“We sometimes stress our own wives” - Perceptions of Maternal Mental Health Challenges and Recommendation towards Emotional and Psychological Support from Mothers, Fathers, Nurses, and Community Health Workers in Western Kenya

doi:10.21203/rs.3.rs-5117194/v1

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Research Article

“We sometimes stress our own wives” - Perceptions of Maternal Mental Health Challenges and Recommendation towards Emotional and Psychological Support from Mothers, Fathers, Nurses, and Community Health Workers in Western Kenya

https://doi.org/10.21203/rs.3.rs-5117194/v1

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Background

In low- and middle-income countries (LMICs), maternal mental health (MMH) during and after pregnancy is often neglected despite ongoing global efforts to reduce maternal mortality and morbidity. The complex nature of MMH problems and their stigmatization require a thorough understanding from the perspective of the different parties involved. Hence, we assessed the drivers of MMH problems, challenges in seeking help, and perceptions towards emotional and psychological support for pregnant women among four stakeholder groups in Western Kenya.

Methodology

A qualitative approach was taken to examine the perspectives towards MMH among mothers, fathers, nurses and community health workers (CHWs). Focus Group Discussions (FGDs) were organized among the four groups. Participants were drawn from three hospitals in Kisumu County, Western Kenya. The socio-ecological model for health behavior structured the analyses, with an initial deductive approach. The identification of specific themes within each level was conducted inductively. Additionally, suggestions for locally acceptable MMH care were collected.

Results

In total, ten FGDs were held with 73 participants. We found a large level of consensus among stakeholders regarding common causes, consequences and coping strategies for MMH challenges, such as poverty, stigma, intimate partner violence and a lack of social support. In contrast to mothers, fathers also highlighted domestic disputes stemming from disagreements over (resuming) sexual activity. Nurses predominantly mentioned medical consequences of MMH challenges, while CHWs had a more holistic perspective. Participants expressed a need and made recommendations for contextualized MMH care, particularly for a group-based intervention led by CHWs with partner involvement.

Conclusions

The findings show that there is a need for MMH support in rural, low-resource settings. Mothers and CHWs showed a high level of convergence illustrating the importance of the liaison function of the CHWs between the nurses and mothers. Group-based MMH care was perceived as suitable by all stakeholders. The results of this study guided the design of an MMH intervention that was tested for feasibility and acceptability in the same setting.

maternal mental health

perinatal depression

postnatal depression

mental health

focus group discussions

Kenya

pregnancy

Maternal, neonatal and child health (MNCH) features high on the global health agenda, while maternal mental health (MMH) is notoriously lacking in large-scale MNCH programs. Mental health is defined as “a state of mental well-being that enables people to cope with the stresses of life, realize their abilities, learn well and work well, and contribute to their community” (World Health Organization, 2022b). Worldwide, nearly one in five women will face an unfavorable mental health condition either during pregnancy or within the year following childbirth (WHO & UNFPA, 2008). Besides the economic and human costs of MMH challenges, the spill-over effects to the child can be significant, with a higher risk for developmental and behavioral problems (Leis et al., 2014; Walker et al., 2020).

In Sub-Saharan Africa (SSA), pregnant women are disproportionally impacted - one out of every four pregnant women are affected by depression (Dadi et al., 2020). Mental health problems are often not socially recognized and consequentially stigmatized in various African contexts (Mutahi et al., 2022), affecting the healthcare-seeking behavior of those facing psychological challenges (Jenkins et al., 2013). In Kenya, it was found that mental illness is more stigmatized than HIV/AIDS or leprosy (Jenkins et al., 2013), demonstrating the magnitude of the problem. Other reasons for low healthcare-seeking behavior with respect to MMH problems were a lack of knowledge, transportation costs to the clinic, and a lack of trust in clinical staff due to fear of confidential information being shared (Nakku et al., 2016).

The causes of MMH problems in women are dominantly routed in previous stressful life events, financial insecurity, intimate partner violence, food insecurity and physical challenges (Bitew et al., 2019; Kariuki et al., 2022). Other studies identified the perceived influence of unsupportive spouses and intimate partner violence as social origins of maternal distress in Eastern Africa (Osok, Kigamwa, Huang, et al., 2018; Tol et al., 2018). This highlights the importance of involving spouses or fathers – who are often excluded from MMH studies and interventions – in an assessment of the perceived need for and attitudes towards MMH care. Even less is known about healthcare worker’s perspectives towards MMH problems, but a recent Kenyan study reported that healthcare workers have a limited scope of practice, which hinders them from adequately following-up on women at risk of developing mental health problems (Goyal et al., 2023).

Besides the low demand for MMH care due to, amongst others, stigma and low awareness, there is a substantial treatment gap due to the absence of available MMH services. While the scarcity of the mental health workforce is a worldwide concern, the problem is most acute in Africa which counts only 1.6 mental health workers per 100,000 population - compared to e.g. a ratio of 44.8/100,000 in Europe (Mental Health Atlas, 2021). Worth noting is that also in many Western countries the human resources constraints in mental health care delivery remain significant. Integration of MMH services at the primary care level is considered a key strategy to improve care accessibility as this will contribute to the normalization of mental health problems and thus reduce stigma and promote efficient use of available resources (World Health Organization, 2022a). In total 25 African countries report that they have national guidelines for the integration of mental health services available (Mental Health Atlas, 2021). Some of these national mental health policies put emphasis on pregnant women as a vulnerable group. However, none of these policies entail plans covering MMH services (Baron et al., 2016).

The Kenya Mental Health Policy 2015–2030 was developed and driven by the need to reform the mental health systems in Kenya (Ministry of Health, 2015). In this document children and women are highlighted as groups vulnerable to mental disorders, requiring targeted mental health interventions. Addressing MMH challenges requires a contextualized and customized approach. The complex nature of MMH problems and their stigmatization in the African context makes it crucial to first understand and contextualize the needs and perceptions of the different parties involved (including healthcare workers and fathers) before developing interventions that aim at improving MMH (Fitzgerald et al., 2024). Hence, this study aims to assess the drivers of MMH problems, challenges in seeking help, and perceptions towards emotional and psychological support for pregnant women among mothers, fathers, nurses, and Community Health Workers (CHWs) in rural Western Kenya. The involvement of the fathers’ perspectives as well as the triangulation of women’s and men’s experiences and attitudes with those of formal and informal healthcare providers differentiate this study from previous research. Findings from this study contribute to ongoing MNCH interventions in LMICs.

2.1 Study design

We designed a cross-sectional qualitative study to assess the drivers of MMH problems, challenges in seeking help, and perceptions towards emotional and psychological support for pregnant women in rural Western Kenya. To encompass all relevant perspectives, we conducted focus group discussions (FGDs) among mothers, fathers, nurses, and CHWs.

2.2 Study setting

The study was conducted in Kisumu County in Western Kenya. The county is inhabited by 1,2 million people and is located along Lake Victoria. The under-five mortality in Kisumu is higher compared to the rest of the country, with, respectively, 45 and 41 deaths per 1,000 live births (KNBS & MoH, 2022). While teenage pregnancy is slightly more prevalent in Kenya compared to Kisumu (15% versus 11%), the prevalence of gender-based violence is higher in Kisumu (36%) compared to the national average (34%) (KNBS & MoH, 2022).

In Kenya, there is a shortage of specialized mental health professionals. Consequently, the government of Kisumu is calling for the CHWs to play an important role in raising awareness on mental health (County Government of Kisumu, 2021). The CHWs are trusted by the community members in their village and often serve as the only link between patients and primary healthcare facilities, making them the backbone of the mental health ecosystem. Kenya launched a new initiative in 2023 in which CHWs receive formal recognition for their critical role (The Community Health Services Bill, 2023), paving the way for even more involvement.

2.3 Study population, sampling and procedures

Clinics and participants were selected from the target population of the MomCare program, which is an initiative of PharmAccess Foundation. MomCare was launched in November 2017 and enrolls pregnant women in a partly or fully subsidized health insurance program. Enrolled women receive a “health wallet” on their phone which they can use to pay for their maternal care services. The MomCare bundle covers basic maternal and neonatal services and concludes with three immunizations for the newborn. The health wallet can only be used at a selected network of upgraded clinics.

The study population consisted of mothers, fathers, nurses, and CHWs who had been involved in MomCare during their own or their wives’ pregnancy, or as a healthcare provider or CHW attached to a MomCare clinic. Women enrolled in the MomCare program were on average 27 years old, had an average household size of four people, and approximately one third (32%) of them were classified as having a low wealth status. More details on the MomCare population are provided elsewhere (Aksünger et al., 2022). In this study we also collected background characteristics during the FGDs for each participant.

Participants for this study were sampled from three health facilities in Kisumu, namely: Kombewa Sub-County Hospital, St. Monica and Masaba Hospital. These clinics were enrolled in the MomCare program and selected purposively for this study. The inclusion criterion for the mothers and fathers was that they (or their partner) recently delivered in a clinic with the MomCare program. They were approached and recruited in the study by the CHWs.

2.4 Conceptual model

The socio-ecological model for health behavior was used to understand the MMH care seeking behavior, needs, and challenges (Mcleroy et al., 1988). Figure 1 shows the adapted model for this study. The model was considered appropriate because it allowed us to pragmatically structure factors operating at different socio-ecological levels in this exploratory study. The intrapersonal level acknowledges that individual choices and motivations play a role in health behaviors, involving personal knowledge, attitudes, perceptions (KAP), and actual behaviors. The next layer depicts the interpersonal level which focuses on the influence of the social network and relationships on individuals’ KAP and behavior. The community level extends to the broader social environment, including the church and school, which are captured in this study. At the institutional level we focused on the healthcare facility and the role of the different healthcare professionals and how they affect KAP and behavior. The final layer, public policy, is depicted in our model with a dotted line because we did not collect data on this level, but it certainly has an impact since the laws and policies affect the accessibility to mental healthcare services. As described in the introduction, the Kenya Mental Health Policy 2015 – 2030 was developed driven by the need to reform the mental health systems in Kenya (Ministry of Health, 2015). While the number of mental health workers per 100 000 population significantly increased between 2017 – 2020 from 0.18 to 15.32, there are no specific programs devoted to MMH promotion and prevention currently in place (World Health Organization, 2020).

It is important to acknowledge that this model emphasizes the interactions between the different levels and that changes at one level can have effects throughout the entire system. Hence, interventions based on this model tend to address factors at multiple levels simultaneously to create a comprehensive and sustainable impact on the health behavior at stake (Golden & Earp, 2012; Lee et al., 2017; Tehrani et al., 2016).

2.5 Data collection

The FGDs were conducted in October - November 2021. The data collection took place in a neutral environment at the healthcare facilities where the participants felt at ease and comfortable to speak out. The stakeholder groups – mothers, fathers, nurses, CHWs – were each placed in a separate FGD consisting of a maximum of ten participants. The FGDs were led by two independent qualitative researchers, and the discussions were audio recorded, verbatim transcribed and translated to English (the discussions were conducted in the local language). The participants received a small incentive in the form of refreshments and reimbursements for their travel costs. The topic guide was structured around the following topics:

Perceptions regarding the emotional and psychological needs of pregnant women and young mothers in this community.
Challenges regarding receiving emotional and psychological support from husbands, relatives and the community.
Currently available support services for pregnant women and young mothers.
The requirements for good emotional and psychological maternal support services.
Other suggestions on making emotional and psychological maternal services more accessible and acceptable.

The same topics were discussed in each stakeholder group, allowing for triangulation and comparison between the different views. The detailed topic guide for each group is reported in Additional file 1. The FGDs lasted between 60-90 minutes.

2.6 Data processing and analysis

All transcripts were translated by two independent translators and imported into the software NVivo release 1.7 (1533). We utilized the socio-ecological model for health behavior (Figure 1) to structure the analyses, and thus the initial analysis approach was guided deductively. We continued with identifying themes at each level of the model. The identification of the specific themes within each level was conducted inductively, allowing for the emergence of new insights grounded in the data. The identified themes are listed for each level in Figure 1. The combined approach enabled us to capture the complexity and interplay of factors affecting health behavior across different levels of influence. We compared the findings between the different stakeholder groups to identify similarities and differences. All transcripts were read and coded independently by at least two researchers (CD and either SK or WJ). Regular meetings between the researchers were organized to review the consistencies and inconsistencies that were highlighted by the software. The third researcher was involved to resolve any inconsistencies. TS and EW assessed the final coding.

2.7 Ethics

Ethical approval was obtained by the Amref Ethics and Scientific Review Committee (ESRC) on September 9, 2021, with approval number P1033/2021. Additionally, all participants were asked to read and sign the informed consent form before the FGDs started. They were informed that they could withdraw from the study at any point in time and that their data would be treated confidentially and securely stored.

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.

This study examined the drivers, symptoms, and consequences of MMH problems, as well as perceptions towards the access to emotional and psychological support for pregnant women among four stakeholder groups in Western Kenya. While we found a consensus among mothers, fathers, CHWs and nurses regarding common causes, consequences and coping strategies of MMH challenges, the findings also revealed important differences. Especially mothers and fathers differed in their assessments of the causes of MMH challenges and potential ways of addressing them. Moreover, CHWs showed a more holistic perspective compared to nurses on the mental health situation of the women. Mothers and CHWs showed a high level of convergence illustrating the importance of the liaison function of the CHWs between nurses and mothers.

The terminology of mental health encountered great stigma. Nevertheless, commonly accepted terms – related to stress, sadness and anxiety – exist in both Kiswahili and Luo (two commonly spoken languages in the community), illustrating the recognition of mental health problems in the community. Despite this recognition, women indicated that a frequent way of coping with emotional distress was just to persevere. Community members generally consider distress around pregnancy as a common issue that all women face and that one should not complain about. Thus, seeking professional help is usually not considered. Other qualitative studies in Africa also report that mental health challenges during pregnancy are recognized, but not labeled as “health” problems (Ng’oma et al., 2020; Teffo & Rispel, 2020). This might partly be explained by a cultural context in which motherhood holds significant importance and women are considered to play a pivotal role in society to ensure the continuity of humanity (Makinde, 2004). Hence, the expression of discomfort and distress while pregnant might be stigmatized and deemed unacceptable.

Poverty was identified by all stakeholders as a major source of stress. When financial resources are scarce, pregnant women fear they will be unable to pay for transport to the clinic or hospital bills, to provide for their baby or to buy food for their other children and themselves. Moreover, disputes over money contribute substantially to domestic conflicts. This has been broadly confirmed in the literature (Palfreyman & Gazeley, 2022). Financial empowerment of pregnant women was suggested as a strategy to reduce their dependency on their partner. One of the suggestions therefore during the FGDs was to link the MMH support sessions to income-generating activities, such as modules on how to (jointly) grow their own crops or develop one’s own business.

The fathers often mentioned conflicts in the sexual relationship during pregnancy and postpartum, noting that women faced body image issues. They also raised that this often results in conflicts between spouses, which they identified as a significant stressor for MMH challenges. While sexual conflicts were not a dominant theme for mothers, domestic conflicts in general, often escalating to domestic violence, were emphasized by both mothers and CHWs. All stakeholder groups recognized the importance of involving partners from the start in MMH interventions. The lack of awareness among fathers, and their inadequate, often violent, responses were identified as major sources of stress for women. Their inclusion could potentially redress these challenges and allow fathers to play a crucial supportive role during the pregnancy of their wives.

The results highlight the pivotal role of CHWs within the community. Triangulation of the findings revealed a high level of consensus between mothers and CHWs on the identified themes, underscoring CHW’s deep understanding of the underlying challenges and needs. This contrasts sharply with the perspectives of nurses, who primarily provided medical insights and refrained from addressing social support issues. Pregnant women do not easily share their emotional challenges with others in the community, whether it be with their relatives, friends or religious leaders. However, CHWs, who are often trusted and have relatively easy access to households, are well-positioned to facilitate discussions on maternal mental health challenges.

Normalizing professional support for mental health challenges is a way to reduce stigmatization among mothers, fathers, CHWs and nurses. However, with Africa having only 1.6 mental health workers per 100,000 population, promoting specialized mental health care as the primary solution is challenging. Advocacy for the integration of MMH services at the primary care level remains essential (World Health Organization, 2022a), but given the high workload of nurses and significant shortages in the mental health workforce, alternative approaches are necessary to fill current gaps. Task-sharing with non-professionals seems to be the clear way forward (Patel, 2022). Hence, the involvement of CHWs in the provision of MMH services is a promising strategy, although the increasing burden on CHWs might limit its feasibility. Working with other lay facilitators from the community, such as retired nurses or teachers, might be another solution.

Nurses highlighted the stigmatization of particularly vulnerable groups among pregnant women, such as those who are HIV-positive, pregnant teenagers, and older women. While older women are an understudied vulnerable group, the literature indicates a high burden of emotional problems among pregnant and postpartum HIV+ women globally (Kapetanovic et al., 2014). Osok, Kigamwa, Stoep, et al. (2018) found a correlation between being diagnosed with HIV/AIDS and depression among adolescents in Kenya. The HIV-related stigma in Kenya among pregnant women has been associated with avoidant coping mechanisms (Cuca et al., 2012). Similarly, adolescent pregnancies in SSA are persistently stigmatized (Mutahi et al., 2022). According to the World Health Organization (2023), there are approximately 21 million adolescent pregnancies in LMICs, with 50% being unintended. Mental stress among vulnerable adolescents in Kenya is a significant problem, highlighting the need for psychosocial support for this specific group (Wainaina et al., 2021).

A strength of our study is its inclusion of four different stakeholders and the triangulation of their perspectives. Other studies mostly focus on one or two groups of respondents, such as the perspectives of Kenyan policymakers (Obonyo et al. (2023), or nurses and CHWs (Bitew et al., 2020; Kumar et al., 2018). Our unique contribution is the inclusion of fathers, which to our knowledge has not been assessed in previous studies. Considering partners’ perspective is highly relevant because our findings, consistent with other studies (Bitew et al., 2019), indicate that they are frequently a source of stress. Our results demonstrate that men often encounter difficulties in offering appropriate support, even when they have the desire to do so, due to a lack of understanding of their wives’ needs. This lack of understanding may be attributed to women not being accustomed – due the cultural stigma - to expressing their feelings and thus often being unable to communicate their needs effectively.

We must acknowledge certain limitations of this research. Firstly, the study was conducted in a specific context, rural Western Kenya. Nevertheless, SSA is home to many comparable rural environments and therefore the findings are likely to be applicable to similar settings where access to mental health professionals is scarce, maternal mental health knowledge is limited and mental health during the perinatal period is stigmatized. Secondly, the sample that we interviewed may suffer from selection bias because individuals who are more likely to open-up are more likely to participate in a research study, leading to the exclusion of those individuals who might be most in need of mental health support. Because this study was conducted within the MomCare setting, which is highly trusted by the community, we expect that also relatively shy people felt comfortable to participate in this study.

Our findings also include a recommendation for MMH services in group sessions, which is an efficient approach considering the limited resources. Such a group intervention may be embedded in a multi-layered intervention that also addresses key social determinants of MMH, particularly poverty and spousal conflict. To improve confidentiality, participants advocated for the inclusion of MMH services within existing programs that are trusted by the community, such as the MomCare program initiated by PharmAccess Foundation. Hence, the involvement of CHWs in the provision of MMH services may be a promising route to take, although caution is need in view of the rising burden on CHWs.

The recommendations resulting from this study have been used to adapt and contextualize the WHO’s group-based Problem Management+ intervention, originally designed to offer psychological support to adults in communities facing adversity (World Health Organization, 2020a). The adapted intervention, delivered by CHWs, was subsequently piloted with pregnant women in the three clinics in our study area, and found to be feasible, acceptable, and scalable in the rural context of Western Kenya (de Sanctis et al., 2024).

For future research, we recommend conducting more needs assessment and acceptability studies among stigmatized sub-groups, like adolescents and HIV-infected women, to develop recommendations for maternal mental health interventions that are suitable for those target groups. There also remains a need for randomized controlled studies that evaluate the long-term impacts of maternal mental health intervention – both for the mother and child – to gain additional insights in the value of investing in preventive and curative services related to MMH. Additionally, such studies could be complemented by a feasibility assessment for the implementation of MMH support at the policy level on a wider county or national scale.

The prevalence of MMH issues is widely recognized, yet adequate care is lacking. This study took a novel approach by incorporating not only the perspectives of mothers, but also those of nurses, CHWs, and fathers regarding the needs and perceptions around MMH care. Our approach highlighted the significance of including diverse perspectives, as we identified not only common viewpoints but also distinct experiences, particularly between mothers and fathers, and between nurses and CHWs. Our findings advocate for a group-based MMH intervention coordinated by CHWs, which could be implemented at relatively low costs.

ANC - Antenatal Care

CHW - Community Health Worker

FGD - Focus Group Discussion

KAP - Knowledge, Attitude and Perceptions

LMIC - Low- and Middle-Income Country

MMH - Maternal Mental Health

MNCH - Maternal, Neonatal, and Child Health

SSA - Sub-Saharan Africa

Ethics approval and consent to participate

Consent for publication

All participants gave their consent for the study results to be published in an anonymized form.

Availability of data and materials

The coded transcripts and analyses files are available from the corresponding author upon reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

We acknowledge the financial support by Share-Net Netherlands (Grant No. 2021-C246) and the Dutch Ministry of Foreign Affairs through the Health Insurance Fund.

Authors' contributions

WJ, TDS, and EW conceived the study; SK, CD and WJ conducted a literature review; TDS, WJ, EW, WT, SJ, CD and EMS designed the study; MO, EW, and RN rolled out the intervention and the data collection; SK, CD and WJ analyzed the data; CD and WJ drafted the manuscript; all authors made a critical review of the manuscript and approved the final manuscript.

Acknowledgements

We extend our heartfelt gratitude to all the MomCare care providers and acknowledge with appreciation the dedication of the entire MomCare team across PharmAccess offices in Kenya and the Netherlands. We are also deeply thankful for the direct support provided by the TINADA Youth Organization teams in adapting the PM+. Additionally, we recognize the financial support from Share-Net Netherlands (Grant No. 2021-C246) and the Dutch Ministry of Foreign Affairs through the Health Insurance Fund.

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Odhi oduogo’ refers to someone who ‘went and came back’. In this context, it serves as a cultural metaphor that reflects the societal and familial pressures women face to remain in marriage, even when they are harmful or abusive.

No competing interests reported.

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“We sometimes stress our own wives” - Perceptions of Maternal Mental Health Challenges and Recommendation towards Emotional and Psychological Support from Mothers, Fathers, Nurses, and Community Health Workers in Western Kenya

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