1. Pregnancy and Maternal Care

2. Summary: Video 1 Deals with a young woman from Khayelitsha. Her pregnancy was unplanned. She finds herself isolated and depressed, with suicidal thoughts. She is lucky to attend Mowbray MOU, where she was screened as part as their Mother’ s Mental Health Project. She receives counselling & support and recovers well. In her testimony she emphasizes the fact that speaking to a stranger felt good and non-threatening The listening skills and advice received was very helpful. By the time she delivers her baby she is a happy and proud mother.

3. What is mental wellness? Not just the absence of illness, but: Social connectedness, Positive relationships, Self esteem, Resilience, Purpose in life, Personal growth, Environmental mastery, Autonomy

4. Risk Factors for Mental Health Problems Lifelong Poverty Domestic violence Sexual abuse Alcohol & substance abuse Stressful life experiences Physical illness Food insecurity Fragile circumstances: conflict, migration, natural disaster History of mental health problems Lifelong Poverty Domestic violence Sexual abuse Alcohol & substance abuse Stressful life experiences Physical illness Food insecurity Fragile circumstances: conflict, migration, natural disaster History of mental health problems Perinatal Period Adolescent pregnancy Unwanted pregnancy Lack of support from partner / in-laws Being unmarried Perinatal Period Adolescent pregnancy Unwanted pregnancy Lack of support from partner / in-laws Being unmarried Postnatal Period Abortion/miscarriage/stillbirth Infant sick, developmental problems, etc. Lack of social support Girl child Postnatal Period Abortion/miscarriage/stillbirth Infant sick, developmental problems, etc. Lack of social support Girl child

5. Protective Factors for Mental Health Problems Having more education Having a permanent job Having a kind, trustworthy intimate partner Companionship in labour Fisher et al, Systematic Review Bull WHO 2012

6. Summary: Video 2 Discusses the negative effects of stress in pregnancy. Cortisol and adrenaline (‘stress hormones’) released into the maternal circulation, get to the foetus circulation. Brief exposure of the foetus to stress hormones causes no harm. Chronic exposure to stress hormones depresses the electrical activity in the areas of the joy, happiness and curiosity. Prolonged exposure to toxic stress affects the baby’s brain, changing its architecture and wiring. Children from stressful pregnancies are withdrawn, cry a lot and have a more aggressive behaviour. A child that is sad, fearful and lacks curiosity does not respond to the stimulation required for full brain development

7. Add slide on frequency of mental health problems

8. Impact of Maternal Mental Health Problems Antenatal depression Poor uptake of health and social services Poor physical health & poor nutrition Substance & alcohol abuse Foetal development Birth outcomes Childhood development problems: behavioural, cognitive, motor & psychological Independent from impact of postnatal depression Antenatal anxiety Pre-eclampsia Intra-Uterine Growth Retardation Preterm birth Low apgar Foetal programming effect (HPA axis) – long term consequences: physical, cognitive, social, mental health Greater impact for offspring than depression? Separate and additional impact to depression ALSPAC study: Avon Longitudinal Study of Parents and Children

9. The mother’ s food security and nutrition choices are very important. Iron and folate micronutrient supplements are critical. Preparing for Exclusive Breastfeeding is the most natural way to foster mother-infant attachment. Nutrition

10. How does the ‘attachment’ relationship develop? The 1st connection with the world is through the body and senses Learning is optimized by the emotional warmth and safety of the interconnectedness Fathers and siblings play an important role in their love and care 10 SAFETY LOVE

11. Implications for Services AntenatalBirth to 6 months7 months to 2 years General Health & wellness Booking < 20weeks; 4 ANC visits; PMTCT; Educate, screen, refer problems of alcohol, tobacco, drugs; Psychosocial risk screen & mental health screen Postnatal care Effective Family Planning PMTCT Immunisations Management of disease (pneumonia /diarrhoea) Developmental screening Hand washing & hygiene Immunisations Management of disease (pneumonia / diarrhoea) Developmental screening Hand washing & hygiene De-worming Adequate nutrition Balanced diet Micronutrients Optimal weight Breastfeeding counselling Support Exclusive breastfeeding Growth monitoring Prevent malnutrition Breastfeeding Complementary feeding Micronutrients Growth monitoring Prevent malnutrition Supplementary feeding Stimulation & Support Psychosocial support Parenting information Promotion of caregiving practices Parenting information Promotion caregiving Early learning (home) Birth registration, Child Support Grant Promotion caregiving Early learning (home) Parenting information CSG

12. Summary of lessons learned - 1 The mother’s relationship with the baby starts in pregnancy When a pregnant woman is depressed the foetus also feels sad and that affects its future growth and development 1 in 3 women in SA suffer from depression Screen pregnant women for psychosocial & mental health problems Missing maternal depression is a huge ‘missed opportunity’ Pregnant women that are depressed need care Prematurity, low birth weight and various types of child development problems can be prevented

13. Summary of lessons learned - 2 The uterus provides the first safe and secure environment for the child to grow and develop Mothers themselves need a supportive environment to provide loving and safe care for the child Antenatal and postnatal services needs to focus on the health and well-being of both mom and baby Currently little attention is paid to the mother well-being and how she interacts with her child The mother’s effectiveness as a parent depends on the support she gets from the father, extended family, employer and the community at large

14. Summary of lessons learned - 3 Promote early bookings Comprehensive risk assessments to identify toxic stress & refer: – Mental Health problems? – Substance abuse, alcohol, smoking? – Food insecurity? – Is counselling & social support required? – Parental readiness? Map your intersectoral service departments /NGOs & refer Ensure effective family planning (birth spacing of at least 2 years) Teenagers vulnerability: stress, depression, birth complications and increased child mortality Exceptional compassion is needed towards adolescent mothers

15. Creating the right conditions is likely to be more effective and less costly than addressing problems at a later age build strong children repair broken men It is easier to build strong children than to repair broken men. Frederick Douglas

16. Acknowledgements: Simone Honikman, Janet Giddy, Elmarie Malek, Michael Hendricks, Wayne Wright (videos) Desmond Hendricks (sound) Thank you!