A unique evidence-based approach to supporting new mothers’ mental and reproductive health in rural Ethiopia has long-term positive impact on symptoms of postpartum anxiety and depression, according to findings from a cluster randomized controlled trial led by the Johns Hopkins Center for Communication Programs.
Mothers Time used a modified version of Cognitive Behavioral Therapy, often considered the gold standard in psychology, where community health extension workers worked with groups of postpartum women in low-resource settings.
The results of the study, published March 31 in the journal Studies in Family Planning, suggest that modifying beliefs and assumptions can lead to positive changes in reproductive health behavior and overall improvements in mental health symptoms.
“We often think about mental health as separate from physical health and separate from reproductive health, but it’s so intertwined,” says Zoé Hendrickson, an associate professor at the University of Pittsburgh who led the research when she was at CCP.
“Anxiety and depression can impact all sorts of other health behaviors when you’re talking about people postpartum, from decisions around having kids talking with your partner about contraception. By integrating mental and reproductive health in the same interventions, we can improve people’s lives in multiple ways.”
Depression and anxiety symptoms are associated with increased unmet need for family planning postpartum, yet solutions promoting the integration of mental health into family planning service settings remain scarce. Roughly eight in 10 people living with mental health conditions in low- and middle-income countries aren’t diagnosed or treated, yet such challenges negatively impact a range of health behaviors, especially for new mothers.
“CBT is used a lot in the United States, but not as much has been captured, documented and evaluated on how it’s been applied in low- and middle-income countries,” says CCP’s Lynn Van Lith, the technical officer with the Breakthrough ACTION program that ran the intervention with its partner Camber Collective.
“Very few efforts, studies, pilots or otherwise, have looked at the intersection of mental health and contraceptive uptake, mental health and reproductive health. This research really filled a gap.”
For the study, a total of 302 postpartum women were recruited from 10 health clusters in northwest Ethiopia. In comparison to control clusters, where participants just received the standard of care, intervention clusters showed significantly greater reductions in symptoms for both depression and anxiety from baseline to follow-up.
Modern family planning use also increased significantly more in intervention clusters as compared to control clusters from baseline to follow-up. While no participants were using a modern method at baseline, this increased to a cluster average of 77 percent among intervention clusters compared to 59 percent among control clusters at follow-up. Results suggest that more holistic family planning services that consider postpartum mental health can both reduce postpartum depression and anxiety and support women in fulfilling their reproductive intentions.
Mothers Time was adapted and co-designed with mothers and mental health experts in Ethiopia based on their lived experiences by distilling the World Health Organization’s Thinking Healthy tool into four modules that could be easily taught and applied by low-literacy community extension workers with new mothers.
Many of those who participated in the Mothers’ Time sessions, which were added into existing outreach supported by the Ministry of Health, were socially isolated after having their children and didn’t know one another. But by coming together, community health extension workers helped create social bonds among the women so they would feel less alone facing the challenges of new motherhood.
“They had one another to lean on,” Van Lith says.
“Mothers Time: A Cluster Randomized Controlled Trial of the Effects of a Community-Based Cognitive Behavioral Therapy Intervention on Postpartum Mental Health and Family Planning in Northwest Ethiopia,” was written by Leah Holmes, Tesera Bitew, Andenet Haile, Lynn M. Van Lith, Sarah Burgess, Jessica Vandermark, Stella Babalola, Hermon Amare, Asaye Tilahun, Dominick Shattuck and Zoé Mistrale Hendrickson.
