The impact of perinatal mental health problems in South Africa
What are the costs?
We are a group of researchers from different parts of the world. We focus on mental health in the perinatal period, which goes from becoming pregnant up to one year after giving birth. With our research, we aim to explore the impact (what are the costs) of perinatal mental health problems for women, their children, and society. In this blog, we will discuss the example of South Africa.
We estimate that the lifetime costs of perinatal mental health problems in South Africa amount to USD 2.8 to 2.9 billion.
This includes costs linked to both, losses in quality-of-life (USD 1.8 billion), which capture years lost through premature death and years lived with disability, and losses in productivity (USD 1.1 billion), which capture a value for the loss of work, as well as additional need for hospital treatment during infancy.
Costs to the public sector are relatively small (USD 3.5 million) — in part because of a gap in the evidence of healthcare use by women with perinatal mental health problems and their children, but mainly because of under-investment.
Findings highlight the importance of investing in this area to support the health and wellbeing of this, and future generations.
Why focus on perinatal mental health?
Mental health problems have a greater incidence in the perinatal period, often with a range of negative consequences for women and their children.
Prevalence is higher in low- and middle- income countries (LMICs) compared to high-income countries, and consequences may also be more severe.
In South Africa, the estimated prevalence of perinatal depression, stress and anxiety is one in three women, although in some communities it is up to one in two. High rates are linked to the burden of socio-economic adversities faced by women. The COVID-19 pandemic has further worsened the situation.
Despite recognition as a major public health concern by international bodies such as the World Health Organization (WHO), action in most countries falls short.
In South Africa, important progress has been made with regards to maternity care policies, national guidelines, and the introduction of routine screening.
Several studies have demonstrated the potential effectiveness of various treatments. Such studies also show that treatments can be delivered in resource-poor settings: task-sharing and shifting approaches, in which professionals or volunteers are trained to provide the interventions, are feasible and can be implemented (cost)-effectively.
However, under-investment and under-resourcing have so far prevented progress and scale-up.
What impacts were included in the costing calculations?
Undiagnosed and untreated perinatal mental health problems, such as depression, anxiety and post-traumatic stress disorder, all lead to substantial losses in quality of life.
Women with mental health problems are also at a significantly increased risk of dying by suicide.
The health, economic and social challenges that women face during the perinatal period are worsened by mental health problems. Women struggle to continue earning an income, and their children are at increased risk of a range of negative health and social impacts.
Thus, we included both quality of life and income losses in the costing calculations, using approaches used by the WHO.
The direct and indirect impacts of perinatal mental health problems on children are also more severe in settings exposed to poverty and crises.
Considerable evidence demonstrates the relationship between perinatal mental health problems and poor pregnancy outcomes, infant growth and development problems, poor child physical and mental health, and reduced children’s educational attainments. For example, maternal depression is the leading risk factor for impaired growth and development of children in LMICs, leading to costs of USD 14.5 billions across 137 countries.
Thus, children’s quality of life and income losses were included in our costing models.
Furthermore, we included costs to the public sector for the additional risk of children’s hospital admissions during the first year after birth. These occur as women with mental health conditions face greater challenges with childcare and may have less access to necessary support.
This costing was necessarily conservative, as there are many additional impacts that could not be included due to a lack of quantifiable data. For example, women with perinatal mental health problems who live with HIV are less able to attend to their physical health and adherence to treatment may be impaired.
In addition, perinatal mental health problems also affect siblings, partners, wider family members and communities, but we were unable to measure those impacts.
Despite the conservative approach taken, the study shows: It’s too costly to do nothing.
What should happen next in South Africa?
In line with international and national policies and guidance, several actions should be taken to reduce the enormous impact of perinatal mental health problems, bearing in mind the under-resourcing and other systemic implementation challenges.
This includes the development of intersectoral, collaborative, community-based strategies to address the social determinants of mental health (such as gender-based or childbirth-related violence, poverty, and social isolation), reduce stigma and increase demand for, and uptake of care.
In many LMICs, such as South Africa, antenatal care visiting rates are as high as 80% to 90% thus making this a window of opportunity to offer mental health care and support.
Competency-based training which enables providers to demonstrate the required skills, supervision and support for maternity staff and other frontline providers needs to be rolled out so that they can provide mental healthcare at each point of contact for people in need, in a whole-of-society approach.
What is the role of economic research in achieving change?
Context matters. Prevalence rates, as well as unit costs, often vary substantially between (and within) countries.
However, data and methods can importantly be “transferable” from and to other countries.
The study we conducted in South Africa builds on our own research in the United Kingdom, as part of a campaign by the Maternal Mental Health Alliance which advocated for increased access to specialist perinatal mental health services.
The UK study estimated the cost of perinatal mental health problems were as high as £6.6 billion for anxiety and depression and £8.1 billion if other conditions were included.
The work led to substantial government investment in specialist care, thus highlighting the role of economic evidence in supporting action.
Our cost methodology has been replicated in other countries, such as France.
Since cost estimates are strongly linked to local context, adapting the methodology to include country-specific evidence is highly recommended.
For example, our recently published research on the lifetime costs of perinatal depression and anxiety in Brazil applied the methodology used for South Africa.
A logical next step is to generate economic evidence on where to best invest state funds. For this, cost-effectiveness evidence is needed.
We recently conducted research showing the economic benefits of increasing access to treatment for women with common mental health problems in the UK, and similar work is underway for Malawi.
The South African Department of Health recently commissioned an Investment Case to estimate the costs, benefits and expected return on investment over a 15-year period from scaling up various mental health interventions, including perinatal depression. The work suggested an economic pay-off for the treatment of perinatal depression of USD 4.7 per 1 spent. However, the estimate assumed a significant investment for training, which was not included in the costs. At the same time, the analysis did not yet include longer-term returns.
Further work on understanding the return on investment for a wider range of perinatal conditions, their costs and impacts, including the perspectives of mothers and children, is therefore warranted.
This multi-disciplinary team plans to continue developing economic evidence in ways that can be used by decision-makers and influencers who want to invest in transforming maternal mental health care.
Note from the Author:
This article has been developed as part of the Global Economics in Maternal Mental Health (GEMMH) project, a 4-year study (2019 to 2022) funded by the Open Society Foundation. Researchers from the Care Policy and Evaluation Centre at the London School of Economics and Political Science (Annette Bauer, Martin Knapp), University of Cape Town (UCT)/ Perinatal Mental Health Project (Simone Honikman, Sally Field, Emily Garman), South African Medical Research Council (Donela Besada), as well as leaders (Alain Gregoire) from the Global Alliance for Maternal Mental Health have come together to produce economic evidence that can inform investment in maternal mental healthcare in South Africa.