Quality of perinatal depression care in primary care setting in Nigeria

Ayinde et al. BMC Health Services Research 879(201): https://doi.org/10.1186/s12913-018-3716-3 RESEARCH ARTICLE Open Access Quality of perinatal depression care in primary care setting in Nigeria Olatunde O. Ayinde1, Bibilola D. Oladeji1, Jibril Abdulmalik1, Keely Jordan2, Lola Kola1 and Oye Gureje1* Abstract Background: Even though integrating mental health into maternal and child health (MCH) is widely accepted as a means of closing the treatment gap for maternal mental health conditions in low- and middle-income countries (LMIC), there are not many studies on the quality of the currently available mental health care for mothers in these countries. This study assessed the existing organization of service for maternal mental health, the actual care delivered for perinatal depression, as well as the quality of the care received by affected women presenting to primary care clinics in Ibadan, Nigeria. Methods: The Assessment of Chronic Illness Care (ACIC) tool was administered to the staff in 23 primary maternal care clinics and key informant interviews were conducted with 20 facility managers to explore organizational and administrative features relevant to the delivery of maternal mental health care in the facilities. Detection rate of perinatal depression by maternal care providers was assessed by determining the proportion of depressed antenatal women identified by the providers. The women were then followed up from the antenatal period up until 6 months after childbirth to track their experience with care received. Results: All the facilities had ACIC domain scores indicating poor capacity to offer quality chronic care. Emerging themes from the interviews included severe manpower shortage and absence of administrative and clinical support for manpower training and care provision. Only 31 of the 218 depressed women had been identified by the maternal care providers as having a psychological problem throughout the follow-up period. In spite of the objective evidence of inadequate care, most of the perinatal women rated the service provided in the facilities as being of good quality (96%) and reported being satisfied with the care received (98%). Conclusion: There are major inadequacies in the organisational and administrative profile of these primary maternal care facilities that militate against the provision of quality chronic care. These inadequacies translate to a large treatment gap for women with perinatal depression. Lack of awareness by service users of what constitutes good quality care, indicative of low service expectation, may hamper user-driven demand for quality improvement. Keywords: Perinatal depression, Chronic care model, Primary care, Low and middle income countries Background Depression is the leading cause of disease burden in women of reproductive age [1]. Perinatal depression affects up to 25% of women in LMIC in the antenatal period and 19% in the postnatal period, rates that are significantly higher than reported for high-income countries [2]. In Nigeria, studies have reported rates of up to 10–30% amongst perinatal women [3–7]. Apart from the suffering and loss of productivity that result from this disabling * Correspondence: 1 Department of Psychiatry, University College Hospital, Ibadan PMB 5116, Nigeria Full list of author information is available at the end of the article condition [8], perinatal depression is an important risk for suicide, a public health problem that is expected to become the leading cause of maternal mortality in LMIC [9]. Perinatal depression is also associated with short and long term adverse maternal and child outcomes, such as pre-term birth and low birth weight, poor mother-child interactions, infant under-nutrition and stunting, higher rates of diarrhoeal diseases, poor infant development, poor interpersonal functioning, insecure attachment and higher rates of emotional and behavioural problems in infants of depressed mothers [10, 11]. There are indications that these adverse child outcomes are worse in LMIC [10]. © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Ayinde et al. BMC Health Services Research 879(201): There is also evidence for the intergenerational transmission of the socio-economic disadvantages associated with perinatal depression, such that its effects continue to echo in the lives of offspring of affected persons up to 18 years after birth [12]. In view of the foregoing, there has been a global call for the expansion of services for perinatal depression globally and especially in LMIC. However, there is evidence suggesting that a focus on coverage alone without due attention to quality of care provided might have hampered the achievement of both the development goals and the protection of human rights of mothers and children in LMIC during the Millennium Development Goals (MDG) era [13]. Perinatal women living in LMIC are at an elevated risk of being denied quality care. The majority of such women have access only to facilities that are poorly resourced [14, 15]. There is an additional disadvantage for women with perinatal depression that is attributable to the pervasive stigma associated with mental illness, especially in LMIC. Persons with mental disorders are often victims of negative attitude that manifests in the form of discrimination and denial of basic rights [16]. Such persons may also internalize shame, anticipate rejection and discrimination, and accept diminished expectations from others [17]. These two forms of stigma, enacted and felt, have the effect of exposing persons with mental disorders to poor and inequitable quality care [18]. The situation is complicated by the pervasive lack of awareness of the true medical nature of depression as well as diverse attributions offered by affected persons that may limit appropriate medical help-seeking [19]. In the context of perinatal depression, therefore, stigma would increase the likelihood of sufferers to being denied access to the basic and oftentimes rudimentary services that may be on offer. Addressing quality concerns in maternal health, as in any other area of health, requires an examination of both micro-level factors such as the structure of clinics and provider behaviour, as well as system-wide factors such as the design of service delivery systems and governance structures [20]. The Lancet Global Health Commission [20] defines a high quality health system as one tha (...truncated)