PERINATAL mental health (PMH) is a growing public health concern globally and in Malaysia. According to the World Health Organization (WHO), one in every five women suffers from mental health problems during and after pregnancy.
The most common PMH conditions associated with pregnancy are:
1. Antenatal depression or postpartum depression (PPD)
2. Anxiety disorders
3. Obsessive compulsive disorder (OCD)
4. Postpartum psychosis (PPP)5. Post-traumatic stress disorder (PTSD)
In worst cases, severe PMH conditions lead to maternal suicide caused by intrusive thoughts and hallucinations.
As reported by the local Malay-language media outlet Utusan Malaysia, just last month a mother in her postpartum confinement period committed suicide. It was reported that the mother, who had just given birth to her fourth child, refused to take the antidepressants provided by the hospital for her mental health condition.
Rapid changes in reproductive hormones such as estradiol and progesterone during and post-delivery of mothers affect the overall mental wellbeing of mothers.
Findings by Aliyah Dosani et al indicate that only a small percentage, 6.5-12.9%, of women in high-income countries experience PMH conditions compared to 48.5% of women in low- and middle-income countries. As a growing middle-income country, this is an indicator for Malaysia to ramp up our obstetrics and gynaecology (O&G) and PMH care in Malaysia.
In Malaysia, untreated and undiagnosed PMH conditions are the proverbial needle in a haystack when it comes to PMH care, aside from worries about lower socioeconomic levels, unplanned and teenage pregnancies, and high-risk pregnancies.
To support the above, let us look at the facts and statistics.
Poor screening instruments and intervention mechanisms are perhaps one of the many reasons that many PMH cases go undetected and untreated, in addition to societal stigmatisation, a lack of knowledge about PMH conditions, and a subpar treatment plan.
A study by associate professor Dr Siti Roshaidai et al, involving 28 healthcare practitioners in Malaysia highlighted the insufficiency and limitation in the knowledge of practitioners, standard guidelines by MOH and modern screening tools as the cause of numerous PMH cases in Malaysia going unnoticed.
Even worse, the shortages of registered psychiatrists, occupational therapists, and O&G specialists makes it impossible to provide excellent care for all pregnant women.
As of 2023, there are only 667 O&G specialists serving under the Health Ministry (MOH) facilities in Malaysia. A study by R. Shaeraine et al shows that the ratio of clinical psychologists in Malaysia is 1:100,000 population. The ratio of mental health nurses is 6:100,000 population.
As Malaysia underachieved the O&G specialist ratio standard (23.7:100,000 women) by the Organisation for Economic Co-operation and Development (OECD), Deputy Health Minister Lukanisman Awang Sauni has stated that the government hopes to achieve 1,000 O&G specialists by 2030, which would be still too low for the desired ratio.
The insufficient number of medical practitioners in this field indicates inadequate distribution of resources, management, and provisions for O&G and PMH care in Malaysia.
Apart from the alarming healthcare situation, perceived discrimination and violence in households, workplaces, and society increases the risk of PMH illness. As a highly stigmatised health issue, PMH conditions are rarely talked about and supported in workplaces.
A 2016 Woman’s Aid Organisation survey indicated that 40% of 222 respondents experienced discrimination at the workplace due to pregnancy.
Another study by Dr Nor Ani Ahmad et al found that postpartum women were 2.3 times more at risk of having mental illness when were exposed to intimate partner violence. (see “Postnatal depression and intimate partner violence: a nationwide clinic-based cross-sectional study in malaysia”, BMJ Open, Vol. 8, Issue 5, 2018)
And to top it all off, society frequently disregards women who have experienced a miscarriage. These women are among the most vulnerable to developing PMH problems.
Though research indicates 80% of miscarriages occur in the first trimester (around the 12th week of pregnancy), under the Employment Act, these women are not provided with specified maternity leave, as maternity leave cannot be taken earlier than 30 days before the confirmed confinement period and prior to 22 weeks of pregnancy. In reality, those who have had a miscarriage need some time to grieve and recover their physical, emotional and mental wellbeing.
While PMH conditions have a higher prevalence in women, research by Jonathan R. Scarff indicates 8-10% of fathers develop PPD following the birth of a child. The likelihood of the spouse experiencing mental health issues increases when a woman in pregnancy or a new mother experiences PMH issues.
In addition, the risk may increase as a result of adjusting to changes in roles, maintaining marital relationships, and potential professional and financial stress caused by having a child.
In relation to work, recently a man expressed his frustration on TikTok after he was fired by his superior for asking for paternity leave to care for his wife following her early delivery. Legally, that man was entitled to a seven-day paid paternity leave under the Employment (Amendment) Act 2022, section (60 FA).
The stakeholders must address the concerns of vulnerable families.
The following are the policy recommendations from Emir Research:
1. Enhance pre-existing social protection acts and policies on maternity
First, provisions for miscarriages should be included in a separate subsection of the Malaysian Employment Act. Currently, there are no provisions for miscarriages. It is also recommended that stakeholders consider providing a minimum of two weeks maternity leave for women who go through miscarriages anytime from trimester one to three.
Second, although the latest policy of 98 days of paid maternity leave pleases employees, this may not be favourable to the majority of employers as currently the cost for the 98 days of paid maternity leave is borne 100% by the employer. This will increase the tendency of employers to recruit male applicants for job openings and promotions in future.
In relation to that, it is recommended that policymakers consider sharing the cost of maternity leave between the employer and the Social Security Organisation. Similar initiatives have been executed by Asean countries such as Vietnam, Thailand, and Singapore. For instance, Thailand provides 98 days of paid maternity leave, whereby the cost is equally shared by the employer and Thailand’s Social Security Office.
Simultaneously, policymakers should consider the addition of special provisions on anti-discrimination under the Employment Act. Such policies will minimise the prejudice experienced by fathers and mothers in the workforce when it comes to recruitment, employability, and job security.
2. Establish a systematic guideline and mechanism for PMH screenings and assessments in Malaysia
Systematic and comprehensive PMH screening interventions should start from the antenatal to the postpartum period.
The mental state of both the mother and father should be assessed during O&G appointments, along with a physical check-up of mother and baby.
Assessment screening tools such as the Edinburgh Postnatal Depression Scale, Patient Health Questionnaire-2 or Whooley Two-Question Screen (as highlighted in the 4th edition Perinatal Care Manual) are the preferred options to detect PMH conditions.
O&G practitioners including doctors and nurses should be educated and be aware of any symptoms that indicate PMH conditions. Once detected, these parents should directly referred to an in-house psychologist for further treatment.
It is also recommended for MOH to establish a systematic open data statistics on mental health prevalence, demographics, conditions, etc in Malaysia. Currently, most data and statistics are gathered from past research and surveys to study PMH conditions. The aim is to have all information related to mental health digitalised and encourage deeper research in future.
3. Flexible work arrangements for women with PMH conditions
As PMH conditions may persist for up to a year, organisations should encourage flexibility at the workplace.
Flexibility in terms of adopting the hybrid workplace model, along with flexible working conditions and hours. Nevertheless, given that it heavily depends on the industry, nature, and scope of the job, this might not be relevant for all; furthermore, a certified medical report should be provided to the employer to be entitled to it.
The outcome will not only strengthen the mother’s bond with her child, but it will also help improve her psychological wellbeing and work performance as a whole.
All in all, it is now more important than ever to address the issue of PMH in Malaysia. – May 26, 2023.
* Jachintha Joyce is research assistant at Emir Research.
* This is the opinion of the writer or publication and does not necessarily represent the views of The Malaysian Insight. Article may be edited for brevity and clarity.