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‘They thought it was contagious’: Teenage mothers at risk from postnatal depression

Women in developing countries are up to twice as likely to develop postnatal depression – so why aren’t teenage mothers in West Africa being treated? -
Women in developing countries are up to twice as likely to develop postnatal depression – so why aren’t teenage mothers in West Africa being treated? -

It’s early afternoon and there’s a low wind blowing clouds of dust and dried-out peanut shells through the farmyard when 10 month old Aminata starts to cry. Marie looks up from her chores – concern sketched across her face as she moves to drop her cleaning brush and soothe the screaming toddler.

Her younger sister gets there first. The 15-year-old’s face falls. “Aminata’s my baby,” she says later. “But they don’t trust me with her any more. They think I’m going to hurt her.” Marie pauses. “I only tried to hurt her once.”

Raised on the outskirts of Fatick in rural Senegal, two and a half hours’ drive from the country’s capital of Dakar, Marie spent the duration of her pregnancy wishing for it to be over. At 14, she felt too small to have a baby, and was so frightened of giving birth that sometimes when she was sick in the dirt behind her bedroom, she figured it was simply from fear.

“I thought having the baby would be the scariest bit,” she says. Many girls from her village have died in labour – most of whom were around her age. “I thought, ‘if I survive the birth, then everything will be OK’. I wasn’t worried about becoming a mother.” She says she didn’t know having a baby could make someone feel so unhappy. “I didn’t know it could make you want to die.”

The World Health Organisation estimates that 300 million women worldwide suffer from postnatal depression – describing it as the most widespread disability to affect women around the world. Yet the chances of developing a maternal mental health disorder are heightened for those in developing regions such as West Africa.

Marie, 15, with her 10-month-old baby Aminata - Credit: Francesco Brembati
Marie, 15, with her 10-month-old baby Aminata Credit: Francesco Brembati

Here, it’s thought that a fifth of all women will present symptoms of postnatal depression or post-traumatic stress disorder after giving birth – unsurprising when you consider the increasing evidence that common mental health problems, including depression and anxiety, are two to three times more prevalent among pregnant women and mothers of infants in resource constrained settings, where money and food are particularly scarce.

The younger the mother, the worse the situation appears to become. The rate of postnatal depression diagnosed in teenage mothers in developed countries is thought to be almost double that of women over the age of 19. Yet few studies have been conducted on the specific prevalence of postnatal depression in adolescent mothers in developing countries – even in regions where the average age of first-time pregnancy is particularly young; such as Liberia (19), Guinea (18.9) and Senegal (21.9).

Local health professionals in all three countries estimate the disorder affects over a third of all teenage mums in West Africa. “But it’s impossible to measure accurately,” says Maguette Seck, 34, a midwife who has been working in Kafrin since 2009 – a region of Senegal particularly affected by adolescent pregnancy. “Until we start to raise awareness of mental health issues, girls are not going to come to us for help and we can’t assess how many of them are suffering.”

Dr Katherine J Gold agrees. As a family physician and mental health researcher at the University of Michigan, she specialises in the study of postnatal depression in women in West Africa.

“There are not a lot of studies in low income countries about postpartum depression, but we do know that rates are higher,” she says. “Physicians in sub Saharan Africa usually have access to basic medications used to treat depression, but patients may not be able to pay for those medications, especially on an ongoing basis. If there are limited resources, mental health usually ends up taking a back seat to acute physical illness.”

Midwife Awa Diouf says babies can quickly become malnourished when the girls are too depressed to breastfeed their children - Credit: Francesco Brembati
Midwife Awa Diouf says babies can quickly become malnourished when the girls are too depressed to breastfeed their children Credit: Francesco Brembati

Women and girls with sick babies are particularly at risk, she says. Nearly three quarters of those studied in Ghana showed symptoms of depression; “yet communities use ‘prayer camps’ to treat mental illness and may not be aware of – or agree with – the idea of depression as a biological mental illness.”

Marie’s first three weeks of motherhood were straightforward. She breastfed Aminata easily, and enjoyed watching her daughter’s face scrunch up if she tapped her on the nose. When the teenager started complaining that she was too tired to get out of bed, no one was particularly concerned. “But then she stopped eating her meals, and refused to feed the baby,” remembers her father, a 65-year-old farmer known simply as Diouf. “We found her yelling at Aminata and threatening to hit her against the wall to make her stop crying, so we took the baby away. But she didn’t get better.”

For four months, Marie sat in her room and stared at the chipped yellow walls while her family members took turns watching over her – keeping their distance to avoid infection from the ancestral spirits that they believed were controlling her behaviour. Her 30-year-old husband, Cheikh Ndong, decided it was all too much, and moved back in with his family. When natural treatments from the local herbalists didn’t work, her parents took their daughter to the local health post, where nurses hooked Marie up to a saline drip and left her alone for 11 days. “They didn’t ask me how I felt,” she says now. “I was very lonely.”

Nobody has ever officially diagnosed Marie with postnatal depression, although the community’s Chief Medical Officer, Djibril Niane, 42, remembers her case and nods at the disorder’s mention.

“But we only have two health huts and one health post to service over 9,000 people within the region, and we have to treat many life-threatening diseases such as malaria and flu,” he says. “Our priority is getting mothers to deliver their children at health centres and with midwives present rather than at home. Young mothers are also prone to premature delivery and complications during the birth. We don’t have the facilities or training to worry about their mental health afterwards as well.”

Binta Doumbouya, 19, with her 10-month-old son Bandjou - Credit: Francesco Brembati
Binta Doumbouya, 19, with her 10-month-old son Bandjou Credit: Francesco Brembati

Funding to the health posts is already stretched as far as it can go, Djibril adds. UNICEF are their major donors – responsible for financing many of the health posts’ much-needed vaccination and nutritional support programmes – but money is tight and it’s often a case of too little, too late.

“The real worry is that when the girls are too depressed to breastfeed their children, their families can’t afford to buy formula milk and the babies quickly become malnourished,” says local midwife Awa Diouf, 32.

“Thankfully we do have emergency food supplies such as Plumpy’Nut paste that we can provide in those circumstances and we can help children before their situation becomes too severe. But without treatment, depression can be really dangerous for both mother and child. Culturally, I don’t know why we don’t take it more seriously here.”

When asked if she plans to try and raise awareness in the future, she looks uncomfortable. She’d like to, but it depends on money, she says eventually.

Over the border in Guinea, the situation is just as concerning. When Binta Doumbaya, 18, from Norassoba, found out she was pregnant two years ago, she was relieved – after all, it meant she would be able to stop having sex with her much older husband.

“Everyone was very happy for me,” she remembers. “They shook my hand and called me ‘cocomanie’, which means ‘pregnant woman’, and treated me with respect. To have a child is the most important thing you can do when you’re a girl.”

A woman waits with her child to meet the doctor at a Senegal clinic - Credit: Francesco Brembati 
A woman waits with her child to meet the doctor at a Senegal clinic Credit: Francesco Brembati

After her son’s birth, she found herself overwhelmed by anxiety. “I stopped sleeping and eating because I was so worried that my baby would die in the night,” she says. “The mosquito nets all have holes in them, so I was certain he would get malaria. Then I was afraid he would have polio, or malnutrition, or some other sickness. One day, he got a bad cough, and I cried so hard I couldn’t breathe.”

When her breast milk dried up after four months, Binta went to the health centre half an hour’s walk away – where the doctor told her she wasn’t eating enough to feed her child. “I told him I was too scared to feel hungry – my feelings were too big for my stomach. But he said I just needed to try harder.”

According to Guinea’s 2014 census, there are only four psychiatrists to serve the whole population of 12.72 million – and in a comprehensive countrywide study of mental health and psychosocial support services by the International Medical Corps in 2015, there is absolutely no mention of postnatal depression or maternal mental health care anywhere in the 34 page report.

“Gender bias [is a significant challenge],” says Mariavittoria Ballotta, UNICEF’s former Early Childhood Development specialist for West and Central Africa. “For example, the majority of health workers in contact with adolescent girls during pregnancy can be men, especially at a community level.”

Mother-blaming, violence against women and a lack of education are all issues that mean teenage girls with postnatal depression don’t get the support they need, she adds. “UNICEF advocates for a double generation approach which takes into account the specific needs of adolescent girls, such as back-to-school strategies, vocational training and counseling.” They’re also working to promote the training of more local female health workers who understand the difficulties faced by vulnerable mothers after giving birth.

The Pipeline health centre in Monrovia, Liberia - Credit: Francesco Brembati 
The Pipeline health centre in Monrovia, Liberia Credit: Francesco Brembati

Liberia is one example of a country taking steps to promote women’s psychological wellbeing post both conflict and Ebola. Three years ago, the Carter Center launched the “Supporting Psychosocial Health and Resilience” project, as funded by the Japanese Social Development Fund and supported by Liberia’s Ministry of Health – with the specific aim of integrating mental health training into its national curriculum for nursing and midwifery schools across the country. Meanwhile, in September last year, French non-governmental organisation Médicins Sans Frontières  began funding four mental health clinics in Liberia – reaching over 900 patients in the past 16 months.

One such clinic is in Pipeline – a suburb of Paynesville, on the edge of Monrovia. Housed in a classroom behind the community health centre, the white-washed walls provide a sanctuary of calm away from the crowded chaos outside. The teenagers who queue up on low wooden benches outside her door are invited in one at a time to answer questions about their eating and sleeping habits. Some bring their babies. Others are escorted by their mums.

“Postnatal depression manifests most often in young mothers here,” says Esther Roger, the clinic’s full-time registered mental health clinician. “But they don’t associate their problems with giving birth – they associate them with hunger, or bad relationships, or financial strain.”

If a case appears severe enough, the girl will be prescribed up to six months’ worth of anti-depressants for free, and offered weekly confidential counseling sessions. “We don’t have the language to describe mental health problems in our culture, so they come to me complaining of a headache,” says Roger. “They say they’re very grateful when it goes away.”

Marie is now recovering from postnatal depression but wishes someone had known how to treat her when she first started to display symptoms - Credit: Francesco Brembati
Marie is now recovering from postnatal depression but wishes someone had known how to treat her when she first started to display symptoms Credit: Francesco Brembati

The clinic’s implementation hasn’t been without its challenges. “The educational level of the local community is very low,” Roger explains. “There is a lot of stigma surrounding mental health problems. People think they are contagious. They don’t want to help if someone is struggling. They refuse to eat from the same spoon, or to drink the same water.

The common belief is that you’re suffering from depression or psychosis then you can’t be cured. So instead of bringing their daughters and wives to the health centre for treatment, they take them to the local church and leave them there.” Nevertheless, she believes the project’s success so far already shows potential for other West African countries to follow suit. “Governments and NGOs just need to make it a priority.”

Marie wishes someone had known how to treat her when she first started to display symptoms of postnatal depression – although she’s grateful to her family for refusing to give up hope. After nearly six months of relative isolation, she’s still not sure what prompted her recovery, although her father attributes it to a combination of ancient Serer clan rituals and regular portions of rice.

Some weeks are more difficult than others, but these days Marie tries not to panic if she starts to feel isolated or overwhelmed. “I didn’t ever stop loving Aminata,” she says now – scooping her daughter up from the floor and hugging the squirming toddler tight. “But being a mother is very hard.”

CASE STUDIES

‘I still have nightmares about giving birth’

Sanaba, 16, from Doko, Guinea, gave birth to her first son ten months ago.

Sanaba, 16, from Doko, Guinea, gave birth to her first son ten months ago - Credit: Francesco Brembati
Credit: Francesco Brembati

“When I found out that I was going to have a baby, I wasn’t very worried. I thought it would be a good thing, because nobody respected me before. I was just a girl. As a mother, maybe I would count for something. People would take me seriously and listen to my voice.

I didn’t know how to give birth to a baby – nobody had told me how it would happen, and I’d never seen anyone give birth before - but I thought maybe there would be an operation, or maybe the baby would be very, very small and could come out of my mouth. It was only when I went into labour that my mother-in-law took me to the hospital and the nurses told me what was going to happen. I cried and screamed at them - ‘no, no, no’ – but they said I didn’t have a choice. Nobody suggested any pain relief.

I think I was giving birth for one whole day, maybe even more. When it was finally over, I didn’t want to hold my son. Everything hurt too much for me to love him, and I asked the nurses to take him away. Eventually, they brought him back, and said I had to take him home with me. I cried again, but I didn’t get a choice. I really want to be a good mother, but it feels very challenging.

My body feels different now, like I can’t trust it. Sometimes I wake up screaming because I’ve had a nightmare about giving birth, and I feel too tired to laugh. My mother-in-law says I’m lazy because I just want to close my eyes and sleep all the time. I think I must be very sick, but there isn’t any medicine to cure me. This is just who I am now.”

‘If I told my husband he would punish me’

Ami, 18, from Fatick, Senegal, gave birth to her third child ten months ago.

Ami, 18, from Fatick, Senegal, gave birth to her third child ten months ago - Credit: Francesco Brembati
Credit: Francesco Brembati

“The loneliness is the worst thing. I live with my parents-in-law and my husband, but there isn’t anybody who I can talk to about my feelings. Nobody would understand. Becoming a mother is very important to our culture. If you don’t get pregnant after two years, then maybe your husband will leave you, and you’ll be all on your own. So you need to give birth and be happy, because then your husband will stay. If my husband left me, I don’t know what I would do. We don’t have enough food anyway. I haven’t eaten in two days and my breast milk is drying up. He’s a peanut farmer, and we rely on his income. All my children are sick and malnourished, and I feel sad all the time. Sometimes I can’t sleep because I can’t stop thinking. I have no hopes for the future at all.

If I told my husband that I was unhappy, he would say I was weak, or that maybe it was bad spirits making me feel that way, and maybe he would punish me for bringing them into the house. I went to the health centre once to ask if they could help me because my head was hurting. It wasn’t like a normal pain like when you cut your knee. It was like thinking was too painful. The doctor told me I was in shock, and gave me some medicine. He didn’t tell me what had shocked me. Anyway, it didn’t help much, so I didn’t talk to anyone about that again.”

‘I think it's all my fault’

Bea, 18, from Monrovia, Liberia, gave birth to her daughter three months ago.

Bea, 18, from Monrovia, Liberia, gave birth to her daughter three months ago - Credit: Francesco Brembati
Credit: Francesco Brembati

“I can’t remember what it was like to feel OK. I look at my baby, and I think ‘I wish you weren’t here’ and I want to close my eyes to make her go away. When I open them again, she’s still there, and I feel like I’m being squeezed so tight that I can’t breathe. I’m angry at everyone and lonely at the same time. It isn’t fair. I didn’t want this. I didn’t want to be a mum. This is a secret, but I didn’t even want to have sex – a man made me, in the middle of the day, while I was selling water by the side of the road. But I didn’t know about family planning, so I think it’s my fault.

I think life is hard in Liberia for every woman, but my life gets worse when my baby cries. I don’t know how to tell her I don’t have any food for her and that I can’t breastfeed because I don’t want to be near her. She’s getting thin, and I’m worried because I know she’s going to get sick, but recently I’ve started putting her down and leaving the room with my hands over my ears when she screams. My mum comes in and takes care of her for me, but afterwards, I feel bad, like I’m letting everyone down.

Giving birth was scary, but when I held my daughter the first time, I felt happy. I thought, maybe you’ll grow up to be a lawyer to help other girls like me in the future. Maybe you’ll stop men from hurting other women in the road. I thought I would be able to love her and cherish her forever, even if we had no money. Instead when I look at her, I wish she didn’t exist at all.”

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