Clarke, KL; (2013) Tension in the Terai: exploring maternal mental health in the perinatal period and interventions to improve it in Dhanusha district, Nepal. Doctoral thesis , UCL (University College London).

Abstract

BACKGROUND Common mental disorders are a major cause of disability among mothers in low and middle-income countries. I explore psychological distress, a proxy for common mental disorders, among mothers in Dhanusha, Nepal. I address the following questions: What are the determinants of postnatal psychological distress, and how is it perceived and experienced in Dhanusha? What possible interventions could reduce distress among mothers in this setting? METHODS I sourced data from a cluster-randomised controlled trial evaluating a community-level participatory intervention with women’s groups delivered by female community health volunteers. The primary outcome was neonatal mortality. Postnatal psychological distress was a secondary outcome measured using the 12-item General Health Questionnaire. Data were also collected on socioeconomic and health factors, and I used multilevel modelling to test their association with distress. Using grounded theory methods I analysed semi-structured interviews with distressed mothers and focus group discussions with community members. I evaluated the impact of women’s groups on postnatal psychological distress using individual and cluster-level statistical approaches. RESULTS Perinatal health problems, lower levels of antenatal healthcare, plains ethnicity, food insecurity, no schooling, caesarean section, multiple birth and having never had a son predicted postnatal psychological distress in Dhanusha. Distress was termed tension and characterised by physical symptoms. Poor health, lack of sons and fertility problems were perceived causes, and limited autonomy and duty towards the family were key components of the context in which tension occurred. Women’s groups had no impact on distress. CONCLUSIONS Future interventions may address context-specific determinants of postnatal psychological distress, possibly as part of maternal and child health programmes. Women’s groups may not be the optimal approach to delivering an intervention in Dhanusha and alternatives should be explored. Collaborative interventions are needed to maximise resources, as are awareness-raising interventions to reduce stigma and increase the acceptability of mental health interventions.

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