Postpartum Depression in Sub-Saharan Africa: An Intersectional Perspective
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Munira Ladan - No Comments on Postpartum Depression in Sub-Saharan Africa: An Intersectional Perspective
Munira LadanPostpartum depression (PPD) is a common and severe maternal mental health issue with devastating effects on the mother and her family1. Diagnosed in the first few weeks after childbirth, PPD can last up to four years and is characterized by symptoms like mood and sleep instability, tiredness, and thoughts of self-harm3. Consequently, PPD adversely affects women’s quality of life, confidence, and marital relationships4 5.
Baby blues, a common form of maternal mood disorder, is a risk factor for developing PPD. Women are already twice as likely to experience depression compared to men, with approximately 40% of women globally experiencing various mood disorders, including depression6 7. The prevalence of PPD is drastically higher in low- and middle-income countries compared to high-income countries. Worryingly, existing research on PPD primarily focuses on high-income countries and often overlooks the experiences of women in low-income settings, particularly in Sub-Saharan Africa (SSA)9.
In SSA, the lack of appropriate treatment plans has led to the misdiagnosis of PPD. Although PPD is curable with timely care, the high burden of PPD cases in these regions is likely due to a lack of prioritization of the issue11. This neglect results in more prevalent and severe outcomes for both mothers and the development of their children12.
Looking Into PPD Through An Intersectional Lens
Postpartum depression is a multifaceted issue affecting women globally, yet every woman’s experience is unique. The concept of intersectionality, coined by Kimberlè Crenshaw, helps us understand how various aspects of a person’s identity, such as race, gender, and socioeconomic status, intersect with structural factors like poverty to shape health outcomes13.
Research shows that women in SSA carry a disproportionately higher burden of PPD, often experiencing chronic and recurring episodes that can escalate to psychosis and, in some cases, suicide14. This burden significantly impacts mothers’ caregiving abilities, leading to detachment and harmful perceptions of their infants15 16.
Studies in Ethiopia and Ghana have even demonstrated a correlation between maternal depression and infant deaths17 18. Despite these severe consequences, PPD remains an underrepresented and overlooked issue, often overshadowed by factors like poverty, intimate partner violence, unwanted pregnancy, and inadequate social care19. Poor early treatment and intervention strategies leave many women with lasting adverse maternal health outcomes20. Therefore, we must move beyond solely considering well-studied obstetric risk factors like gestational diabetes and vitamin D deficiency21. It is crucial to explore the intersectional dynamics of PPD, examining factors such as gender roles and expectations, socioeconomic stressors, and cultural beliefs and practices. By identifying how these factors intersect and compound the experience of PPD, we can work towards more comprehensive approaches and support systems.
Cultural Beliefs And Practices
Communities in SSA are multi-ethnic, with people engulfed in cultural and traditional practices, some of which have contributed to the development of PPD24. Many women are coerced into participating in such practices due to familial and societal pressure, even if it is against their will22. Specific SSA culture and value systems, such as “polygamy, rejected paternity, difficult relationships with in-laws as well as feelings of cultural dissonance,” have been identified to be associated with PPD23.
Traditional postpartum rituals are believed to provide support to new mothers, potentially reducing their risk of PPD24. However, research has shown that postnatal practices in African cultures may increase the risk of developing PPD. For instance, a study in Nigeria highlighted the intricacies of extended family structures, where the mother-in-law typically stays with the family to care for the newborn baby. During this period, a complicated relationship with the mother-in-law could affect the mental health outcome of the new mother. Furthermore, many women in traditional African communities do not utilize modern healthcare services but instead rely on spirituality as a method of cure through attending prayer sessions in spiritual houses like churches and seeking the help of “witch doctors.” These cultural and religious beliefs and practices hinder access to care and prevent women from expressing their feelings after childbirth, worsening symptoms of PPD and, in some cases, leading to suicidal deaths.
Understanding Gender Roles And Expectations
In many African societies, the Strong Black Woman stereotype requires women to remain resilient and suppress their emotions despite adversity25. Post-partum mothers often tend to keep their depressive symptoms to themselves as they fear being judged by their family or society because giving birth to a child is usually a momentous occasion that should bring immense happiness. Women are expected to resume household and caregiving duties after childbirth, which can be overwhelming and stress-inducing, leading to a higher risk of PPD9. Being a single mother and having a baby outside of a marriage is often stigmatized as immoral and socially unacceptable behaviour, which can contribute to the development of PPD26.
In many communities, patriarchal norms call for a preference for male children, as they are expected to take over the family’s wealth and status when they come to age. As a result, women who give birth to female babies may face stigma, which can negatively impact their overall mental health26 27.
Women in many societies have long endured violence, and sadly, this remains a reality for many mothers in SSA today. Global estimates show that about 30% of women under the age of fifteen have experienced a form of gender-based violence 28. A multi-country study by the WHO revealed the stark difference in intimate Partner Violence (IPV) prevalence, with only 15% in urban places and 71% in local regions such as Ethiopia29. Marital relationship issues that manifest into different kinds of violence have affected the mental well-being of women. For example, research findings indicate that women who experience IPV have a higher likelihood of developing PPD, and young women who have not experienced PPD before are more likely to develop it when they experience IPV30 31.
Socioeconomic Factors: Poverty and Education
Due to poverty, the quality of women’s lives is considerably poorer than men’s, and women are at a higher risk than men of developing mental disorders at some point in their lifetime32 33.
There is strong evidence from research showing that there is a correlation between the low socioeconomic status of women and their risk of developing PPD34. The expectation that women stay at home and care for children even when they desire to work has impacted their socioeconomic status, limiting their access to financial resources and affecting their health outcomes35.
Education is vital in redirecting women’s habits and practices when utilizing prompt healthcare services36. However, most countries in SSA struggle to close the gaps in educational inequality for most populations of women, limiting their access to literacy and health education resources, which has negatively impacted their health outcomes. In many SSA countries, early girl-child marriage is common. This girl-child marriage practice prevents girls from attending school and gaining knowledge, leaving them unaware of mental health issues. Evidence has shown that there is a correlation between marital age and the increased risk of PPD, with one study showing three times the risk of PPD in women below the age of 2537 38.
How Do We Move Forward?
We can see that even though post-partum depression (PPD) is treatable, its manifestation can stem from intersecting factors such as gender role discrimination and violence, socioeconomic stressors, and cultural beliefs and practices. These factors, coupled with a lack of effective policies, create a challenging environment for mothers, which increases their vulnerability to post-partum depression. Consequently, this has infringed upon women’s health rights, which highlights the role of social determinants of mental health in achieving the highest standards of psychological well-being39. Therefore, it is imperative to take a multisectoral approach, which includes looking at the social determinants of mental health40 to promote women’s right to good maternal mental health in SSA.
Breaking The Stigma and promoting awareness
Stigma, as defined by the World Health Organization, is the “social isolation and discrimination, which impacts a person’s ability to earn an income, have a voice, gain access to quality care, be part of their community and recover from their mental health condition.” 41 The discrimination and negative perceptions associated with mental health issues can lead to violations of human rights. In many communities in SSA, there is a lack of awareness and understanding of mental health issues. This lack of knowledge has led to stigmatization. Women in my communities steer away from talking about mental health issues and talk less about seeking help when experiencing PPD. This highlights a significant issue: women endure and conceal their pain. The challenge of mental health stigma in obtaining support affects health. Therefore, we must work to destigmatize PPD through culturally and religiously sensitive awareness and advocacy programs, like involving communities in identifying danger signs and using religious houses as a medium to destigmatize experiences of postpartum depression and save women’s lives.
To the best of our knowledge, activists working specifically in support of postpartum depression are very few or non-existent in Africa. This lack of representation demonstrates how the issue remains out of the limelight. Nonetheless, StrongMinds is making strides. As one of the world’s most significant non-profit charities, they are working to destigmatize postpartum depression in the African community, even while navigating structural disparities that limit the scope of their work.
Advocating for women’s freedom and rights
While the United Nations condemns gender-based violence and discrimination, many women in Sub-Saharan Africa and globally continue to face subjugation and violence. In SSA, intimate partner violence (IPV) is primarily linked to patriarchal hegemony, which strips women of their fundamental rights45. IPV and depression are deeply intertwined, with IPV increasing the risk of depression and vice versa. Therefore, we urge policymakers to adopt a multidimensional approach that simultaneously provides interventional treatment for depression and reduces the incidence of IPV46 in SSA.
Education and empowerment strategies for women
According to the International Bill of Women’s Rights, “Women’s empowerment is a fundamental human right” 49. Women are entitled to education to ensure their well-being. Yet, the experience of PPD for women, especially those in rural communities, violates this right as they have limited access to information and educational resources. Empowered women with access to economic resources and social support are associated with positive mental health outcomes. However, efforts to ensure women’s rights are respected are falling behind in SSA. Mental illness in the form of PPD can hinder women’s capacity to pursue employment and support themselves financially. Therefore, we must work to empower women through education to impact their ability to make informed health-seeking decisions50. Community-based outreach programs can go a long way in closing the gaps in health education accessibility, promoting health-seeking behaviours, and improving the overall mental well-being of women. This vision is currently supported by Women Africa to enable women to realize their full potential in a “violence-free, gender-responsive and inclusive way” 51.
Increasing access to mental health services and care
Access to healthcare, particularly mental health services, is a prominent human rights issue that hurts a large number of women worldwide40. This is particularly true in areas with limited resources, where a lack of government prioritization obstructs access to these essential services52. Furthermore, research has shown that healthcare providers, especially at the primary level of care often lack competence in providing patient-centred and culturally tailored care, which may contribute to the misdiagnosis of PPD among women in Sub-Saharan Africa14.
Strengthening primary health systems capacities can be crucial to timely mental health services. These systems serve as the first point of contact for many women in many communities. This strengthening can be achieved by training health workers to provide accurate and timely interventional care.
Leveraging the strong sense of community inherent in many African cultures, building community-based focus groups can be highly effective in bolstering community-based advocacy and care. These groups can offer a safe and supportive environment for women to share their experiences with PPD openly.
While challenges remain, the current state of maternal health services in SSA is progressing. One significant initiative is the African Alliance for Maternal Mental Health working diligently in ten different Sub-Saharan countries, they join forces with healthcare providers, individuals, and organizations such as Elkheir Healthcare Foundation to advocate for and promote policies that increase access to mental health services. However, further commitment from stakeholders is needed to raise financing and build the capacity of health systems to support and improve maternal health services across Sub-Saharan African countries effectively.
Programs dirctor, elkhEIr foundation
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