Healthcare providers (HCPs) views regarding the availability, accessibility, and management of maternal mental health of adolescent mothers were explored. Participants (n = 36) included six HCWs who participated in in-depth individual interviews and 30 traditional practitioners, including 10 traditional healers, 10 community volunteers, six traditional birth attendants and four spiritual healers who participated in the three FGDs (9 males and 21 females). Eighteen participants were Christians, four were Muslims, and eight belonged to traditional religions. Ten participants had never been to school.
Overview of themes and conceptual model
Four main themes emerged to help understand the perceptions of healthcare workers (HCWs) and traditional practitioners regarding the access and availability of mental health services for adolescent mothers in rural Malawi. The themes of inadequate staff development, limited resources, limited policy, and guidelines implementation pertain to health systems. The theme Cultural background and beliefs influencing seeking help describes cultural norms.
Inadequate staff development
The theme of inadequate staff development has four subthemes: health providers’ skills and knowledge, standard mental health screening tools, qualified mental health professionals, and health worker workforce.
Health provider’s skills and knowledge
All healthcare providers acknowledged encountering many adolescent mothers during their daily activities. HCWs reported focusing on physical examinations, nutrition assessments, nutrition counselling sessions and other health education sessions for pregnant mothers in clinics and at the community level. However, they did not address mental health. However, HCWs perceived themselves to be strategically positioned to provide initial mental health assessments and support to mothers. Some HCWs acknowledged their hesitancy to include mental health assessments as they felt they lacked the skills to identify symptoms of mental health problems and to provide appropriate mental health support. Furthermore, they expressed a need for regular professional development, for example:
Some of health workers have the skills but… most of us do not have the skills to conduct a mental health assessment…. An in-service or reorientation would be good. Of course, we had a training during our clinical placement but…. psychiatric or mental health is difficult, we have forgotten (HCW1).
Similarly, traditional practitioners also expressed concerns about their limited awareness about mental health and perceived deficiencies in counselling skills. Community volunteers and traditional birth attendants do not routinely include mental health care. Many community volunteers had received prior training in conducting home visits to pregnant women, offering nutrition education, and performing basic physical assessments, which they believed positioned them well to support mothers in crisis before directing them to clinics. While traditional practitioners discussed their need for basic counselling skills, they also recognized the need for experienced counsellors they could refer adolescent mothers to. Other traditional practitioners, such as traditional birth attendants and herbalists, also felt they would benefit from mental health awareness and basic counselling skills.
The major reason for us who live and work in the community…. We do not have the capacity or basic skills for counselling or communicating with someone about their mental health. We do not have the knowledge for counseling. We need counsellors…. To be honest we don’t teach about mental health but about nutrition only because we don’t have the required skills or knowledge in the mental health field. (Community volunteer FDG1)
If there was an opportunity for us to learn how to manage mental health and teach about mental health, (it would) be good …. so that we can help adolescent mothers live without stress. We will be incredibly grateful also because we will add more knowledge to what we already teach mothers. (Community volunteer FDG1).
Standard mental health screening tools
Most HCWs were willing to screen women for possible common mental health problems. However, they attributed the lack of culturally approved screening instruments as a challenge to screening. HCWs felt it important to have a standard screening tool for common disorders incorporated into their routine assessment guides. They reported that most adolescent mothers with common mental health issues requiring help go unrecognized, especially when they look happy or do not show any visible signs of sadness. One health worker summarized this sentiment, suggesting the identification of mothers with mental health problems is mostly “accidental’ due to the lack of formal screening and assessment.
Most of the time we prioritize those who come here as a family to seek help because we encourage family involvement or partner involvement. So, if someone comes alone, we explore further to identify the reason she has come alone. That is when we identify the issues. We can say identification is accidental (HCW3).
Qualified mental health professionals
Most participants acknowledged the importance of specialized mental health professionals who offer tailored and comprehensive assessments and psychological support that incorporate mothers’ specific psychosocial needs. For example,
Some mothers needed counselling services and most of them would need psychosocial counselling and psychosocial counselling (which) would range from 1 week to up to 6 months and (this) needs qualified psychosocial counsellors (HCW 2).
Participants reported that at the time of the study, the hospital had only one mental health nurse working in the labor ward who was responsible for managing clients with severe mental illnesses. To address the issue of limited staff, some HCWs suggested a need for integration of mental health services into primary health care. It was suggested that this could be achieved by engaging non-mental health professionals to support mothers and implement early intervention. This would enable support to be provided to mothers immediately, which was especially important for young mothers, many of whom travel long distances, often on foot, to get to the clinic.
Another thing, is if we can have enough mental health personnel …for example, we only have 1 psychiatric nurse, the one who deals with all mental health issues… So, it will be ideal…if we have … a psychiatric nurse or anyone who looks into all those mental health conditions in the department like for example …. here at antenatal have one-person, general wards should have one and the other departments as well. That would help rather than just referring them to one person… It may happen that the person on that particular day is absent he is engaged with other issues so it means these people (adolescent with mental health issues) will not be assisted. And then telling them (adolescents) you should come another day will look like a burden to them. Looking at the distance they walk from home to here. I think that can be a problem. So…If we can have more mental health experts here (HCW 2).
Health worker workforce
HCWs acknowledged the government of Malawi’s commitment to strengthen human resources for health including accelerating training and recruiting health professionals to support all positions required in the health sector. However, some HCWs also expressed concerns over the limited number of staff employed at the facility. Lack of staff was an issue, with the clinic treating around fifty mothers daily with only two nurses per shift, which tended to result in staff prioritizing physical health issues. Some HCWs and community volunteers suggested that community volunteers and community health workers can assist with screening mothers for mental health issues. Community volunteers concurred this would be feasible if they received appropriate training regarding screening procedures and mental health problems.
Given the workload at the clinic, little time is available to screen for mental disorders and hence they go unrecognized…they should be assisted (but) it is only the psychiatric nurse that decides the kind of medication. So, most of us will just look at the condition and we do not help much. We only focus on anemia, malaria, and pregnancy. Furthermore, community workers can assist with screening. (HCW 5).
Only if there was that opportunity for us (community volunteer) to learn how to teach about mental health and support mothers so that they could live without stress. We will be incredibly grateful because we will add more knowledge to what we already teach. ….and assist them properly (Community volunteerFGD1).
Yes, we can use community workers or can find volunteers in the community who can identify people with mental issues and record their names and bring them to the hospital or provide mental health support (HCW 3).
Limited resources
Resource availability was cited as a facilitator for effectively delivering appropriate mental health services. Besides limited human resources, HCWs expressed concerns about the availability of other key resources to deliver the services. This theme has two subthemes: medication availability, lack of appropriate infrastructure. and competing priorities.
Medication availability
HCWs reported that all health services provided at the facility are free of charge. Hence, mothers do not pay for consultations and medication received at MRH. The faith-based organization St. John of God Hospitaller Services also partially supports mental health services with a free monthly mental health mobile clinic that provides medications for those with severe mental illnesses who attend the clinic on their clinic day. However, MRH provides perinatal and other outpatient services daily. Therefore, it was challenging for MRH to support mothers who required treatments on non-clinic days because MRH frequently experienced shortages of essential medications used to treat common mental disorders such as depression. HCWs attributed these shortages to limited government financing for medication and that mental health is not considered a priority by the authorities. Additionally, some HCWs also highlighted that medications safe for pregnant and lactating mothers were often not available, leaving some mothers untreated unless they could afford to pay for medication from the pharmacy.
Sometimes we have capacity, but we do not have resources. For example…. having safer antidepressants, we rarely have them …. we have the patients, but we are failing to put them on safe anti-depression medications… we could ask the family to buy, from pharmacies or private clinics… The situation is worse with mental health. No medication at all and we prioritize other medication (HCW 6).
Lack of appropriate infrastructure
Some health workers expressed concern that the current hospital infrastructure does not allow for privacy, making some interventions difficult to implement. Rooms were difficult to access for private counselling sessions. The available open public spaces did not allow confidential discussions and did not have the capacity for partners to attend and accompany their spouses for labor, delivery, and clinic checkups. The need for privacy for mothers who had lost a baby was also emphasized by one participant who expressed concern that these mothers remained on the ward with other mothers and their babies.
Our hospital physical environment will not allow them (spouses/partners) to come…. postnatally …. they can’t be assisted well if they come with partners ……at least if the facility had rooms to provide privacy (HCW2).
We should have a separate room to deal with or to treat the mothers and give counselling because most of them would need psychosocial counselling and psychosocial counselling that would range from 1 week to up to 6 months and (this) needs privacy. (HCW3).
Particularly those that have lost their babies we need… a separate room for them because if we put them together with the mothers that have babies that brings in more mental disturbance…being traumatized (HCW6).
Competing priorities
HCWs also expressed concerns over competing priorities with limited funding from the Malawi government and a lack of other non-government organizations and stakeholders supporting mental health services. Participants described how some health conditions receive special donor funding through specific projects. Some of these projects include funding of medication for communicable diseases such as malaria, sexually transmitted infections, and HIV/AIDS. However, there are currently no similar projects that fund mental health medications. This affects the availability of safe treatment options since government funding is insufficient to procure pregnancy-safe antidepressants. Further, during the COVID-19 pandemic, the situation worsened as funding and interventions shifted. For example, “We noticed that there is a lack of resources, particularly drugs because now the focus is on COVID-19 prevention supplies; this has affected the supply of other medications, including medication used during emergencies such as adrenaline” (HCW6”). Another health worker who was involved in providing mental health services stated:
We have patients who have chronic diseases such as epilepsy and mental illnesses, these have been affected more compared to patients that come for malaria or TB treatment Because malaria and TB have specific donors that supply medication but for epilepsy and mental health, we don’t have any medications (HCW3).
Limited policy and guidelines implementation
Policy and guidelines were highlighted as facilitators to improved mental health care for women. Nurses and doctors acknowledged the availability of policies and guidelines regarding antenatal and postnatal care. However, the HCWs discussed the gap between these policies and their implementation. HCWs attributed gaps in implementation to issues such as fragmented care and inadequate financing for mental health services, insufficient workforce, unclear practical guidelines specific to maternal mental health care and a lack of staff orientation to new guidelines.
While the Ministry of Health had recently reviewed the antenatal guidelines and incorporated maternal mental health assessment, not all HCWs in this study were aware of these changes. Those who were aware reported that many staff were unfamiliar with recent guidelines. Some participants suggested the guidelines are not explicit, and HCWs require orientation to familiarize themselves with the changes. Furthermore, participants indicated that current antenatal policy does not clearly stipulate the mental health screening of postnatal mothers. HCWs suggested mental health screening should be mandatory.
Yes, the policies and guidelines might be there…so many people (nurses and clinicians) are not even aware of what is in the policies and to use them (policies)…Even the new anti-natal guidelines if you ask some nurses, they just know they are there but still practicing old ways where we only assess for physical problems like anemia, gestation age, and malaria (HCW1).
If you may ask me about motivational interviewing, and screening, I don’t know what it entails (HCW2).
I am personally not familiar with the changes; these were not disseminated to us. Orientation would help and for postnatal women we only assess for physical problems up to six weeks postnatal checkup. Probably screening should be mandatory (HCW 3).
Cultural background and beliefs influence on help seeking
Adolescent mothers’ cultural backgrounds and beliefs impacted access to services. Broader community influence and traditional healer’s influence were sub-themes of this theme.
Broader community influence and beliefs
Traditional practitioners had different perceptions of how they described mental health problems. Mental health disorders were perceived to be the result of witchcraft or “someone just being silly” or “stupid”, with some participants in the traditional practitioners FGDs suggesting these issues do not warrant hospital treatment. The following quotes from herbalists and a spiritual healer support these sentiments:
Mental health conditions are because of stupidity mmm …Some people say it’s stupidity …but sometimes it’s indeed witchcraft (Herbalist FDG3).
You don’t think straight when you have mental issues. If such things happen, some say it is witchcraft, some say it is madness, and others say it’s Satanism. People talk a lot about these things (Spiritual healer FDG2).
……. aah! I think maybe we don’t know that this depression is a condition that can be treated if they can seek help… Only if we know that this is a disease can people go and seek medical help, but the problem is that people don’t know that this is a disease (Herbalist FDGs3).
Traditional practitioners discussed informal support provided within the community rather than the hospital. The discussion with community volunteers highlighted differing approaches. For example, a community volunteer shared an example of an adolescent mother who attempted suicide, refused to breastfeed and abandoned her baby. The mother was taken to the police as laws were broken, instead of being taken to the hospital for mental health support. Some community volunteers agreed with this, for example: When someone has dumped a baby because the mother is not thinking well …, hmm we take the mother to the police station so that the mother is punished” (Community volunteer FDG1). However, other participants focused on the safety of the child and the mother in this situation, for example: “It is because they fear for the life of that child. So, to protect their lives (the children), they first go to the police station because if the child dies in their hands, they (the mothers) may be in trouble. We do not only want to get help for the baby but also save the life of the mother who dumped it. When you get to the police station, they tell you to go to the hospital” (Community volunteer FDG1).
Traditional healers influence
Traditional practitioners discussed providing mental health support within rural communities and the importance of traditional social support systems in the context of accessing mental health care. HCWs and traditional practitioners felt mothers seek help from spiritual healers, traditional healers or the health care system based on their perception of their health issue. Therefore, some community members consider traditional healing services the first point of contact for support.
Traditional practitioners reported that some adolescents with symptoms of mental health problems visit traditional practitioners for ‘breaking of spells’, a spell being cast by ancestor’s spirits upon the person for wrongdoing with mental health problems as a form of punishment. One traditional healer commented: “Some of the mental health disorders come when the adolescent’s parents or ancestors did not follow some rituals, and therefore, they are spiritually tied like a chain…. and this is like a covenant…… and therefore it runs in the families, and these can only be healed by breaking the chain…. another one echoed this sentiment: “They are spells from their ancestors, they can only be healed through exhortation” (Traditional healer FGD3). A spiritual healer brought a different dimension to dealing with mental issues. For example, one spiritual healer recounted an incident whereby a girl visited the spiritual healer with issues, and the healer felt the girl’s mental health issues were because she was “thinking too much”: “I had a certain girl at home who was 7 months pregnant. She was always worried when she came to me, she never opened up. I do not have a clinic, but I practice spiritual healing. She came to me and said you should test me…so I asked her what I should check on. She said just check me. When I consulted the spirits, they told me that the girl has no problems in her life, but she thinks a lot because of her wrongdoing so she should stop that. I told her that when she stopped thinking a lot, her health would improve (Spiritual healer FGD2). Similarly, another spiritual healer discussed encouraging mothers to talk, pray and make peace with others to alleviate mental health problems:
When someone with worries comes to me, we encourage each other by talking with them through prayers. Then we advise the person on how to behave where she is staying with her neighbours…If some people were not talking to her, she should be the first to open up by starting with greeting them. When they do that, they come back here to give a testimony…God has helped in resolving the disputes! And most mothers say that …. I thank God and praise him for what He has done because I never thought I would ever be happy again, but your prayers and my prayers have worked. God has answered the prayers (Spiritual healer FGD2).
In addition, traditional practitioners across all three groups perceived that sometimes, HCWs’ attitude encourages mothers to opt to seek help from traditional healers and other community-based informal providers for their mental health problems rather than HCWs. Traditional practitioners reported that the reception people receive when they visit the hospital is not always positive. For example, in FGD3 with traditional healers, one traditional healer, a traditional birth attendant, stated “Health workers are the biggest problem, so let us be open here. Instead of welcoming and assisting us based on our feelings, you treat us badly… (Traditional birth attendant FGD3). Another Herbalist stated sometimes you (health workers) take too long to assist someone…instead of assessing someone to know how they are, you are busy chatting or sliding your smartphones (Herbalist FGD3). Similarly, a spiritual healer in FGD2 stated when adolescents come to us (spiritual healers), we pray for them, sit down with them, and hold their hands. However, in hospitals, the care is left to cleaners, who sometimes send them back even without seeing a professional health worker (Spiritual healer FGD2). Given these experiences some traditional practitioners discussed the need to provide better and more compassionate care than hospitals. For example:
Even though you (health workers) do not allow women to deliver at traditional caregivers… more women around this hospital prefer to go there because they are treated well. The treatment we get from the traditional caregivers and here at the hospital is very different because of the behaviour of the people who work at the hospitals (Traditional birth attendant FGD2).
If you put the nurses and the traditional caregivers here and compare them, you will see that we manage to help people deliver babies properly in the villages. We treat people very well but at the hospital they are very cruel, they shout at pregnant women (Traditional birth attendant FGD2).
Notably, all participants from the FGDs and in-depth interviews discussed the need to collaborate with each other. Traditional practitioners felt that traditional healers and birth attendants should refer clients to the hospital. In addition, all traditional practitioners, including community volunteers, wanted more mental health training to enhance their confidence to identify and refer clients with potential mental health problems to the hospital. Participants discussed that while mental health support can be provided by different groups, such as the church, community volunteers, traditional birth attendants, and other people within the community, it was important that mothers experiencing mental health problems were referred to the hospital. HCWs emphasized that proper sensitization and awareness of traditional practitioners and the community around mental health issues is very important due to traditional practitioners’ limited knowledge and skills about maternal mental health. There was a general agreement that task sharing with collaboration is more important than working in isolation. Participants felt utilizing current community structures (community health workers, community health volunteers, and village health committees) would assist in extending support to more mothers. For example:
The traditional healers and government health workers should work together so that we should encourage the pregnant girls with such conditions (mental health problems) to go to the hospital. So that when they give birth to their baby they can go back to school, and this will ensure a better future for those young people and if we see that the girl needs counselling, we should take them to the hospital. We should work together because we are all helping people (Herbalist FGD3).
I hope the best lesson is that we should work together, we are all helping people including girls. Sometimes we are ignorant of some things, do not neglect us, give us trainings so that we refer clients to each other when we meet somethings that we cannot manage. (Traditional Birth Attendant FGD2)
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