Barriers to maternal mental healthcare in Sri Lanka: a health systems puzzle

By: Sabine Margarete Damerow

Maternal healthcare in Sri Lanka is a health systems success story against many odds (1). Sri Lanka is a lower-middle income country (2), which was heavily affected by both a protracted civil war and the 2004 Indian Ocean tsunami (1). Nevertheless, public health has been politically prioritized throughout Sri Lanka’s history (3). Large-scale health system strengthening measures to promote maternal health have thus not only been adopted as early as the 1930s, but also expanded since then (3,4).

Notable examples include the country-wide establishment of community-based maternal healthcare services alongside universal health coverage, midwifery professionalization, expansion of skilled birth assistance, and investments in higher-level referral networks and family planning services (3,4). These measures have contributed to an impressive reduction in Sri Lanka’s maternal mortality ratios (4). Between the 1930s and 2015, maternal mortality plummeted from almost 2,000 to 33 deaths per 100,000 live births (4); meanwhile this accounted for 257 deaths per 100,000 live births across all lower-middle-income countries in 2015 (5). Justly, Sri Lanka serves as a role model for maternal health promotion among developing countries (1,4).

In the light of this remarkable success, downtrends in the country’s maternal mental health outcomes provide a puzzle. These have been observed since the 2000s. Between 2002 and 2010, maternal suicide ratios sharply increased from 0.8 to 12.1 suicides per 100,000 live births (6,7), and maternal suicides were found to be Sri Lanka’s leading cause of maternal deaths (8). At the same time, Sri Lanka is burdened by a high prevalence of peripartum depression.

Accordingly, the prevalence of antenatal depression was estimated to be 16% in pregnant women in Sri Lanka’s Anuradhapura district in 2013 (9), while postpartum depression affected 27% of mothers island-wide in 2010 (10). In contrast, recent global estimates account for 10% and 13% in pregnant and postpartum women, respectively (11). Like general maternal health outcomes, adverse maternal mental health outcomes are suggested to be effectively preventable by adequate health systems responses. These include timely diagnoses and appropriate treatment of mental health issues (6). This raises the question of why Sri Lanka’s health system is struggling to promote maternal mental health as effectively as general maternal health.

This summer, during a three-week field course on cross-disciplinary health research I pursued in Anuradhapura, the capital of Sri Lanka’s north central province, our team wanted to find out more about this puzzle on-site, keen to contribute to its solving. Organized by the University of Copenhagen in partnership with the Rajarata University of Sri Lanka, this field course brought together 25 postgraduate students and professionals from eleven countries to gain hands-on field research experience in some of Sri Lanka’s pressing issues in the field of global health, facilitated by researchers from both universities and local medical students.

Our team, consisting of four international and two local students from the fields of Anthropology, Economics, Global Health and Medicine, decided to use a qualitative, exploratory approach to assess barriers to maternal mental healthcare services in the Anuradhapura district. We interviewed a wide range of potential stakeholders and carried out participant observation with the aim of achieving a thorough overview of potential barriers. Participants included local mothers (sometimes alone and sometimes with their husbands), service providers and regional health system officials, using mainly in-depth interviews and one focus group discussion.

Our field research provided us with striking observations: Firstly, the mothers reflected a clear demand for maternal mental healthcare in their communities – support was consistently deemed required. Easily accessible, community-close maternal mental healthcare services seem to be, however, largely lacking. Although we met public health midwives who try to close the gap by putting incredible efforts in providing community-based maternal mental health support on top of their daily duties, the official health system response appears to be concentrated on highly-specialized, tertiary level psychiatric care. These services, in turn, seem to be linked to many acceptability and accessibility barriers and mothers hence described largely comprehensible reasons for avoiding their utilization, such as fear of stigmatization and distance constraints. Additionally, not all mothers were aware of the existence of these services. Unsurprisingly, an insufficient service utilization was portrayed by both service providers and regional health system officials, and service providers referred to mothers’ attitudes and their reluctance to attend treatment as barriers to maternal mental healthcare services.

These observations call for an improved health system response along with further research. A patient-centered, community-based provision of maternal mental healthcare and measures to mitigate stigmatization seem to be urgently needed. One approach that appeared to us both relatively quickly implementable and economical would be an establishment of community-based self-help groups under the guidance of public health midwives. Apart from providing a setting for discussing personal issues, these self-help groups might contribute to an increased awareness of maternal mental health issues, empower mothers and mitigate stigmatization. In the long-run, however, an expansion of maternal mental healthcare services to primary and secondary levels seem to be pivotal to sustainably solve Sri Lanka’s maternal mental healthcare puzzle.

Disclaimer: The views and opinions expressed in this article are those of the author, based on experiences gained during the 2018 edition of the field course on cross-disciplinary health research in Sri Lanka organized by the University of Copenhagen in partnership with the Rajarata University of Sri Lanka, and the teamwork conducted in this context.

Acknowledgements: I am grateful for the great collaboration with Ina Siby, Maya L. Schtulberg, Nanna Witt, Tharushi H. Dissanayake and H.M.U. Tharuprabha Herath and the guidance and support of our supervisor, Dr. Thilini C. Agampodi from the Rajarata University of Sri Lanka, both in preparation to this summer school and on-site in Anuradhapura that paved the way for a great field research experience. Furthermore, I would like to thank the course facilitators, coordinators and the supervision team from the University of Copenhagen and the Rajarata University of Sri Lanka for the very smooth organization, their encouragement and advice.

References:

1. UNICEF (s.a.) Prioritizing maternal health in Sri Lanka. Available from: https://www.unicef.org/sowc09/docs/SOWC09-Panel-1.5-EN.pdf (24 September 2018)
2. The World Bank (2018) World Bank Country and Lending Groups. Available from: https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups (24 September 2018)
3. Seneviratne, H.; Rajapaksa, L. (2000) Safe motherhood in Sri Lanka: A 100‐year march. International Journal of Gynecology & Obstetrics. 70(1), 113-124. Doi: 10.1016/S0020-7292(00)00223-X
4. The World Health Organization Country Office for Sri Lanka; Ministry of Health, Nutrition and Indigenous Medicine (s.a.) Public health success in Sri Lanka. Available from: http://www.searo.who.int/srilanka/documents/policybriefsfinal.pdf?ua=1 (30 September 2018)
5. The World Bank (2018) World Bank Open Data. Available from: https://data.worldbank.org/ (24 September 2018)
6. Isuru, L.L.A.; Gunathillaka, K.D.K.; Kathriarachchi, S.T. (2016) Reducing maternal suicide in Sri Lanka: closing the gap. Sri Lanka Journal of Psychiatry. 7(1), 1-3. Available from: https://sljpsyc.sljol.info/articles/abstract/10.4038/sljpsyc.v7i1.8095/ (30 September 2018)
7. Jayaratne, K. (2013) Maternal Suicides in Sri Lanka: Lessons learnt from review of maternal deaths over 9 years (2002-2010), in University of Colombo (ed.) Suicide in Sri Lanka: Past, present and future transformations [Conference Proceedings], 22. Available from: https://suicideandculture.files.wordpress.com/2013/03/suicide-in-sri-lanka-proceedings_final1.pdf (30 September 2018)
8. Fernando, R. (2013) Maternal suicide is the leading cause of pregnancy‐related deaths in Sri Lanka. Journal of Obstetrics and Gynaecology Research, 39(10), 1492-1493. Doi: 10.1111/jog.12134
9. Agampodi, S.B.; Agampodi, T.C. (2013) Antenatal depression in Anuradhapura, Sri Lanka and the factor structure of the Sinhalese version of Edinburgh postpartum depression scale among pregnant women. PLoS ONE, 8(7), e69708. Doi: 10.1371/journal.pone.0069708
10. Agampodi, T.C.; Agampodi, S.B.; Wickramasinghe, W.A.N.D.; Adhikari, A.M.C.W.B.; Chathurani, H.K.J.U. (2011) Post partum depression – a problem that needs urgent attention. Ceylon Med J, 56(4), 183-4. Available from: https://cmj.sljol.info/articles/abstract/10.4038/cmj.v56i4.3907/ (30 September 2018)
11. The World Health Organization (2018) Maternal mental health. Available from: http://www.who.int/mental_health/maternal-child/maternal_mental_health/en/ (30 September 2018).