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Maternal Mental Health Scaling-Up Strategy for Mexico
Word Count: 1637
This proposal outlines a scaling-up strategy for maternal mental health (MMH) services in
Mexico, with reference to the framework of Eaton et al. (2011).
Situational Analysis
The prevalence of Mexican women with children under five years of age with depressive
symptoms is estimated to be around 20% (de Castro et al., 2017). Furthermore, Mexican
women are significantly more likely than men to suffer from psychological distress, yet on
average only 16% of them seek treatment (Mendoza et al., 2017). The undertreatment of MMH
issues is of particular concern given the research evidence showing that MMH issues beyond
the severe burden they place on women, both in terms of their quality of life and economic
costs, the children of these mothers are at significantly higher risk of health, developmental,
and behavioural problems (Rahman, Fisher, et al., 2013). Research conducted in Mexico on
mothers with MMH issues showed an association between the mother’s ill MH and a reduction
in breastfeeding and attendance at health check-ups, and that the children of these mothers
had a significantly greater risk of experiencing ill-health and accidents (de Castro et al., 2017).
These issues are augmented by the high risk of exposure to issues such as poverty, social
conflict, and gender-based violence in Mexico, all of which are associated with higher
prevalence of MH issues (Zeligman et al., 2019). Despite the demand for MMH services in
Mexico, less than half of the public obstetrics clinics have provisions in place for their detection
and treatment (de Castro et al., 2017).
The Mexican government has adopted a policy of integrating MH services into primary care
(PC), falling in line with international best practice guidelines on reducing the treatment gap
for mental illness (Galván et al., 2017). However, this policy has had limited impact in practice,
given the finite funding and poor resource allocation to MH services, with the government
allocating only 2% of its total health budget towards MH (Miguel-Esponda et al., 2020). PC
facilities are chronically underfunded, with 70% lacking the appropriate resources to diagnose
mental illnesses (Mendoza et al., 2017). PC centres in marginalized areas suffer the greatest
disadvantage, while providing for the population most in need of MH services (Galván et al.,
2017). MH is determined by a broad range of factors, including social and cultural
determinants, thus policies which target improvements in women’s social status can help to
reduce the incidence of MMH issues (Atif et al., 2015). The Mexican government has
developed specific policies targeted towards women’s health. For example, prenatal care and
family planning services have been emphasised as a priority by the state, however appropriate
training for these services remains low and MMH issues are not integrated into these
programmes (DiGirolamo & Salgado de Snyder, 2008).
Planning
The situational analysis of MMH services in Mexico provides strong justification for scaling-up
MMH provision. Given the variety of factors influencing MMH in Mexico, multiple
complementary strategies are proposed in order to tackle the issue holistically. Firstly, the
strategy proposes to further integrate MMH services into routine PC, as research evidence
suggests this significantly improves MMH outcomes (Atif et al., 2015). Various LMIC have
successfully integrated MMH into routine maternal and child health programmes, such as
nutrition and immunization programmes (de Castro et al., 2017). In Sub-Saharan Africa and
Pakistan, cognitive behavioural therapy interventions were adapted for integration into child
nutrition programmes (Atif et al., 2015; Lasater et al., 2017). A benefit of this form of integration
is that it reduces stigma by combining MH with physical health treatment (Rahman, Surkan,
et al., 2013).
To date no research study has attempted to integrate MMH into PC in Mexico, however there
is evidence of effective integration with regards to MH services more broadly. One study
conducted in the rural region of Chiapas managed to successfully implement MH services into
ten PC clinics (Miguel-Esponda et al., 2020). Another study found that integrating MH services
into PC increased women’s rates of follow-up for MH issues (Mendoza et al., 2017). The
integration of MMH into PC in Mexico could help to reduce stigma and to reach individuals
who typically avoid use of MH services (Zeligman et al., 2019). Furthermore, integration could
help to improve outcomes for other government funded initiatives such as breastfeeding
programmes, as rates of breastfeeding are significantly below international standards
(González de Cosío et al., 2018).
Given the restricted capacity of the Mexican healthcare system due to understaffing, the
second element of the proposed scaling-up strategy is task-shifting. Task-shifting involves the
redistribution of tasks from more specialised health workers to less specialised (Iwu &
Holzemer, 2014). Various systematic reviews have highlighted the effectiveness of task shifting in improving MMH outcomes in LMIC (Atif et al., 2015). There is significant evidence
to suggest non-specialists are capable of alleviating the burden of MMH issues when trained
to deliver basic MH services (Lasater et al., 2017). Peers are individuals who have common
characteristics and similar lived experience to service-users. Peers have been found to reduce
feelings of isolation and low self-esteem in mothers (Jones et al., 2014) and one study found
service-users to prefer peers to health professionals for delivering MMH interventions. The
proposed scaling-up strategy therefore encourages task-shifting to be carried out with PC
professionals, such as midwives, nurses and peers, in regions where PC professionals are
over-burdened with additional tasks (Atif et al., 2015). Although no research has been
conducted in Mexico with regards to task-shifting for MMH, various task-shifting interventions
for other MH issues have proven successful and helped to extend MH provision where these
services did not exist previously (Miguel-Esponda et al., 2020; Zeligman et al., 2019).
Finally, the scaling-up strategy will employ e-mental health services in order to alleviate
financial costs and provide oversight for task-shifting. E-mental health services provide MH
services via the Internet, reducing time and travel costs (Sprenger et al., 2017). It is particularly
useful in a highly fragmented context such as Mexico that has many isolated rural regions
without access to MH professionals. Peer-support providers and PC workers alike can use e mental health services to keep in contact with MH specialists increasing oversight of task shifting practices (Miguel-Esponda et al., 2020). With regards to MMH, e-mental health
services, due to their anonymity, have been shown to reduce stigma for service-users.
Additionally, they provide mothers the flexibility to access MMH services on their schedule
leading to an increase in mothers engaged with services (Sprenger et al., 2017).
Identifying potential barriers and developing associated risk-management plans is crucial to
the success of the strategy (Eaton et al., 2011). One potential risk is insufficient support for
the strategy from key stakeholders. If policy-makers and government do not consider the
strategy a worthwhile investment it is unlikely to ever reach fruition, as they are crucial to the
funding and service provision (Atif et al., 2015). In order to ensure their commitment, they
should be lobbied on the synergistic results that arise from integrating physical and MH, and
informed on the benefits investment in MMH can have on their existing maternal health
programmes (Rahman, Surkan, et al., 2013). The perspectives of service providers, as well
as service-users provided crucial insights into the aspects of the healthcare system that
require improvement which will help to inform the design of the strategy (Lasater et al., 2017).
Furthermore, stakeholder perspectives must be obtained throughout all regions in Mexico,
particularly due to the country’s fragmented healthcare system, in order to ensure a
comprehensive picture is obtained of the necessities of each region (Martinez et al., 2016).
The strategy may lack cultural competency if its design is heavily based on research findings
from other LMICs. In order to mitigate this risk, evidence from Mexico should heavily inform
the strategy design; however it is important to be aware that the limited research conducted
in this context may limit the generalizability of the research findings (Eaton et al., 2011).
Additionally, it is crucial to place local expertise at the centre of the strategy’s design so that
local idioms of distress and social determinants of ill-health are properly accounted for
(Mendoza et al., 2017).
Implementation
Scaling-up strategies without appropriate implementation will cause them to deviate from their
intended objectives (Eaton et al., 2011). Poor implementation can result in low levels of
service-user engagement and deviations from strategy guidelines. The use of e-mental health
services should help to improve adherence to the strategy and provide additional support to
those working in remote regions (Miguel-Esponda et al., 2020). The support of community
leaders, such as teachers, priests, and traditional healers will need to be obtained in order to
increase levels of community engagement (Zeligman et al., 2019).
Evaluation
The most successful scaling-up strategies are not static, but rather are designed with
evaluation and adaptation in mind (Eaton et al., 2011). Evaluation is required in order to
ascertain whether the measures taken were successful in improving MMH outcomes or
whether changes to the original design are required. Evaluation is particularly pertinent in
Mexico given the limited availability on MMH strategies in the country (Martinez et al., 2016).
In particular, attention should be given to evaluating the success of the strategy in rural
regions, as they are typically the most underrepresented and the worst affected by MH issues
(Zeligman et al., 2019). Evaluation should be conducted in partnership with academic
institutions to provide independent reports of the effectiveness of the programme. Importantly,
all stakeholders’ perspectives should be obtained as part of the evaluation process to ensure
outcome measures represent the views of all involved in the strategy (Eaton et al., 2011).
Summary
Mexico stands to benefit from the scaling-up of MMH services both economically and with
regards to improving the quality of life for its citizens today and in future generations. This
proposal has outlined a feasible scaling-up strategy for MMH which is based on the best
available research evidence and builds upon the existing health care framework.
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