). This helped to remove health. Many healthcare providers reported that a lack
potential bias and strengthen the results. of time due to the large number of women attending for
McCauley et al. BMC Psychiatry          (2019) 19:279 Page 4 of 8
Table 1 Enabling factors for the provision of maternal mental health
Sub-theme Quote
Awareness of mental health Q1 “… when it comes to mental health it’s a vast variety, like it’s a whole spectrum …
spectrum for poor mental health to good mental health...” (A12, KII, Doctor)
Q2 “… some people have pre-existing … mental illnesses that carry on into pregnancy, and
then you have another group … who would have the just the post-partum blues … so I
think it’s a whole spectrum …” (A16, KII, Doctor)
Awareness of maternal mental health Q3 “… most pregnant women are at risk or suffering from one or two mental conditions
especially in the post-partum …” (A10, KII, Doctor)
Q4 “We have post-partum psychological problems which is a spectrum, we have maternal
blues, we have depression, we have psychosis and all postnatally …” (A4, KII, Doctor)
Q5 “… the commonest ones we have is postpartum depression, and postpartum psychosis
…” (A18, KII, Doctor)
Awareness of the effect of poor maternal mental Q6 “Poor mental health can affect your day to day activities, your work, your schooling and
health on the mother, baby, family how you relate to other persons …” (A12, KII, Doctor)
Q7 “… if the mother is not excited or happy about giving birth to the child and there is no
natural bonding between the mother and the child, the baby is neglected, the baby is not
fed properly, the baby becomes malnourished …” (A3, KII, Doctor)
Q8 “… the woman who is suffering from schizophrenia, who has paranoid delusions … can
feel that they’ve sent the baby to come and harm her or something, so she will just
withdraw from the baby …” (A8, KII, Doctor)
Q9 “...if the woman is not in the best state of mind and she gives birth … the family tends to
suffer a lot because they find it difficult to associate with such a person so it’s not a good
thing...” (D, FGD, Junior nurse-midwife)
maternity care and the lack of staff, were challenges that suggested. Healthcare providers were keen for the intro-
made it difficult for them to screen and/or manage and/ duction of routine mental health guidelines and a stan-
or refer women with mental health problems (Table 2: dardised questionnaire to help guide the assessment of
Q10, Q11, Q12). women as part of routine antenatal and postnatal con-
Some healthcare providers commented that working in tacts (Table 3: Q26, Q27, Q28). The use of visual post-
a busy teaching hospital with time pressures resulted in ers, lectures and health talks on the topic of maternal
staff burnout and healthcare providers were keen to leave mental health (Table 3: Q 29, Q30, Q31); education to
as soon as the obstetric and general physical care of the promote awareness on the importance of mental health
women was achieved (Table 1: Q13, Q14). Some health- not only for healthcare providers, but also for women,
care providers commented that undergraduate and post- their families and the wider community (Table 3: Q32,
graduate teaching on mental health was not promoted as Q33); and a multidisciplinary team approach, collaborat-
much as other areas of medicine (Table 1: Q15, Q16). ing with psychologists and/or psychiatrists in an
Many healthcare providers reported significant stigma additional clinic, as part of routine maternity clinics,
associated with maternal mental health and that women (Table 3: Q34, Q35, Q36) were suggested to encourage a
fear being labelled as ‘not in their right mind’ if they more comprehensive and holistic approach to maternal men-
were diagnosed with a mental disorder (Table 1: Q 17- tal healthcare.
Q21). Many healthcare providers commented that ma-
ternal mental health disorders were perceived to have Discussion
‘spiritual origins’ and that women would prefer to seek Statement of principal findings
care from a religious leader as opposed to clinical care Many healthcare providers were aware of the problem
from the healthcare facility (Table 1: Q22, Q23). Some and impact of poor maternal mental health and would
healthcare providers shared extreme views on maternal be keen to support women. Healthcare providers under-
mental health and perceived women with poor mental stand that maternal mental health should be continu-
health as ‘mad’ (Table 1: Q24, Q25). ously assessed along the continuum of care from early
pregnancy to the late postnatal period, as early identifi-
Solutions cation would enable early referral and treatment (de-
Many healthcare providers were keen to discuss solu- pending on availability). However, healthcare providers
tions and recommendations regarding how to introduce do not currently screen women for maternal mental
mental health screening as part of antenatal and postna- health problems during and after pregnancy due to a
tal care and various approaches to implementation were lack of training and/or time and because mental health
McCauley et al. BMC Psychiatry          (2019) 19:279 Page 5 of 8
Table 2 Barriers to the provision of maternal mental health
Sub-theme Quote
Lack of time Q 10 “… everybody wants to deal with the more … organic things … because the outpatient department is choked, you must
see as many people as you can … “(A13, KII, Doctor)
Q 11 “But we don’t spend much time with the patient, so you don’t get to see their worries...” (A6, KII, Doctor)
Q 12 “So, you just have so many [patients] at a time, that there’s no time to really give that kind of care that you should. We know
we should be giving it, but we don’t give it, there’s really no time to do that …” (A11, KII, Doctor)
Lack of staff Q 13 “… we need more doctors so that the workload will come down, then one can have enough time, addressing mental issue
… but one doesn’t have a luxury to do it …” (A10, KII, Doctor)
Q 14 “… everybody is stressed, even the doctor! How can a stressed person look after somebody who is stressed?” (A6, KII, Doctor)
Lack of Q 15 “We don’t take psychiatry serious at all … even in medical school …” (A6, KII, Doctor)
education
Q 16 “I don’t think mental health has really been one of those things that is commonly taught … part of our training which is
dedicated to mental health is small.” (A4, KII, Doctor)
Stigma Q 17 “… mental health comes with some stigma” (A8, KII, Doctor)
Q 18 “… you see we live in a society where mental health is being stigmatised … people who have mental problems are
stigmatized …” (A18, KII, Doctor)
Q 19 “… most people want to [help] but the fear of stigma wouldn’t allow them to do it” (E, FGD, Junior nurse-midwife)
Q 20 “… you see because we live in a society where mental health is being stigmatised people who have mental problems they
are being stigmatized, so, to go and discuss something like that with the person … they might think that you are tagging
her as having a mental problem.” (A18, KII, Doctor)
Q 21 “The first impression that comes to your mind when you hear mental health is hmm …. ‘this person is not in the right mind’
yeah, so it comes with its own stigma.” (A8, KII, Doctor)
Cultural beliefs Q 22 “… they attribute it to these spiritual things, so most of the cases won’t come to the hospital … unless of course they realise,
maybe, it’s getting out of hand and then they go to the pastor …” (E, FGD, Junior nurse-midwife)
Q 23 “… [if] you’re crying more or you’re behaving differently than somebody else … they would consider it as … of spiritual
origin...” (A11, KII, Doctor)
Q 24 “the perception about schizophrenia was that people are ‘mad’ because that’s when they hallucinate, they hear auditory
hallucinations and visual hallucinations they have paranoia and all that.” (A8, KII, Doctor)
Q 25 “...in our part of the world, nobody would like to be called a ‘mad man or mad woman’, so we have to be tactful...” (A2, KII,
Doctor)
is often considered a spiritual issue within the cultural during and after pregnancy and, to our knowledge is
setting. Further education and training of healthcare the first study to assess this subject in a low resource
providers (undergraduate and postgraduate) would be setting. This study discusses solutions that can sup-
useful to develop their confidence to approach this po- port future policy and programme development to
tentially culturally sensitive topic and to enable routine introduce and establish routine maternal screening for
screening and management of maternal mental health mental health during and after pregnancy in a low re-
disorders during and after pregnancy. Healthcare pro- source setting. A wide spectrum of responses were
viders need support from a wider multidisciplinary team, obtained by interviewing different cadres of healthcare
ideally with a psychiatrist to work together in a com- providers (both female and male), who worked in dif-
bined approach to ensure women receive the best pos- ferent departments within the maternity setting and
sible care in a more holistic and comprehensive way. had varied level of experiences. Most of the health-
The healthcare providers interviewed suggested that care providers interviewed welcomed the discussion
education and sensitisation programmes regarding the surrounding screening for maternal health in preg-
aetiology and evidence-based management for mental nancy, recognised it as a neglected area and were
health during and after pregnancy that would be aimed keen to contribute to solutions in their settings.
at the community, families and women would be benefi-
cial. The healthcare providers recommended the intro- Limitations of the study
duction of culturally appropriate routine mental health This study population comprised mainly doctors provid-
screening tools for use within existing services. ing routine maternity care in a large teaching hospital
and excludes other cadres of healthcare providers who
Strengths of the study do not provide maternity care and may have alternative
This study assessed the knowledge and attitude of perspectives or different insights. Similarly, this study
healthcare providers regarding maternal mental health was carried out in an urban setting and the findings
McCauley et al. BMC Psychiatry          (2019) 19:279 Page 6 of 8
Table 3 Suggested solutions for the provision of a maternal mental health service
Sub-theme Quote
Guidelines Q 26 “I think there should be guidelines …” (A4, KII, Doctor)
Q 27 “There should be guidelines so that there’s a kind of purpose, there’s a reason why you are doing it, so you can’t
just be screening women with no purpose or no guidelines.” (A8, KII, Doctor)
Q 28 “I just wish it becomes part of the routine screening of our patients because if you are able to detect … those
with such conditions or who need help early that will prevent us from getting to them late” (A20, KII, Doctor)
Q 29 “if it is a poster that I turn, and I look, and I see something that reminding me that ‘we must ask this’ it’s helpful …
something so people will be reminded everywhere in your hospital ‘mental health in women is important” (A6, KII,
Doctor)
Antenatal screening Q 30 “We could include it into our antenatal book then routinely, and postnatal of course, routinely when the patient
comes as part of the questions we ask …” (A12, KII, Doctor)
Q 31 “… at the first visit, the booking visit, if we had … a structured questionnaire or a tool that could be used, it will
go a long way so that right from booking...potential problems are picked up early enough...” (A16, KII, Doctor)
Education for mothers Q 32 “It should be part of...the antenatal clinic, because when they come we give them talks …” (A20, KII, Doctor)
Education of healthcare Q 33 “… we need to have public education, we need to educate people, we need to educate ourselves as healthcare
providers providers, we need to educate the pregnant women, we need to come up with policies, we need to improve and
set up a structured plan in a way to attack this situation …” (A3, KII, Doctor)
“… we need to train [healthcare providers] we have to get the techniques to do it … and you need to get things
in place to do it...” (A16, KII, Doctor)
Multidisciplinary team Q 34 “I would say that there should be separate unit in the antenatal clinic where a psychiatrist or psychiatric nurse or
approach psychologist could do the screening and counselling (A1, KII, Doctor)
Q 35 “… having a multi-disciplinary approach to it involving the physicians coming to [the antenatal clinic] some days
… if they are there at the same clinic it might improve the management than losing and managing them …” (A9,
KII, Doctor)
Q 36 “I think we need psychiatry units … so that we know where we are directing our patients to when it comes to
mental health” (C, FGD, Junior nurse-midwife)
cannot be assumed to be the same in other settings. that, culturally, mental disorders were believed to have
There is a need to assess the views of community-based ‘spiritual origins’. Similar responses were found in an-
healthcare providers in different settings who may have other study in Ghana where mental ill-health was associ-
different cultural perceptions, beliefs and experience. ated with spiritual influences and methods of treatment
Their opinions would be important to ensure a seamless included visits to a religious leader or harsh beatings to
home to hospital continuum of care regarding maternal remove ‘evil spirits’ [20]. In many LMIC settings, fam-
mental health referral and treatment pathways. ilies tend to seek care from traditional healers and/or
churches as opposed to seeking clinical care at health-
How does this study relate to other literature? care facilities [21]. These perceptions and beliefs are
In our study, healthcare providers felt unable to rou- ingrained in the cultural context making it difficult for
tinely screen women for mental health due to the lack of healthcare providers to discuss mental health as part of
training, lack of resources and lack of time in a busy a routine ‘normal’ health consultation with a woman
urban healthcare facility. Furthermore, healthcare pro- during and/or after pregnancy. Lack of education and
viders reported that mental health was associated with awareness surrounding the spectrum and available man-
significant stigma. These findings are similar to those agement for mental illness within the communities may
from other studies from a variety of settings where continue to contribute to misconceptions on mental
stigma and discrimination against women with mental health [21].
health disorders still exist [19]. In our study, mental In our study, many healthcare providers suggested that
health was surrounded by a shroud of cultural miscon- an integration of routine mental health guidelines into
ception, with a reported cultural context of mental ill- the existing maternal health system would be beneficial.
ness being associated with extreme cases such as ‘those There are many international clinical and policy guide-
mad homeless people, living on the streets, naked and in lines on who should enquire, screen and manage mater-
poverty’. This understanding is similar to other studies nal mental health during and after pregnancy and how
in low resource settings, where the term ‘madness’ was this should be conducted, including identification, coun-
used to describe mental health, and people with mental selling, documentation, first line medication and
illness being perceived as ‘dishevelled and homeless’ provision of higher referral pathways [8, 15]. Further-
[20]. In our study, many healthcare providers explained more, in high income countries, there are
McCauley et al. BMC Psychiatry          (2019) 19:279 Page 7 of 8
recommendations that every woman should be asked Acknowledgements
about her emotions every time she is seen by a health- We would like to thank Dr. Joseph Adu, Dr. Titus Beyuo, Dr. Henry Kumi,
Philomina Tamakloe for their help and support with the ethical approval and
care professional during and after pregnancy, in an open data collection processes. Thank you especially to all healthcare providers
and non-judgemental way, highlighting that screening from the Department of Obstetrics and Gynaecology at Korle-Bu Teaching
tools may help, but a prompt to ask is important also Hospital, Accra, who participated in this study and who continue to work in
sometimes difficult situations, striving to provide good quality of care. We
[14]. However, the practicalities associated with the im- sincerely applaud them and their work.
plementation and acceptability of these recommenda-
tions in countries such as Ghana is currently uncertain. Authors’ contributions
There is a need to further understand how maternal MMC conceived the study idea and design. AB developed the topic guide,conducted the interviews, transcription and data analysis, interpreted and
mental health is experienced and understood within dif- presented the results, and contributed to the manuscript. BO contributed to
ferent cultural contexts to ensure that the interventions data collection and analysis. MMC co-ordinated and supervised the research
to be implemented are culturally and contextually ap- activities, contributed to the interpretation of results and wrote the manu-script. NvdB reviewed the results and contributed to the manuscript. All
propriate [1]. There is also debate as to who is most authors have read, edited and approved the final manuscript for submission.
suitable to enquire, screen for and manage maternal
mental health and at what level of the health system Funding
This study was partly self-funded by Abigail Brown as part of her dissertation
(community, primary or secondary health care level) of the Master’s in International Public Health programme at the Liverpool
across LMIC. In many HIC, specially trained midwives School of Tropical Medicine. The co-authors from the Centre of Maternal and
routinely assess, support and provide further referral be- Newborn Health were funded by a grant from the Global Fund (20168770).
The Global Fund did not have a role in the writing of the manuscript or the
tween different levels of care [14]. This approach in a decision to submit it for publication.
low resource setting requires further research. A system-
atic review in 2013 assessed the effectiveness of interven- Availability of data and materials
The dataset used and analysed during the current study are available from
tions to improve the maternal mental health in LMIC the corresponding author on reasonable request.
and concluded that interventions could be delivered by
supervised non-specialists [17]. An intervention package Ethics approval and consent to participate
The Liverpool School of Tropical Medicine, Liverpool, United Kingdom,
for perinatal depression (cognitive behaviour therapy, (LSTM14.025) and Korle-Bu Teaching Hospital, Accra, Ghana (KBTH-STC
psycho-education, problem solving, parenting skills) is 00055/2017) both granted ethical approval. All participants provided written
being delivered by community midwives with support informed consent.
from doctors in facilities and enhanced compliance with
Consent for publication
mobile phones in Nigeria [22]. Evaluation is awaited. Not applicable.
Competing interests
Conclusion The authors declare that they have no competing interests.
Across many LMIC, women are increasingly accessing Author details
antenatal care and there is now a window of opportunity 1Centre for Maternal and Newborn Health, Liverpool School of Tropical
to adapt and amend available care packages to include Medicine, Pembroke Place, Liverpool L3 5QA, UK.
2Korle-Bu Teaching
Hospital, Accra, Ghana.
routine screening and management of maternal mental
health during and after pregnancy as a component of Received: 3 July 2018 Accepted: 28 August 2019
comprehensive quality of care. Many healthcare pro-
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