Task sharing of a psychological intervention for maternal depression in Khayelitsha, South Africa: study protocol for a randomized controlled trial

Abstract

BackgroundMaternal depression carries a major public health burden for mothers and their infants, yet there is a substantial treatment gap for this condition in low-resourced regions such as sub-Saharan Africa. To address this treatment gap, the strategy of “task sharing” has been proposed, involving the delivery of interventions by non-specialist health workers trained and supervised by specialists in routine healthcare delivery systems. Several psychological interventions have shown benefit in treating maternal depression, but few have been rigorously evaluated using a task sharing approach. The proposed trial will be the first randomised controlled trial (RCT) evaluating a task sharing model of delivering care for women with maternal depression in sub-Saharan Africa. The objective of this RCT is to determine the effectiveness and cost-effectiveness of a task sharing counseling intervention for maternal depression in South Africa.Methods/DesignThe study is an individual-level two-arm RCT. A total of 420 depressed pregnant women will be recruited from two ante-natal clinics in a low-income township area of Cape Town, using the Edinburgh Postnatal Depression Scale to screen for depression; 210 women will be randomly allocated to each of the intervention and control arms. The intervention group will be given six sessions of basic counseling over a period of 3 to 4 months, provided by trained community health workers (CHW)s. The control group will receive three monthly phone calls from a CHW trained to conduct phone calls but not basic counseling. The primary outcome measure is the 17-Item Hamilton Depression Rating Scale (HDRS-17). The outcome measures will be applied at the baseline assessment, and at three follow-up points: 1 month before delivery, and 3 and 12 months after delivery. The primary analysis will be by intention-to-treat and secondary analyses will be on a per protocol population. The primary outcome measure will be analyzed using linear regression adjusting for baseline symptom severity measured using the HDRS-17.DiscussionThe findings of this trial can provide policy makers with evidence regarding the effectiveness and cost-effectiveness of structured psychological interventions for maternal depression delivered by appropriately trained and supervised non-specialist CHWs in sub-Saharan Africa.Trial registrationClinical Trials (ClinicalTrials.gov): NCT01977326, registered on 24/10/2013; Pan African Clinical Trials Registry (http://www.pactr.org): PACTR201403000676264, registered on 11/10/2013.

Identifying inequities in maternal and child health through risk stratification to inform health systems strengthening in Northern Togo

“…A postnatal health check for mothers is particularly crucial as more maternal deaths (36%) occur in time period following the first 24 hours of birth and within six weeks of delivery than any other phase of pregnancy [28]. Our bivariate findings showed the lowest percentage of women who accessed maternal and child health services were those who resided farthest from health facilities.…”

“The sun has set even though it is morning”: Experiences and explanations of perinatal depression in an urban township, Cape Town

“…The interviews were part of the formative research for the South African section of the Africa Focus on Intervention Research for Mental health (AFFIRM) study. This is an individual-level randomised controlled trial (RCT) to determine the effectiveness and cost-effectiveness of a task-sharing counselling intervention for perinatal depression in a low resource context in Cape Town (Lund, Schneider, et al, 2014). …”

Addressing the Unmet Need for Maternal Mental Health Services in Low‐ and Middle‐Income Countries: Integrating Mental Health Into Maternal Health Care

“…In cases of crisis, such as suicidal ideation or behavior, or other mental health problems, such as posttraumatic stress disorder, mental health specialists are available for case management and referrals to more specialized care beyond what is available at the community level. Meanwhile, Lund and colleagues are conducting a randomized control trial in South Africa to investigate the impact of a task‐shifting approach among community health workers to deliver care to women with maternal depression . Such studies provide much needed practical guidance and evidence from which to adapt locally relevant screening tools and intervention packages.…”

“…These include nonpsychotic mental disorders, such as depression, anxiety, and somatoform disorders, which are commonly found in community and primary care settings and are responsible for increased morbidity and mortality among childbearing women worldwide . Perinatal depression, defined here as a depressive episode beginning during pregnancy or up to one year postpartum, is the most common perinatal mental disorder and the second leading contributing factor to the disease burden of childbearing women globally . Despite their high prevalence, common perinatal mental disorders often go undiagnosed and untreated due to a lack of or limited mental health infrastructure.…”

“…1,2 Perinatal depression, defined here as a depressive episode beginning during pregnancy or up to one year postpartum, is the most common perinatal mental disorder and the second leading contributing factor to the disease burden of childbearing women globally. 1,3,4 Despite their high prevalence, common perinatal mental disorders often go undiagnosed and untreated due to a lack of or limited mental health infrastructure. This is particularly true in low-and middle-income countries where scarce resources limit the ability of the health system to address even the most pressing needs.…”