Maternal mental health as a neglected dimension of primary health care systems responsiveness in low- and middle-income countries: a mixed methods cross-sectional study in Ghana

BACKGROUND: Pregnancy and postpartum-related mental health problems present serious public health threat to the society; however, this is not prioritized in sub-Saharan Africa (SSA). We aimed to determine the prevalence and analyze perceptions and experiences of maternal mental health (MMH) distress and health systems responsiveness to mental well-being of pregnant and postpartum clients and their relatives, and frontline health workers in two districts of Southern Ghana. METHODS: The study used a cross-sectional mixed methods design and purposively selected study sites to provide insights from rural and urban settings. A structured survey involving antenatal (n = 827), postnatal (n = 618), and delivery (n = 58) maternal health clients was conducted in primary healthcare facilities using a modified World Health Organization health systems responsiveness questionnaire and the 21-item screening tool for depression, anxiety, and stress scale (DASS21). Eighteen focus group discussions (FGDs) were conducted, fourteen involving antenatal and postnatal clients with/without mental health conditions (n = 104), and four with frontline healthcare providers (n = 24). We also conducted six in-depth interviews, four (n = 4) involved postnatal clients with mental health conditions and two (n = 2) involved clients' relatives. Quantitative data were analyzed using Stata 15 and employing descriptive analysis and generalized linear models. Thematic analysis was done on the qualitative data, with some further analysis of themes using the text sort function in Microsoft Excel. RESULTS: Mild, moderate, and severe MMH distress were experienced in pregnancy and post-partum, but were not addressed as part of routine formal care. The DASS21 showed 19%, 31.6%, and 16.3% of symptoms of mild to severe depression, anxiety, and stress, respectively. Mental health and maternal health services are part of primary healthcare in Ghana, but work in silos. There is an insufficient number of community mental health officers and community psychiatric nurses in the districts, and their work is not synergized with maternal healthcare. CONCLUSIONS: MMH is an important dimension of primary care, and interventions to integrate mental health into maternal health are required. Screening using simple tools may enable prompt detection and management of MMH issues among at-risk groups, as part of making the Ghanaian health system more responsive.