3.1 Sample characteristics
We conducted ten FGDs with a total sample size of 73 participants: Three FGDs were with mothers (N=30), one FGD with fathers (N=10), three FGDs with nurses (N=15) and three FGDs with CHWs (N=18) (see Table 1). Most of the nurses and CHWs were women, with only one male nurse and two male CHWs. The average age of the groups varied between 25 and 45 years, with the mothers being the youngest and the CHWs the oldest. The educational level was highest among the nurses. Most of the mothers and fathers were married, except for eight mothers. The average years of experience of nurses and CHWs was above ten years, indicating that most of them were well experienced.
Table 1. Background characteristics of the FGD participants (N=73)
|
Mothers (N=30)
|
Fathers (N=10)
|
CHWs (N=18)
|
Nurses (N=15)
|
Gender (% female)
|
100%
|
0%
|
88.9%
|
93.3%
|
Average age in yrs (min – max)
|
25 (19 – 41)
|
42 (30 – 52)
|
45 (34 – 57)
|
37 (24 – 58)
|
Educational level (%)
|
|
|
|
|
Primary
|
23.3%
|
20%
|
33.4%
|
0%
|
Secondary
|
53.3%
|
30%
|
38.8%
|
0%
|
College
|
13.3%
|
40%
|
27.8%
|
86.7%
|
University
|
10%
|
10%
|
0%
|
13.3%
|
Marital status (%)
|
|
|
NA
|
NA
|
Married
|
73.3%
|
100%
|
|
|
Single
|
26.7%
|
0%
|
|
|
Average experience in yrs (min – max)
|
NA
|
NA
|
11 (1 – 25)
|
12 (1 – 32)
|
We first discussed with the groups the terminology they would use in daily life to refer to MMH problems. While an explicit reference to mental health was generally thought to suffer from stigma, there were commonly accepted terms related to stress, sadness, and anxiety in both Kiswahili and Luo (two commonly spoken languages in the community). The variety in terms highlighted that these concepts are recognized and have names in the local languages, indicating familiarity. Specifically, they introduced the following words: mawazo, paro, huzuni and kuyo, which were subsequently used during the remainder of the FGDs.
The FGD results are presented in the paragraphs below, stratified by the different levels of the conceptual model (see Figure 1) and the identified themes. We compare the findings of the different stakeholder groups and highlight the discrepancies between the groups.
3.1 Intrapersonal level
Causes of MMH challenges
Emerging themes at the intrapersonal level were causes, symptoms, and consequences. The identified causes for MMH problems were multifaceted and encompassed social, economic, cultural, relational, and medical factors. Many causes were raised by all respondent types, such as a low socio-economic status, frequently associated with limited education, unemployment, and financial insecurity. This issue was highlighted due to the anxiety stemming from having insufficient financial resources to afford pre- and postnatal care, transportation to healthcare facilities, necessities for the baby, as well as food for the family. Also, teenage pregnancy was an emerging theme in all respondent groups. It was discussed that this can lead to broken family relationships while teenage girls experience stigmatization leading to MMH challenges. Gender preference within the family was raised as another stressor for the mother by all respondent types – except the nurses. Birth given to an undesired gender can lead to strain within families, and this will increase the emotional burden on the mother even more, as demonstrated by the quotes below.
“I had a case where the partner refused to speak to his wife after she gave birth to a girl, and he wanted a son. The mother decided to pack her stuff and move back to her parents’ house. Some women even choose to stay in hospitals because of gender preference.” #CHW
This finding was also confirmed from a father’s perspective.
“When a woman gives birth to a girl and the partner was expecting a boy, the baby will not have warm welcome from the father thus stressing up the mother.” #Father
Conflict or disagreement with the partner, often resulting in domestic violence, was flagged as another important cause of stress by all parties. Mothers indicated that these conflicts are often caused because women experience a lack of support during pregnancy. According to the fathers, the reason for conflict frequently comes from the disagreement or pressure to resume sexual activity. Concerns about body image were cited by fathers as a factor contributing to MMH challenges. These concerns seemed to be related to the conflicts around sexual intercourse. Mothers did not explicitly mention body image concerns or sexual inactivity.
In addition to the above, mothers raised loneliness, lack of support and love from those around them, and uncertainty about the mode of delivery as important stressors. While the lack of partner support was also raised by the nurses and CHWs, the mothers specifically mentioned the feeling of isolation in a broader sense, also referring to other people in the community.
Regarding medical factors, mothers raised concerns regarding the uncertainty about the mode of delivery. Nurses and CHWs raised other medical factors as a cause for stress. They both highlighted that women living with HIV/AIDS who become pregnant often face emotional challenges due to fear of judgement from healthcare workers and the community. The following quote demonstrates that such situations are likely to come along with other complexities.
“Some are impregnated by boda boda [bicycle taxi] riders who happen to be married themselves. They fear disclosing the identity of the one who got them pregnant. The worst part is if the boda boda riders were HIV positive, then they will be infected too.” #Nurse
Nurses moreover mentioned medical conditions - like hypertension, anemia, and urinary tract infection – as stressors for MMH challenges. These observations are understandable given that nurses are regularly consulted for these health issues during antenatal care visits.
Symptoms & coping
While the identified causes are rather broad – ranging from economic and social to medical causes – the symptoms of MMH challenges were more homogenous. Quarreling with family members, being silent, socially withdrawing, crying, and tiredness were frequently mentioned by women, fathers, and CHWs. In addition to these symptoms, fathers mentioned mood swings, body image concerns, and refusal of sex as common symptoms. The absence of reports on MMH challenges by nurses might be attributed to the nature of their consultation. To the extent that these are predominantly focused on medical complaints, they leave little opportunity for discussions about mental health concerns.
The way how women cope with MMH challenges can best be described as them perceiving the struggles as a common issue that people face in their lives, leading mothers to regard these challenges as something they must endure. Consequently, women adopt a coping strategy of perseverance, believing that their challenges will eventually pass, as illustrated in the quote below.
“People, as in pregnant women and mothers who delivered, they just see it as a common problem that other people faced, why not them. ‘Let me just face it even if it is stress, it will end someday’, so they don’t think that there are other people who can support or care about them.” #Mother
This coping mechanism was also raised by the CHWs but not by the fathers and nurses.
Consequences of MMH challenges
The symptoms and coping strategies inevitably come along with associated consequences. Mothers, nurses and CHWs identified malnourishment, susceptibility to illness for the pregnant women and increased risk of miscarriage. These consequences flow logically from earlier identified symptoms because these described a situation in which women withdraw themself, increasing the likelihood of a vulnerable physical state. Both mothers and fathers raised that maternal stress may disrupt (intimate) relationships, potentially leading to domestic violence, as shown in the quote below.
“The libido is lowered in women thus resulting to violence.” #Father
A decrease in milk production among breastfeeding mothers was raised as a post-partum consequence by all groups, except by the fathers. Additionally, a weaker emotional bond between mother and child was another identified post-partum consequence raised by mothers and CHWs. CHWs mentioned that stressed pregnant women/mothers may not go for ANC visits or take their newborns for postnatal care and miss scheduled immunizations, or be unresponsive, as noted by a nurse:
“Some refuse to talk. If you want to probe them more, they are just quiet and stare at you.” #Nurse.
MMH challenges may also have consequences for family life and verbally or physically violent reactions of mothers towards their children and partners, as illustrated by a CHW:
“A mother who is stressed will beat up the young children in the family, is ever quarreling, not ready to listen to reasons and may even leave their homes and go back to their parents’ house.” #CHW
3.2.2 Interpersonal level
Spousal relations
Spousal relations were the first theme at the interpersonal level that emerged from the FGDs. Pregnant women were hesitant to share emotional challenges with their partner. The women raised that they are afraid to share their struggles because they fear a breach of confidentiality, which demonstrates a sign of mistrust in their partner. Women also raised the fear of physical threats and violence from their partners when they would share their emotional challenges. This anxiety towards domestic violence was also mentioned by the nurses and CHWs as demonstrated by the quote below.
“They fear repercussions of sharing with partners, especially the violent partners.” #Nurse
Interestingly, this fear is also acknowledged by the fathers, as one of them describes:
“Some are afraid to tell their partners because once they tell them they will offer solutions out of total sacrifice, and they don’t want to burden them with their feelings. Some also don’t share for the fear of their partners overreacting and thus resulting to violence.” #Father
It is important to note that the fathers not necessarily shared their own experiences but also reflected on behaviors they observed from others. The above quote also shows that fathers believed that some women do not want to burden their partners with their emotions. Fathers on the other hand found it difficult to provide appropriate support to their wives. Often, they did not fully understand her challenges and realized that they were unable to immediately solve the problem. Fathers emphasized that they were also in need of mental support because they face emotional challenges when their wives are in distress.
Families
Whether women shared their emotions with family members varied according to the type of relationship they had, but it was not a common practice. In the case of teenage pregnancies, girls generally feared parents’ attitudes, which could create a significant barrier for underage girls to ask for support when they experience emotional challenges. Both mothers and CHWs described these situations. The quote below illustrates a consequence of unsupportive family members.
“In my unit there was a teen girl who the mother helped terminate her pregnancy as the father threatened to discontinue paying her school fees.” #CHW
Friends
The friends make part of another social layer that women could use to share their emotions with. Here too, the concerns about privacy make women hesitant to share intimate problems. While some women share their feelings and challenges with close friends, other women are feeling shy or are worried that it will lead to gossiping. Besides this, a common perception among women was that they doubt whether sharing problems will lead to any meaningful help and support. This perception relates to the earlier discussed coping mechanism of perseverance when facing emotional challenges. Additionally, women raised that some may choose to share their problems more openly after giving birth - when the burden has lifted – because, at that point, they are able to share these emotions more easily. The fathers do not favor it when their partner shares emotional struggles with their social environment, as shown in the quote below.
“We would approve for them to get help when they are seeking help from professionals. But we don’t approve of them seeking help from friends especially female friends as they most often than not deceive them thus creating more problems.” #Father
CHWs were aware that some women seek advice from friends, who in turn direct them towards the CHWs. Nurses seemed to be less informed than CHWs in the way that women may seek help from their friends or relatives when they have emotional challenges.
3.2.3 Community level
Community views & stigma
According to the women, their community members view the emotional challenges faced by pregnant women as a natural part of life. Consequently, complaining about MMH struggles is not considered acceptable within the community:
“The community does not fully understand this. They feel that you are not the first to get pregnant or even give birth. They feel the mother should harden a little bit.” #Mother
Because of these persistent views within the community, women often do not disclose their true feelings to others as described in the quote below.
“When you say you are mentally disturbed or emotionally disturbed in our society, they’ll say you’re just pretending. They’ll tell you that you are not the first to give birth or to get pregnant. People have done it. You see, you can’t come out, you just die inside slowly.” #Mother
Additionally, women also raised that they will not share their problems openly because they want to fit in the social circle. The urge to behave in a socially acceptable manner aligns with the nurses’ and CHWs’ perspectives as they shared that women fear the judgement from others. The quote below shows how far women can go to maintain their social image.
“The reasons why women stay in abusive marriage is they don't want to be labeled as one who couldn't keep their marriage 'odhi oduogo'1, their dowry had already been paid and find it hard to go back to the parents’ house, some mothers also advice their daughters to stay as they themselves went through the same ordeal.” #CHW
Besides the stigma towards emotional challenges during pregnancy, nurses also raised the existence of stigma towards certain groups, like pregnant adolescents; women with HIV who are pregnant; and older pregnant women. The fear of stigma among those groups can prevent women from opening up, making them vulnerable for mental health challenges. The fathers did not share any insights on views or stigma within the community.
Church & school
The fear of gossip is not restricted to neighbors and friends but is also extended to the church. While the fathers indicated that most women are comfortable within the church and tend to seek help in churches by approaching the pastor, mothers raised that they feel restricted to openly share emotions with the – mostly male – religious leaders in their communities. Additionally, women indicated that they have privacy concerns when consulting pastors or other church members. This was also mentioned by the CHWs:
“They sometimes use your problems as a sermon topic and preach it to everyone. Also, some pastors snatch people's wives as they know the ins and out of that family.” #CHW
On the other hand, women mentioned that churches do provide practical support as illustrated in the quote below.
“Okay, one can go to church and get help, especially food donations.” #Mother
The nurses shared that within schools, the stigma towards teenage pregnancies is persistent, with both peers and teachers contributing to this.
3.2.4 Institutional level
Mothers’ perceptions on the availability of institutional emotional support
While participants were able to identify non-institutionalized routes for support, albeit imperfect ones, mothers were unaware of official routes for obtaining maternal emotional support. According to CHWs and women, mothers may only briefly share their feelings with nurses but tend not to open up due to nurses’ perceived negative attitudes and harsh behavior, as illustrated in the below quote from a mother.
“Also, the way the health care workers handle you will prevent you from seeking care.” #Mother
The CHWs voiced similar experiences.
“They don’t share because as my colleague has said, you would love to share with the nurse but when you look at them, they would be moody and in a rush of finishing their work. The minute you want to talk to them they call someone else inside.” #CHW
Consequently, the current situation in healthcare facilities – the perceived negative attitude of healthcare workers – creates fear and deters (pregnant) women from seeking emotional support. However, when appropriate mental health support would be available, mothers indicated that they would make use of it because it removes the confidentiality issues they face in their own social environment. The support from family members, including fathers and parents-in-laws, to seek institutional emotional help will be crucial, according to the women, but surely not a given, as illustrated in the quote below.
“They'll say you pretend to go for counseling sessions but instead have other plans. They might even insult you.” #Mother
The role of CHWs in providing institutional emotional support
CHWs could also play a role in supporting women’s mental health needs. The CHWs mentioned that many (pregnant) women share their emotional challenges and feelings with them due to their close connection, which encourages them to open up. The CHWs characterize their function as that of a liaison between women and nurses because they are uniquely positioned to identify challenges. The CHWs emphasized the noted lack of formal psychosocial support services and showed their willingness to receive training to provide emotional support.
The role of nurses in providing institutional emotional support
In line with the experience of CHWs, the nurses encounter challenges regarding the provision of professional emotional support to pregnant women. They highlighted the lack of a referral system, a shortage of trained counselors and the absence of a designated space for counseling. The nurses stated that they do their best to collaborate with CHWs to improve the wellbeing of pregnant women. On top of this, nurses indicated that they face emotional distress themselves because of their inability to offer appropriate treatment to the women, as described in the quote below.
“It's not easy. We also undergo psychological problems. When they are not getting the treatment they need, you can also get mad.” #Nurse
3.3 Suggestions for an MMH intervention
Finally, the FGD participants were asked about their views of how to design and implement a MMH intervention that would be acceptable to the women, fathers, healthcare workers and the community. Based on the in-depth discussions of needs and challenges in the first part of the FGDs, most participants were well able to reflect on their preferences in this regard. The insights from the different groups are synthesized in Textbox 1. We differentiate between suggestions on who should be involved, the topics to cover, and the practical requirements of the care.
All respondent groups advocated for the involvement of fathers during MMH care, either in a separate male group or together with the women. It was emphasized, however, that friends or other members of the community should be excluded to ensure confidentiality. CHWs were willing to take up a central role, but they insisted on receiving training to learn to communicate effectively without getting emotionally involved. In terms of topics, stimulating income-generating activities was a dominant suggestion by the CHWs and nurses to make women more financially independent, while the mothers prioritized receiving health information, and the fathers prioritized emotional support. There was an overall agreement to offer the care within the hospital, as this would enhance privacy while simultaneously underscoring that the intervention is part of standard care, thereby reducing stigmatization and improving normalization. Although confidentially was highly valued, the women were in favor of receiving MMH care in a group setting with fellow pregnant women who are in the same situation so they can relate to each other.
Based on these findings, a recommendation that may be supported and accepted by all stakeholders is an intervention at the institutional level, e.g. in the form of group sessions at the health facility. Involving the partner in such an intervention is valued by all parties, which captures the interpersonal level. In addition to providing support on how to cope with emotional challenges, information on mothers’ and babies’ health issues as well as on how to enhance financial empowerment were valued in terms of content.
Textbox 1. Recommendations for a contextualized MMH intervention in Kenya according to different stakeholders
Who should be involved?
|
Mothers
|
Fathers
|
Community Health Workers
|
Nurses
|
… want their fathers to be involved because they are often part of the problem.
|
… are open to be involved to understand their partner better.
|
“I’d love to accompany her for counseling. I wouldn’t want her to go by herself. I’d want to hear what she’s being told.”
|
… are in favor of involving fathers, which could be in a separate session.
|
… want to involve fathers from the beginning of ANC visits.
|
… consider it important to involve family when the pregnant women still live with their parents.
|
Not mentioned.
|
Not mentioned.
|
… mentioned that family can be included during outreach.
|
Not mentioned.
|
Not mentioned.
|
… would like to receive continuous advice and support from other healthcare professionals.
|
… want CHWs to play an important role.
|
Not mentioned.
|
Not mentioned.
|
… are open to involve other influential community members.
|
“Spiritual leaders and even chief's as they deal with security.”
|
Not mentioned.
|
What topics should be covered?
|
Mothers
|
Fathers
|
Community Health Workers
|
Nurses
|
… would like to receive mother and child health education on e.g. breastfeeding.
|
Not mentioned.
|
… suggested health education on e.g. nutrition, family planning, importance of ANC visits.
|
… suggested health education to stimulate ANC visits and to offer basic birth packs.
|
Not mentioned.
|
Not mentioned.
|
… suggested activities to financially empower women, such as income generating activities.
|
… suggested activities to financially empower women, such as income generating activities.
|
Not mentioned.
|
… mentioned that they (the partner) are also in need for emotional support.
|
… suggested to provide emotional support (e.g. teaching on psychological problems)
|
… suggested to provide emotional support (e.g. teaching on psychological problems)
|
… also want to meet peers who experience the same to share experiences and for support.
|
Not mentioned.
|
Not mentioned.
|
… suggested for women to meet peers to share experiences and for support.
|
What are practical requirements?
|
Mothers
|
Fathers
|
Community Health Workers
|
Nurses
|
… preferred group sessions in the hospital to avoid stigma
|
… suggested to make it part of ANC visit in the hospital.
|
… preferred group sessions held within the community (e.g. in hospitals, schools, churches).
|
… preferred group sessions.
|
… preferred a stranger to lead the sessions for confidentiality. Ambivalent regarding the gender.
|
… preferred a stranger to lead the sessions. Ambivalent regarding the gender.
|
… considered the attitude of the counselor as crucial.
|
Not mentioned.
|
… needed a written confirmation regarding the sessions.
|
“Written would be good as verbal might create conflict at home when husband thinks you are not going where you said you were going.”
|
…considered respect for privacy very important.
|
Not mentioned.
|
… considered respect for privacy very important.
|
“If their problems are not shared, it will motivate them to attend more sessions.”
|
… preferred a form of refreshments during the sessions.
|
… want a form of financial support.
|
… suggested transportation reimbursement and refreshments during the sessions.
|
… suggested transportation reimbursement, the provision of birth packs and refreshments.
|
Not mentioned.
|
Not mentioned.
|
… raised that outreach to mothers after delivery is important to check mental well-being.
|
… suggested outreach to mothers after delivery.
|