|Year : 2019 | Volume
| Issue : 2 | Page : 160-168
Supporting maternal mental health of Rohingya refugee women during the perinatal period to promote child health and wellbeing: a field study in Cox’s Bazar
Francesca Corna1, Fahmida Tofail2, Mita Rani Roy Chowdhury3, Cécile Bizouerne4
1 Clinical Psychologist and PhD in Social Psychology, Previous Mental Health and Care Practices Advisor for Action Against Hunger, France
2 PhD Scientist in Nutrition and Clinical Services Division (NCSD) and Sr Consultant Physician, Dhaka Hospital, International Centre for Diarrhoeal Disease Research, Bangladesh
3 Clinical Psychologist, Gender-Based Violence Coordinator for Action Against Hunger, Bangladesh
4 Clinical Psychologist and PhD in Clinical Psychology, Mental Health Care Practices, Gender and Protection Senior Advisor for Action Against Hunger, France
|Date of Submission||20-May-2019|
|Date of Decision||29-Sep-2019|
|Date of Acceptance||14-Oct-2019|
|Date of Web Publication||29-Nov-2019|
56 rue Jean Jacques Rousseau 75001, Paris
Source of Support: None, Conflict of Interest: None
In humanitarian crises, such as the Rohingya situation in Bangladesh, maternal and child health may be strongly affected. Maternal mental health is a well-recognised key factor for child survival, development and health. Promoting maternal mental health during the perinatal period, especially in emergencies, contributes to the prevention of child mortality, morbidity and psychological distress. Despite this, few humanitarian psychosocial interventions have been evaluated to measure their effect on maternal mental health and child care. In 2012, Action Against Hunger in collaboration with the International Centre for Diarrhoeal Disease Research, Bangladesh, evaluated the effect of a psychosocial support groups intervention on 260 pregnant Rohingya women, living in the registered camps of Cox’s Bazar. A set of questionnaires (including MMSE, CES-D scale and Rosenberg’s Self-Esteem scale) was administered to participants to measure the improvement on mental health and childcare knowledge after a three-month psychosocial intervention. Maternal wellbeing and childcare knowledge improved significantly over the three months of intervention. Findings suggest psychosocial intervention can be effective despite the chronic stressful conditions of the refugees in the camps. This study reinforces the importance of community-based interventions promoting mental health in contexts of chronic crisis and contributes to the research discussion on the impact of maternal mental health and childcare promotion programming.
Key implications for practice
- Supporting maternal mental health during the perinatal period has a positive impact on women's wellbeing and is also a key factor for good childcare, children's wellbeing and early childhood development. In an emergency situation such as the Rohingya crisis in Bangladesh, promoting maternal mental health is an effective way of preventing difficulties during the perinatal period that may aggravate family, maternal and children's wellbeing.
- Psychosocial support groups appear to provide an effective methodology to work with refugees on mental health and childcare promotion, since refugees are often isolated, with disrupted social support and with limited access to external resources.
- Reinforcing women's internal and external resources through group support helps to improve their self-esteem, which is a key factor for general wellbeing.
Keywords: child development, maternal and child care, maternal mental health, nurturing care, perinatal depression, psychosocial intervention, refugee mental health, Rohingya refugees
|How to cite this article:|
Corna F, Tofail F, Chowdhury MR, Bizouerne C. Supporting maternal mental health of Rohingya refugee women during the perinatal period to promote child health and wellbeing: a field study in Cox’s Bazar. Intervention 2019;17:160-8
|How to cite this URL:|
Corna F, Tofail F, Chowdhury MR, Bizouerne C. Supporting maternal mental health of Rohingya refugee women during the perinatal period to promote child health and wellbeing: a field study in Cox’s Bazar. Intervention [serial online] 2019 [cited 2021 May 7];17:160-8. Available from: https://www.interventionjournal.org/text.asp?2019/17/2/160/271886
| Introduction|| |
Action Against Hunger in Bangladesh
Action Against Hunger (AAH) is an international humanitarian organisation working since 1979 to treat and prevent child undernutrition and provide humanitarian support during crisis in nutrition and health, mental health, care practices, gender and protection, water, sanitation and hygiene, food security and livelihood, and disaster risk reduction sectors. AAH began working in Bangladesh in 2007 and in the Cox’s Bazar area in 2008 to support registered Rohingya refugees.
Rohingya population and mental health
The Rohingya population is a minority group originating from Rakhine State of Myanmar, though not officially recognised as citizens of Myanmar. They are the largest stateless group in the world (United Nations High Commissioner for Refugees [UNHCR], 2018). Until recently, more than one million Rohingya were living in Rakhine state with 850,000 in the Northern Rakhine State, adjacent to Bangladesh (Dapice, 2015). From 1948 to 1962 Rohingya were fully recognised citizens of Myanmar, but after the military coup their situation worsened and they have gradually lost all their rights (UNHCR, 2018). They have suffered from decades of persecution and repression in Myanmar and most of them have been obliged to seek refuge in Bangladesh.
The initial influx of Rohingya refugees to Bangladesh dates back to 1978, with a large arrival following in 1991–1992 (UNHCR, 2007). As of March 2012 (the period of the research study), Kutupalong official camp in Ukhiya sub-district hosted around 11,560 refugees registered with UNHCR and Nayapara camp in Teknaf sub-district hosted around 17,600 refugees. In addition, there were an estimated 200,000–500,000 undocumented Myanmar nationals living in non-official camps or in villages in the area, with limited humanitarian assistance.
The multiple and chronic stresses of everyday life at the camps (poor living conditions, dependency on food assistance, domestic violence, safety and protection issues, no social and leisure opportunities, rupture of social and emotional links due to the migration process, etc.) have added to the traumatic events the Rohingya people have experienced and negatively impacted their mental health (Riley, Varner, Ventevogel, Taimur Hasan, & Welton-Mitchell, 2017) since the refugees camps were established.
Mistrust, symptoms of paranoia, depression, psychosomatic symptoms, PTSD symptoms, anxiety, psychotic-like symptoms, and sleeping problems are some of the major expressions of their distress as confirmed by several internal reports of AHH since 2008 (Dozio, 2008) and reported more recently by UNCHR (2018) in a review of epidemiological studies of mental health in the Rohingya population.
Rohingya women’s situation
The 2017 crisis, with the violence and intensive people displacement associated, has worsened the situation of Rohingya women living in Bangladeshi camps. This was already precarious as we found during the period of our research study in 2012, due to several factors associated to context, culture, individual and community life stories.
In the Rohingya community, where a conservative form of Islam is practised, women are restricted in their participation in public and social life. These factors appear to promote the isolation of women, resulting in limited social support and gender discrimination.
Culturally, women have restricted or non-existent access to education and their freedom of movement and decision-making are limited, especially amongst young women. They are discouraged from working outside the house, under continuous stress of limited livelihoods and overwhelmed by housekeeping and family care.
Most women and girls report acts of harassment, economic deprivations and psychological and physical violence (UNHCR, 2018). In the refugee settlements, sexual and gender based violence (SGBV) has always been a major protection concern. Formal and informal reports of AAH since 2008 show that Rohingya women express fear of being abused both at home and outside, anger (often directed towards their children), stress, feelings of despair and suffocation (Dozio, 2008; AAH, 2017). As reported by UNHCR, being female is one of the main risk factors for mental distress among Rohingya people (UNCHR, 2018),
Supporting maternal mental health in the perinatal period to promote child growth and wellbeing
Promoting maternal mental health contributes to the overall goal of good health and wellbeing, both for women and children.
Depression is the leading cause of disability worldwide and is a major contributor to the overall global burden of disease (World Health Organisation, 2018). Women are more affected by depression than men. An estimated 20% of women are at risk of depression during any stage of their lives (Brockington, 2004; Kessler et al., 1994). However, the onset of depressive symptoms frequently peaks during the childbearing years (Kessler et al., 1994), usually within a couple of weeks after delivery (Cox, Murray, & Chapman, 1993). Worldwide, about 10% of pregnant women and 13% of women, who have just given birth, experience a mental disorder, primarily depression. In developing countries, this is even higher, with 15.6% during pregnancy and 19.8% following childbirth (Fisher et al., 2012). Moreover, women who have experienced past or current abuse (as it is frequently the case for Rohingya women) are at high risk for postpartum depression, which can affect the relationships with their babies (Kendal-Tacket, 2007) and have an impact on their development (Stein et al., 2014; Howard & Challacombe, 2018).
Psychiatric morbidities after childbirth are more prevalent in South Asian countries when compared to other countries around the world (Affonso, De, Horowitz, & Mayberry, 2000; Klainin & Arthur, 2009; Villegas, McKay, Dennis, & Ross, 2011). Pressure created by women’s multiple roles, gender discrimination and associated factors of poverty, hunger, malnutrition, overwork, domestic violence and sexual abuse are considered as underlying factors in this part of the world. Moreover, the prevalence of common mental disorders such as depression tends to increase (more than double) in emergency situations or crisis (World Health Organisation, 2019).
The mental health situation of Rohingya refugee women in Bangladesh, who have lived for decades in chronic emergency conditions, suffered daily stressors, violence and often traumatic events throughout their life, can be expected to be among the poorest in South East Asia. As highlighted before, maternal mental health is a well-recognised key factor for child survival, development and health (Black & Surkan, 2015; Britto et al., 2016; Engle, Lothskà, & Armstrong, 1997). There is evidence of a link between maternal mental health problems and infant growth and undernutrition (Surkan, Kennedy, Hurley, & Black, 2011; Stewart, 2007), especially in South Asia (Patel, Rahman, Jacob, & Hughes, 2004). In the long term, maternal depression and child undernutrition may negatively impact child cognitive, motor, emotional and relational development (World Health Organisation, 2008), leading afterwards to poor school performance and subsequent barriers to economic productivity (Grantham-McGregor Cheung, Cueto, Glewwe, Richter, & Strupp, 2007). Martins et al. (2011) have shown that compared to a well-nourished child, a malnourished child’s earning potential is reduced by 10% over the course of his lifetime. This damage, however, may be preventable. Aware of this fragile and peculiar period of perinatality for woman and child’s health, WHO has acknowledged the 1,000-day window of opportunity approach, proposing interventions from pregnancy to the baby age of two years to reduce the risks of undernutrition that bear long-lasting consequences and promote maternal health.
Additionally, the ‘care’ conceptual framework developed by UNICEF (Engle et al., 1997), more recently reshaped as ‘nurturing care’ (Britto et al., 2017), clearly shows that child growth and development directly depend on caregiving behaviours related to caretakers’ resources, including mental health, stress and self-esteem. The framework emphasises the importance of working in the crucial period of pregnancy and childcare, both for mother and child. Therefore, promoting maternal mental health during the perinatal period is essential for preventing child mortality, morbidity and psychological distress (Wachs, Black, & Engle, 2009; Black & Surkan, 2015).
Although there is a clear link between maternal mental health problems and poor child growth and WHO recommendations (See WHO Mental Health Gap Action Programme – MhGAP launched in 2008, WHO MhGAP Intervention Guide, 2010 and Thinking Healthy Approach, 2015) for integrated mental health and social care interventions, it is still challenging to find effective and sustainable packages of services that address both the physical and mental health of reproductive mothers and can positively influence their childcare practices.
AAH since 2002, in line with the UNICEF framework, adopted an approach of mental health and maternal and childcare practices promotion with the aim of improving child and women physical and mental wellbeing. Since 2010, AAH established support groups for pregnant Rohingya women in Cox’s Bazar registered camps.
In response to the need of exploring strategies in designing effective programmes and to measure the impact of its psychosocial intervention, AAH in collaboration with the International Centre for Diarrheal Disease Research, Bangladesh (ICDDR,B), and the Child Development Unit (CDU) conducted an evaluation of the community based psychosocial programme based on these support groups.
| Method|| |
The research study presented here was conducted in 2012. The study aimed to evaluate the effects of a comprehensive psychosocial support intervention (PSI) among pregnant women of two official refugees camps in Cox’s Bazar. The research focuses on the effects of a three-month psychosocial intervention (March to June 2012), mainly based on support groups.
The study described here was a single arm pre-post study. The initial research design, as we will discuss later, was more complex (multiple arm intervention study with a control group), but, due to field constraints and data collection limitations, the research design had to be simplified.
The sample of Rohingya women living in the official camps of Cox’s Bazar received three months of PSI starting from the end of March 2012. The PSI ended in June 2012. The assessment phase was carried out at two time points: T0–March 2012 (pre-assessment) and T1–July 2012 (post-assessment).
The research study design passed French Research Ethics Committees, the internal ICDDR,B research ethics procedures and was presented to the local refugee camps authority and Rohingya community before research enrolment.
260 pregnant (and later lactating) refugee women (PLRW) were enrolled from the two official refugee camps of Cox’s Bazar, Kutupalong (N = 130) and Nayapara (N = 130). Women were included in the PSI from their fourth to sixth month of pregnancy. They were enrolled in the AHH intervention through the lists obtained by Ministry of Health (MoH) hospitals and AHH nutrition centres inside the two camps. The PSI was presented to women and they were free to participate or not in the intervention. Once they expressed their intention to be included in the PSI, they also received explanations concerning the research study. Each woman accepting to be involved in the research study received and signed an informed consent paper.
All Rohingya refugee women were living in one of the two government-run refugees camps − Kutupalong (Ukhia Upazila) and Nayapara (Teknaf Upazila) in Cox’s Bazar, Bangladesh, in most cases since 1991. The two camps are located in the south eastern part of Cox’s Bazar district of Bangladesh.
Psychosocial support intervention
The PSI offered to the women was part of a larger psychosocial and mental health intervention proposed by the organisation to treat and prevent child undernutrition and to promote and support mental wellbeing of refugees, especially women and children, in line with the 1,000 days window of opportunity approach.
The PSI was presented to the community and families to ask for support. The PSI followed the ‘do no harm approach’: AAH was attentive to remarks coming from the community and provided specific support to women presenting peculiar difficulties (those who were more isolated, rejected, young, etc.)
The intervention included women’s support groups and home visits. Each women’s support group included seven to eight women. Women were included in the group between their fourth to sixth month of pregnancy. Support group activity was offered twice per month. The activity allowed women to share their feelings, fears and thoughts on being pregnant and encouraged women to bring out culturally and socially appropriate solutions to identified problems. Support group sessions were guided by a psychosocial intervention protocol developed by AAH and covered eight different topics on maternal and child care, mainly inspired by the UNICEF Care Initiative approach of 2007 and mental health and care practices approach developed by AAH France (AAH, 2005 and AAH, 2006). The sessions topics included care for women, breastfeeding and feeding practices, child development and psychosocial care, food preparation and food hygiene, hygiene practices, home health practices and resources for care at family and community level. Each session lasted for at least 40 minutes to maximum of 90 minutes, depending on the topic. To maintain privacy and confidentiality, group sessions were organised in private and closed spaces (family houses). The group rule of confidentiality was presented to women several times and agreed. Psychosocial workers who were regularly trained and supervised by a clinical psychologist provided support group sessions and home visit support.
Once per month (more, if necessary) women received extra psychosocial support at home, through home visits. The aim of home visits was to provide specific support to each woman as well including the rest of the family in supporting the woman during her pregnancy. This activity allowed us to address important messages to family members about the care of women and child stimulation as well as to invite mothers-in-law and husbands to attend further psychosocial activities. These visits were also used to follow up issues in more detail from the psychosocial support groups, answer to questions and doubts in line with a ‘do no harm approach’ and discuss family support for the activities.
The PSI was also complemented by specific educational activities for husbands, mothers-in-law, traditional birth attendants and community leaders to reinforce their competencies and resources to provide adequate support to women in the delicate perinatal period.
A comprehensive set of questionnaires was used to collect outcome measurements. Four specifically trained AAH psychosocial workers, not involved in the PSI, collected the information in each camp. All tools were translated in Bengali, Chittagong dialect (similar to the Rohingya dialect and used by field workers to communicate with the refugees). At the research time (March 2012), interviewed women were living in the camps for several years and, in that period, no major language difficulties were faced by psychosocial workers working with Rohingya refugees. Language difficulties, on the contrary, has been a major problem in psychosocial work since the 2017 crisis.
The measures included in the assessment were as follows:
- Socio-demographic information: General socio-demographic information has been collected on the family’s assets, housing condition, access to water and sanitation, electricity, crowding condition and parental education and occupation.
- Maternal depression was assessed using the Centre or Epidemiologic Studies Depression scale (CES-D) which addresses six aspects of depression: depressed mood, guilt/worthlessness, helplessness /hopelessness, lethargy/fatigue, loss of appetite and sleep disturbance. A Bengali version of this scale has been used in several studies of Bangladesh (Radloff, 1977; Black et al., 2007).
- Maternal self-esteem was assessed using the Rosenberg’s Self-Esteem scale. This scale has been previously used in Bangladesh (Rosenberg, 1965).
- General mental health state has been assessed by the Bangla adaptation of Mini-Mental State Examination (MMSE) which is culturally relevant to Bangladesh. MMSE has been used in Bangladesh and its items were changed in such a way that they would be applicable for illiterate individuals (See Kabir & Herlitz, 2000; Folstein, Folstein, & McHugh, 1975).
- Caregivers' skills (a Knowledge Attitude Practices questionnaire) were assessed by a questionnaire and observation sheet covering the following areas:
- Self-care of women during pregnancy (KAP-CW)
- Pregnancy and delivery care (KAP-PD)
- Care of newborn and feeding practices (KAP-NB)
- Access to resources for care (KAP-AR)
- Child development and psychosocial stimulation (KAP-CD).
Inter-observer reliabilities were assessed on all measurements before the study began and the interviewers were allowed to start data collection after achieving >85% agreement with the trainers.
The questionnaires were anonymous and a system of code have assured the respect for anonymity.
We evaluated the impact of PSI on maternal knowledge gain and practice, mental health status, depression level and self-esteem assessing the same measures before the intervention, base-line at T0, and after the intervention, end-line at T1.
| Findings|| |
General description of the study population
Descriptive findings showed that the overall socio-economic, heath and hygienic conditions were poor in both Kutupalong and Nayapara camps.
Ninety percent of interviewed women lived in houses provided to them by UNHCR. Qualitative data report that houses were congested, shabby, single roomed or partitioned, with almost no ventilation. They possessed limited assets and there was hardly any furniture in the house. In both camps, more than 95% of households had no electric supply. They mostly used supply water for drinking and had access to semi-sanitary latrines provided by UNHCR.
19% of families in Kutupalong depended only on rations compared to 8% of families in Nayapara. The majority of other families earned additional money as well as the assigned ration they received. Overcrowding, with a median of five people (range 1–10) living in one single room, was common in these camps. In both camps, around 20% of households had five or more people sharing one single room.
The median number of children in the families was three (range 0–11) excluding the step children.
Pregnant women were relatively young with a mean age of 24.6±6 years. Around 15% of them were of less than sixteen years old. 22% of mothers in both camps were pregnant for the first time (primipara).
This population had access to primary education only.
[Table 1] shows house and family socio-economical conditions and women’s characteristics for each camp. Women’s characteristics were quite similar in both camps, but in Kutupalong women were more affected by undernutrition.
|Table 1 Distribution of socio-demographic variables, maternal characteristics and nutritional status|
Click here to view
Impact of the psychosocial support intervention
As the two camps are different in geographical location and some living standards, we conducted the analysis separately for both sites.
Unfortunately, we were unable to analyse child birth weight as an outcome measure for child wellbeing as initially planned, as not all the children were born during the final assessment and there were difficulties in collecting accurate anthropometric data.
[Table 2] shows the mean distribution, mean differences and 95% confidence interval of changes on eight outcome measures. All measures, except KAP-AR, showed significant improvement between the two time points.
|Table 2 Mean difference between baseline and final measures on pregnant mothers enrolled in the three months PSI − Kutupalong|
Click here to view
[Table 3] shows the mean distribution, mean differences and 95% confidence interval of changes on all eight outcome measures. All measures, except maternal depression assessment, showed significant improvement in these women.
|Table 3 Mean difference between baseline and final measures on pregnant mothers enrolled in the three months PSI|
Click here to view
| Discussion|| |
This paper presents a single arm pre- and post-evaluation of the community based PSI implemented in 2012 by AAH in the registered refugee camps of Bangladesh. The psychosocial intervention, through support groups and home-based follow up methodology, was offered to pregnant Rohingya women with the aim of promoting maternal mental health and women knowledge on maternal and child care practices in the delicate period of perinatality.
Despite the recognition that millions of young children in developing countries are not reaching their developmental potential and the prevalence of maternal depression is very high, especially in developing countries, most intervention strategies have been directed towards the promotion of either early child development or maternal mental health, but not both (Black & Surkan, 2015). AAH since 2002, has adopted a double approach to focus on maternal mental health, as well as to reinforce child care. The psychosocial intervention associated to this study is an example of this rare, but pertinent approach.
The study, in spite of field constraints that we will detail later, suggests the positive impact of AAH psychosocial support groups on pregnant Rohingya women’s mental health and childcare resources. The analysis provides important data for the psychosocial work with refugees, especially in the framework of the perinatal period. Such data keep a certain value for the current humanitarian situation of Rohingya people in Bangladesh and for the psychosocial work with Rohingya women.
As described by data, Rohingya women were living in 2012 in very poor conditions, with limited external resources. Limited opportunity of movement, of access to regular jobs, education restricted to primary level, limited electric supply that does not favour exposure to media, limited options for recreation or relaxation, overcrowding and safety risks do not allow Rohingya refugees, particularly women, to feel hope for future and better life and keeps them feeling powerless. This was the case in 2012 and is still confirmed and even worsened in the current situation of Rohingya in Cox’s Bazar camps (Toma et al., 2018). The precarious and restricted lifestyle has a clear impact on the psycho-physical wellbeing of the population (World Food Programme, UNHCR, Government of Bangladesh, 2012), especially in refugee women who are at a delicate period of pregnancy. As previously mentioned, women are more at risk, during pregnancy and lactating period, to show psychological distress and suffer more from mental and physical health problems (Martins & Gaffan, 2000). Our data show clearly the limited psycho-physical wellbeing of Rohingya pregnant women in the pre-assessment phase. General mental health condition, self-esteem and women’s knowledge on maternal and child care are poor and depressive symptoms are high. Even cognitive functions (a dimension of general mental health) are affected in the refugee women and we can make the hypothesis that is related to cognitive overcharge, low personal and social resources, but as well the effect of traumatic experiences as attention reduction due to a need of allocating resources to cope with psychological distress (Twamley et al., 2009). These first results are alarming since they have strong consequences on women’s general health, as well as future child wellbeing. Precarious women’s health conditions are expressed in our sample also by the high rate of maternal undernutrition that confirm data of several NGOs over many years and that is still currently high (Oxfam, AAH and Save the Children, 2018).
Pregnant refugee women, enrolled in the PSI provided by Action Against Hunger, showed significant improvement in their mental health status, in almost all mental health dimensions, after three months of programme. This is evident in both camps. Exposure to the intervention is the most plausible reason for this significant gain over the assessment period. There were no major contextual changes in the camps during the research period (2012 Rohingya crisis started few months later) that could explain an important mental health improvement in the sample and the PSI proposed by AAH was the only mental health intervention proposed, at that moment, to the target population. Moreover, being closer to delivery could have had an opposite effect on women wellbeing as well as the month chosen for post-assessment (June) that is the hottest and rainiest month stressing strongly families and individuals. Instead, we consider that group support methodology increasing and reinforcing internal resources (through discussion, role playing, specific exercises) in addition to the perception of better social support and stronger external resources (through group experience and psychoeducation) are key factors for the registered improvement, especially on self-esteem. Moreover, reinforced social support and self-esteem may be positively associated to reduction of depressive symptoms. Several studies have shown how low self-esteem may be a prospective risk factor for depression, following the vulnerability model (Orth & Robins, 2013). In addition, the general improvement of mental health, including cognitive dimension, may also be associated to self-esteem improvement, as well as to reduction of the stress associated to isolation or lack of knowledge. Women’s knowledge on maternal health and childcare were significantly improved and this is an important personal resource for women preparing themselves to become mothers and to welcome a newborn. A mother, with increased knowledge and understanding of nurturing care, stronger confidence and less isolated, is a mother with better resources to provide adequate care to the child. It seems therefore more than pertinent in such contexts to work on self-esteem and reinforcing both internal and external resources of refugee women as already confirmed by other researchers (Kira and Tummala-Narra, 2015).
The support group methodology adopted by AAH seems particularly pertinent and sustainable for this population of women since the creation and reinforcement of personal and social links (key external resources) potentially helps women, through sharing and discussion, to bring out solutions for different mental, physical and care related problems and to get out of isolation. The group support process aimed to facilitate autonomy and resources activation in Rohingya women and helping them to find solutions to their problems that are more practical, feasible and culturally appropriate. Group interventions emphasising peer support and problem-solving have also shown promise in addressing mental health in Rohingya population in other countries (Duchesne, 2016).
It is also interesting to note that a clear effect of PSI on the mental health conditions of women is evident after only three months of bi-monthly group sessions (six sessions, in total). Findings after three months of PSI were good. This data informs us that a three-month intervention (short-term intervention) may already be effective, and is an important data for humanitarian work.
A final interesting point highlighted by this field work was the pertinence to work on maternal mental health even with no specialist mental health workers. As Chowdhary’s studies review (Chowdhary et al., 2014) shows, psychological interventions delivered by non-specialist mental health workers are effective for the treatment of perinatal depression. Our study confirms this data. AAH working in several humanitarian contexts supports mental health intervention even in areas where no mental health specialists are present. This approach is possible and effective on the condition that social workers have a good psychosocial background, practical competencies and strong field experience, thanks to permanent technical and on-job trainings and regular clinical supervision proposed by expert clinical psychologists.
The study presented several limitations mainly related to study design that reduce its strength and limit the opportunity of findings generalisation. Initially, the study design planned by AAH and ICDDR,B considered having a control group with no PSI as well as a second interventional group with women included in a six-months PSI. But due to field constraints related to field workers research competencies and due to time and budget restrictions, these two extra arms were not able to be implemented.
Given that this study was a one arm pre and post evaluation rather than an RCT study, the improvement registered in all outcome measures should be interpreted with caution since we cannot exclude other contextual variables related to the observed changes in measures and that were not under our control. Having a control group posed ethical consideration for not including distressed pregnant women in the PSI: almost all pregnant women present in the camps in March 2012 were included in AAH study. A ‘waiting list’ was not considered appropriate since women need a specific support in the delicate period of pregnancy to have an effective prevention purpose. This aspect should be reconsidered in case of replication and further study.
Moreover, with the current study we cannot confirm long term improvement in the mental health and childcare measures of women, since the timing of final observation was right after the PSI. A follow up phase (middle and long term) should be considered as future perspective to confirm a stable improvement of mental health and childcare measures and a real impact on child wellbeing and growth.
Due to lack of time in the AAH programme a more qualitative analysis is also missing. This approach could have helped to clear out and enrich some findings.
Lastly, some important programmatic data, for example, nutritional data were collected from record books and the reliability of the measurements were not satisfactory, so these data have not been included in this paper. These data could have helped to show the positive impact and the sustainability of the psychosocial intervention on maternal and child undernutrition. Moreover, as mentioned, not all children were born at the stage of final assessment, so child nutritional data at birth could not be related to maternal mental health data. An interesting future perspective could be to integrate also child development measures in study design to link them with maternal mental health and childcare knowledge.
| Conclusion|| |
The community-based PSI offered to Rohingya refugee women by AAH significantly improved maternal mental health status and their self and child care related awareness. It is promising that despite the various barriers, restrictions and chronic difficulties faced by Rohingya women, such as underlying extreme poverty, hunger, lack of facilities and limitations of earning, safety and violence problems, chronic and acute stressors, the psychosocial intervention contributed to an improvement in almost all outcome measures of mental health and maternal and child care knowledge, even if this result should be interpreted with caution due to the specificity of the study design. These findings confirm and reinforce the approach adopted by AAH to work on supporting maternal mental health during the perinatal period to reduce perinatal distress, reinforce maternal resources for child care and limit the risks for child health, wellbeing and development. It is interesting to see wellbeing and care resources improvement in such a short intervention duration conducted by paraprofessionals under clinical supervision. This approach reinforces the idea that even in very severe crises and in contexts with very limited resources, working on reinforcing mental health and maternal and childcare is pertinent and effective. Relatively short interventions proposed by paraprofessionals with a strong training and supervision system can really make the difference. This is an interesting perspective for mental health programming in humanitarian contexts. An important focus and attention of work on self-esteem, through reinforcement of women’s resources and the access to them, seems essential and useful to have an improvement of general wellbeing.
The programmatic and operational points, highlighted in this paper, are all elements that may be taken in consideration for analysis and programming, even in the current 2019 Rohingya situation in the refugee settlements in Bangladesh. Crisis of August 2017 has worsened living conditions of refugees in the formal and informal settlements in Cox’s Bazar creating a chaotic and stressful situation for the population and increasing problems of safety and protection. The Rohingya seeking refuge in Bangladesh after the strong violence of August 2017 are often survivors or powerless witnesses of traumatic events, such as violence, torture and aggression. Therefore, providing specific psychosocial support in the perinatal period seems an essential axis of intervention in a such a crisis for promoting women’s wellbeing, child health, child development and family resilience. The results presented in this paper support recommendations on how NGOs and mental health practitioners may work on maternal mental health promotion in context of chronic crisis, but due to some study limitations need to be replicated and reinforced for further generalisation. A randomised controlled trial including a follow up phase with child anthropometric and development measurements is an interesting future perspective.
The authors are grateful for BPRM support that allowed the establishment for this research study and to AAH France, AAH Bangladesh mission and Child Development Unit of ICDDR,B to have provided support to all the research process. A special thanks to Anne Filorizzo Pla, Prathama Raghavan and Benedicte Duchesne for the support provided to this field study.
Financial support and sponsorship
BPRM and AHH France contributed to funds for this research study.
Conflicts of interest
There are no conflicts of interest.
| References|| |
AAH/ACF Myanmar. (2017). Mental health and psycho-social support rapid needs assessment in undocumented Myanmar refugees settlements (unpublished report)
Affonso D. D., De A. K., Horowitz J. A., Mayberry L. J. (2000). An international study exploring levels of postpartum depressive symptomatology. Journal of Psychosomatic Research
, 49(3), 207-216.
Black M. M., Baqui A. H., Zaman K., McNary S. W., Le K., Arifeen S. E., Black R. E. (2007). Depressive symptoms among rural Bangladeshi mothers: implications for infant development. J Child Psychol Psychiatry
, 48(8), 764-772.
Black M. M., Surkan P. J. (2015). Child development and maternal wellbeing: Family perspectives for low-income and middle-income countries. Lancet Global Health
Britto P. R., Lye S. J., Proulx K. (2016). Nurturing care: Promoting early childhood development. Lancet Early Childhood Development Series Steering Committee
, 389(10064), 91-102
Brockington I. (2004). Diagnosis and management of postpartum disorder: A review. World Psychiatry
, 3(2), 89-95.
Chowdhary N., Jotheeswaran A. T., Nadkarni A., Hollon S. D., King M., Jordans M. J., Patel V. (2014). The methods and outcomes of cultural adaptations of psychological treatments for depressive disorders: A systematic review. Psychological Medicine
, 44(6), 1131-1146.
Cox J. L., Murray D., Chapman G. (1993). A controlled study of the onset, duration and prevalence of postnatal depression. Br J Psych
, 163(1), 27-31.
Dapice D. (2015). A fatal distraction from federalism: Religious conflict in Rakhine
. Ash Center, Kennedy School, Harvard University.
Dozio E. (2008). Mental health and care practices assessment Cox’s Bazar − Bangladesh. AAH Bangladesh. Unpublished report
Duchesne B. (2016) A rapid assessment on psychosocial needs and resources: Maungdaw and Buthidaung townships. ACF Myanmar. Unpublished report
Engle P., Lothskà L., Armstrong H. (1997). The care initiative: Assessment, analysis and action to improve care for nutrition
. New York, NY: Unicef Nutrition Section.
Fisher J., Cabral de Mello M., Patel V., Rahaman A., Tran T., Holton S., Holmes W. (2012). Prevalence and determinants of common perinatal mental disorders in women in low-and lower-middle-income countries: A systematic review. Bulletin of the World Health Organization
, 90(2), 139-149H.
Folstein M. F., Folstein S. E., McHugh P. R. (1975). ‘Mini-mental state’ . A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research
, 12(3), 189-198.
Grantham-McGregor S., Cheung Y. B., Cueto S., Glewwe P., Richter L., Strupp B. (2007). Over two hundred million children fail to reach their developmental potential in the first 5 years in developing countries. Lancet
, 369(9555), 60-70.
Howard L., Challacombe F. (2018). Effective treatment of postnatal depression is associated with normal child development. Lancet Psychiatry
, 5(2), 95-97.
Kabir Z. N., Herlitz A. (2000). The Bangla adaptation of Mini-Mental State Examination (BAMSE): an instrument to assess cognitive function in illiterate and literate individuals. Int J Geriatr Psychiatry
, 15(5), 441-450.
Kendal-Tackett K. (2007). Violence against women and the perinatal period: The impact of lifetime violence and abuse on pregnancy, postpartum, and breastfeeding. Trauma, Violence, Abuse
Kessler R. C., McGonagle K. A., Zhao S., Nelson C. B., Hughes M., Eshleman S., Kendler K. S. (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Archives of General Psychiatry
, 51(1), 8-19.
Kira I. A., Tummala-Narra P. (2015). Psychotherapy with refugees: Emerging paradigm. Journal of Loss and Trauma
, 20(5), 449-467.
Klainin P., Arthur D. G. (2009). Postpartum depression in Asian cultures: A literature review. Int J Nurs Stud
Martins C., Gaffan E. A. (2000). Effects of early maternal depression on patterns of infant-mother attachment: A meta-analytic investigation. J Child Psychol Psychiatry
, 41(6), 737-746.
Martins V. J., Toledo Florencio T. M., Grillo L. P., do Carmo P. F. M., Martins P. A., Clemente A. P., Sawaya A. L. (2011). Long-lasting effects of undernutrition. Int J Environ Res Public Health
, 8(6), 1817-1846.
Orth U., Robins R. W. (2013). Understanding the link between low self-esteem and depression. Current Directions in Psychological Science
, 226, 455-460.
Patel V., Rahman A., Jacob K. S., Hughes M. (2004). Effect of maternal mental health on infant growth in low income countries: New evidence from South Asia. BMJ
, 328, 820-823.
Radloff L. S. (1977). The CESD scale: a self-report depression scale for research in the general population. Applied Psychological Measurement
, 1, 385-401.
Riley A., Varner A., Ventevogel P., Taimur Hasan M. M., Welton-Mitchell C. (2017). Daily stressors, trauma exposure and mental health among stateless Rohingya refugees in Bangladesh. Transcult Psychiatry
Rosenberg M. (1965). Society and the adolescent self image
. Princeton, NJ: Princeton University Press.
Stein A., Pearson R. M., Goodman S. H., Rapa E., Rahman A., McCallum M., Pariante C. M. (2014). Effects of perinatal mental disorders on the fetus and child. Lancet
, 384(9956), 1800-1819.
Stewart R. C. (2007). Maternal depression and infant growth: A review of recent evidence. Maternal and Child Nutrition
, 3(2), 94-107.
Surkan P. J., Kennedy C. E., Hurley K. M., Black M. M. (2011). Maternal depression and early childhood growth in developing countries: Systematic review and meta-analysis. Bulletin of the World Health Organization
, 89(8), 607-615.
Tay A. K., Islam R., Riley A., Welton-Mitchell C., Duchesne B., Waters V., Ventevogel P. (2018). Culture, context and mental health of Rohingya refugees: A review for staff in mental health and psychosocial support programmes for Rohingya refugees
. Geneva: United Nations High Commissioner for Refugees.
Toma I., Chowdury M., Mushfika L., Gora N., Padamada N. (2018). Rohingya Refugee Response Gender Analysis: Recognizing and responding to gender inequalities.
Joint Assessment Mission Oxfam, AAH and Save the Children.
Twamley E., Allard C., Thorp S., Norman S., Hami Cissell S., Hughes Berardi K., Stein M. (2009). Cognitive impairment and functioning in PTSD related toto intimate partner violence. Journal of the International Neuropsychological Society
, 15(6), 879-887.
United Nations High Commissioner for Refugees. (2007). Bangladesh: Analysis of gaps in the protection of Rohingya refugees
. Retrieved from https://bit.ly/2pdvB4x
Villegas L., McKay K., Dennis C. L., Ross L. E. (2011). Postpartum depression among rural women from developed and developing countries: A systematic review. The Journal of Rural Health,
Wachs T., Black M., Engle P. (2009). Maternal depression: A global threat to children’s health, development, and behavior and to human rights. Child Dev Perspect
, 3: 51-59.
World Food Programme, UNHCR, Government of Bangladesh. (2012). Myanmar refugees in Cox’s Bazar district, Bangladesh. Joint Assessment Mission
. Retrieved from https://www.unhcr.org/555c8c459.pdf
World Health Organisation. (2008). mhGAP Mental Health Gap Action Programme. Scaling up care for mental, neurological and substance use disorders
. Geneva: WHO.
World Health Organisation. (2010). mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings: Mental Health Gap Action Programme (mhGAP)
. Geneva: WHO.
World Health Organisation. (2015). Thinking healthy. A manual for psychological management of perinatal depression
. Geneva: WHO.
[Table 1], [Table 2], [Table 3]