In South Africa, one in three women experience depression or anxiety during pregnancy and after the birth of the child. Photo: David Harrison, M&G
Every August, South Africa celebrates Women’s Month to honour the courage, leadership and contributions of women past and present. We remember the 20,000 women who marched to the Union Buildings in 1956. Their struggle was for the right to participate fully and equally in society.
Though many of the barriers these women fought to dismantle have been removed, gender inequality remains deeply entrenched. Gender-based violence, poverty, lack of social support and the burden of unpaid childcare persist, all of which drive the high levels of common maternal mental health conditions that we see.
In turn, maternal depression, anxiety and post-traumatic stress make women more vulnerable to being victims of violence, trapped in poverty and socially isolated. Caring for the next generation becomes extremely difficult in these circumstances.
Nomsa*, a 22-year-old mother of a three-year-old and a four-month-old, knows these problems intimately. Her partner is mostly absent and verbally abusive when at home. Her mother, already raising her late sister’s children, cannot offer daily help. Nomsa feels isolated, overwhelmed, and stuck.
The hidden crisis
In South Africa, the numbers for perinatal mental ill-health are stark. During pregnancy and the first year after birth, one in three women experience depression and or anxiety. These are among the highest rates in the world.
These conditions are not simply “baby blues” or private struggles. If ignored, they limit women’s agency and social connectedness, restricting access to care, completion of education, income-generation, and the ability to take part in community life. They also contribute to poor physical health and in severe cases can result in suicide which is a leading cause of maternal death worldwide.
The wellbeing of mothers and caregivers is inextricably linked to the wellbeing of their children. Pre-term birth, low birth weight, disrupted learning and emotional difficulties in children are linked to untreated depression and anxiety in their mothers. For many of these children, these problems continue throughout their lives and present as a failure to thrive and may also perpetuate a cycle of mental illness.
There is hope, however. When women are supported socially, economically and psychologically, their children are far more likely to grow up healthy and thrive.
The mental health gap
In low-resource settings, mental health services are scarce. Of the 84% of South Africans without medical insurance, only 7% who require outpatient mental health services, receive this care. The vast majority of women with depression or anxiety will not receive any care for this, but a small proportion will receive support from overstretched general nurses, community health workers or staff working in non-governmental organisations.
But the health economics research commissioned by the department of health demonstrated in 2021 that for every R1 invested in perinatal mental healthcare, there is a return of R4.70 in economic and social benefits.
The perinatal period offers a critical opportunity for mental healthcare for those women who are already in regular contact with health services during pregnancy and postpartum. With the right training, supportive supervision and referral systems, primary care providers, such as non-mental health specialists can identify distress early and offer evidence-based, affordable support, including counselling and effective referrals.
At the antenatal clinic, Nomsa’s midwife noticed she was tearful and very low, and referred her to one of the on-site counsellors. Three sessions, timed with her antenatal visits, allowed her to tell her story and feel heard. With gentle support, she developed plans for returning to school and finding childcare help. She was also connected to a local support group, where she met other women facing similar struggles.
From Women’s Month to action
A mother supported by her community and the state is more likely to participate in society through work, activism and education, and to nurture the next generation of citizens.
This Women’s Month should be about more than commemoration. We can honour the legacy of 1956 by tackling structural barriers to women’s wellbeing, starting with maternal mental health.
There are three key opportunities:
- Integrate mental health into maternity care: Standard maternity care should include screening for distress and its socio-economic drivers. Primary care staff need training and supervision to provide Respectful Maternity Care, basic counselling for patients and to make timely referrals. On-site trained counsellors should be assigned to every maternity unit.
- Invest in community-based support: Community health workers and peer groups can reach women in their own neighbourhoods. With improved mental health and practical skills, they can detect distress, draw on local resources, and link women to help.
- Address the social determinants: Implement funded strategies, and not just policies, to reduce gender-based violence, improve food security, protect incomes, and expand early childhood services.
Democracy starts at home
When maternal mental health needs are ignored, we exclude women’s skills, leadership and voices. A healthy democracy begins with healthy communities and in the earliest caregiver-child relationships. These are shaped by the mental wellbeing of mothers and the social and economic conditions around them. The women who marched in 1956 knew freedom meant creating conditions for all to flourish. Maternal mental health is one of those conditions.
Supporting women during the perinatal period is an investment in equality, human rights, and the nation’s future. This Women’s Month, let us recognise that perinatal mental healthcare is a necessity for gender justice, economic stability, and democratic vitality.
*A pseudonym
Associate Professor Simone Honikman is the director of the Perinatal Mental Health Project based in the Centre for Public Mental Health at the University of Cape Town.