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Supporting mothers with HIV and depression to help children thrive

Professor of Child and Adolescent Psychiatry Alan Stein is helping HIV-positive women with depression during pregnancy and the postnatal period. By improving their wellbeing he wants to help their children get the best start in life. He explains what his team has achieved so far in South Africa and the global implications of this work.

Professor Alan Stein

Imagine receiving an HIV diagnosis when you’re pregnant. You’re bringing a new life into the world. Then you receive news that you have an infection which requires lifelong treatment. You’re unsure if you will pass it onto your child and you may feel stigmatised. Disclosing your HIV status to your partner, or family, may also be a major worry.

Over 30% of pregnant women in parts of Southern Africa are HIV positive. Many of these women will receive their diagnosis while pregnant.

Screening for HIV during pregnancy is a successful way of preventing mother-to-child transmission. But for individual mothers, news of an HIV diagnosis can be very distressing. So it’s not surprising that rates of depression in these women are high. Up to 40% of pregnant women with HIV in Southern Africa also experience depression.

Depression and parenting

Depression can take its toll on the mother and her social functioning, which can include her parenting. Depression can trigger a state of self-focused attention. This state can involve repeated, intrusive thoughts which dominate the mind and are difficult to control.

It can also interfere with attention and responsiveness to the external world, including the response of a parent to their child. This response is critical to early child development, especially cognitive development.

An integrated two-part treatment

So there are two challenges: to develop interventions which help the mother with her depression, and to support parenting and child development. We’ve found that, in the context of low and middle income countries, community or ‘lay’ healthcare workers can be the answer.

Supported by the MRC Public Health Intervention Development scheme we have developed an intervention which lay counsellors can deliver. It begins in pregnancy and continues into the postnatal year.

It’s made up of a psychological treatment for depression, known as ‘behavioural activation’ and a parenting programme to improve early child development. We adapted this programme from the ‘Care for Child Development’ package developed by UNICEF and WHO.

Changing behaviour

Behavioural activation works on the principle that changing behaviour may be enough to change someone’s outlook on life. A changed outlook can lead to changes in thoughts and emotions. It focuses on helping people engage in the activities they enjoy and find rewarding.

As it focuses on behaviour – rather than attitudes, beliefs or culture – behavioural activation can be used in a wide range of contexts. It promotes self-care, routines and nourishing activities adapted to different cultures and settings.

The parenting intervention aims to support parenting, to improve early child development. We help the mother increase the stimulation she provides to her baby. In particular, we help the mother to focus on her baby’s cues and signals. Then we guide her to respond promptly and appropriately.

We also support women to take antiretroviral medication as prescribed, prepare for their baby’s arrival and explain and promote exclusive breastfeeding.

Keeping it simple

The simplicity of behavioural activation gives it a major advantage over other treatments. Simpler treatments can be taught quickly and cheaply, and to more healthcare staff as they don’t require long and expensive training. This means treatments are more likely to be delivered effectively.

In our pilot study, we established that lay counsellors could deliver the treatments in mother’s own homes. The treatment led to a reduction in depression and the mothers found it highly acceptable – many described it as empowering.

Scaling up

We’re now planning a rigorous test of the intervention: a large, cluster randomised controlled trial funded through the Joint Global Health Trials scheme, run by the MRC, Department for International Development (DFID) and the Wellcome Trust. We’ll follow up with the families until the children are two years of age.

We want to see if we can deliver our combined approach in a sustainable way. Our hope is that it will reduce maternal depression and lead to positive outcomes for the children involved. If so, it could have the potential to work in other countries around the world, to help parents and children thrive.

MRC PHIND Feasibility study grant reference MC_PC_14096 (Newton Fund); Joint Global Health Trials RCT grant reference number MR/P006965/1 (Global Challenges Research Fund). The trial will be conducted with the Africa Health Research Institute in collaboration with the Human Sciences Research Council.

Applications are welcome for the MRC Confidence in Global Mental Health Research scheme under the Global Challenges Research Fund (deadline 14 September).

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