Maternal Psychosocial Well-Being: Critical for Maternal and Child Health

Prof. Shamsa Rizwan

Conventionally our discourse about maternal health invariably refers to merely the physical health of the mother. The World Health Organization (WHO) in its constitution has defined health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. However, the psychosocial paradigm of maternal well-being has remained a neglected dimension, especially in the low and middle income countries (LMIC) including Pakistan.
Maternal psychosocial distress is not uncommon. The 1997–1999 report of the Confidential Enquiries into Maternal Deaths identifies suicide as the leading cause of maternal death.¹ There is compelling evidence from South Asia that one in four women have poor mental health, which not only impacts her own health behaviors and physical health but is also associated with impaired growth^2-5 and poor cognitive development⁶ of the infant. Maternal depressive symptomatology at any time, especially prenatally, is a risk factor for the child’s well-being.⁷ Experience of stressful life events during pregnancy also increases the odds for the early cessation of breastfeeding8 and hence affects child`s nutrition. Depressive symptoms during pregnancy are associated with negative psychosocial factors, particularly the number of daily stressors and low satisfaction with receipt of social support.⁹
The wellbeing concept nevertheless is somewhat abstract and elusive. The term well-being is most commonly used in philosophy to describe what is ultimately good for a person and it has become standard to distinguish theories of well-being as either hedonist (pleasure) theories, desire theories, or objective list theories. Well-being is also attributed to absence of mental health issues but contrary to this belief  an American study into mental health found that, while one in four respondents were depressed, only one in five was happy. The WHO, has worked with the concept of subjective quality of life as a dimension separate from social disability¹⁰ and the WHO-Five Well-being Index of subjective quality of life belongs to the dimension of psychological well-being (positive mood, vitality and interest in things).
Well-being is a valid population outcome measure beyond morbidity, mortality, and economic status but most maternal, newborn and child health (MNCH) programs address antenatal care, postnatal care, child health, immunization, nutrition, and family planning and a very few measure postpartum depression but none address the psychosocial well-being of women. The factors that influence maternal well-being are manifold and are mostly interrelated. These include; relationship with the spouse, network of close friends, self-esteem, exercise, diet, sleep, hobbies, career , religious beliefs, optimism, ability to adapt, money and living in a fair and democratic society.
The interpretation of wellbeing is very subjective and though it is important to define maternal psychosocial well-being, it is not an easy task. Does it encompass happiness, satisfaction, ability to cope, social/ family support, and autonomy of a mother or is it the mere absence of stressful life events, anxiety or depression? Or should it include all of the above?
Though we cannot undermine or challenge the importance of the physical health of a woman, especially in our poorly resourced settings, as obstetricians it is an earnest task to think beyond the maternal physical health as the impact of psychosocial health on child health is immense.  Defining maternal psychosocial well-being in our own cultural context, identifying ways of measurement and integration into the existing health service delivery, is critical for maternal health in our country and is an innovative area for future research. 

References

1. CEMD (Confidential Enquiries into Maternal Deaths) (2001)Why Mothers Die 1997–1999. London: Royal College of Obstetricians and Gynaecologists.
2. Rahman A, Iqbal Z, Bunn J, Lovel H, Harrington R. Impact of maternal depression on infant nutritional status and illness: a cohort study. Arch Gen Psychiatry 2004;61:946-952.
3. Patel V, Rahman A, Jacob KS, Hughes M. Effect of maternal mental health on infant growth in low income countries: new evidence from South Asia. BMJ 2004;328:820-823.
4. Harpham T, Huttly S, Abramsky T. Maternal mental health and child nutritional status in four developing countries. Journal of Epidemiology and Community Health 2005;59:1060-1064.
5. Rahman A, Patel V, Maselko J, Kirkwood B. The neglected 'm' in MCH programmes-why mental health of mothers is important for child nutrition. Trop Med Int Health 2008;13:579-583.
6. Patel V, DeSouza N, Rodrigues M. Postnatal depression and infant growth and development in low income countries: a cohort study from Goa, India. Arch Dis Child 2003;88:34-37.
7. I Luoma, T Tamminen, Pälvi K,  Kaija P, Raili S, Fredrik A. Longitudinal Study of Maternal Depressive Symptoms and Child Well-being. J. Am. Acad. Child Adolesc. Psychiatry;2001, 40(12):1367–1374.
8. Li J., Kendall G, Henderson S, Downie J, Landsborough L, Oddy W. Maternal psychosocial well-being in pregnancy and breastfeeding duration. Acta Paediatrica 2008; 97: 221–225.
9. K. M. Paarlberg, A. J. Vingerhoets, J. Passchier, A. G. Heinen, G. A. Dekker, H. P. Van Geijn. Psychosocial factors as predictors of maternal well-being and pregnancy-related complaints. Psychosom Obstet Gynaecol 1996 June; 17(2): 93–102.
10. Bech P. Rating scales for psychopathology, health status and quality of life. A compendium on documentation in accordance with the DSM-III-R and WHO systems. Springer: Berlin 1993.