Perinatal mental distress in a rural Ethiopian community: a critical examination of psychiatric labels

BACKGROUND: Perinatal mental distress poses a heavy burden in low- and middle-income countries (LMICs). This study investigated perceptions and experiences of perinatal mental distress among women in a rural Ethiopian community, in an effort to advance understanding of cross-cultural experiences of perinatal mental distress. METHODS: We employed a sequential explanatory study design. From a population-based cohort study of 1065 perinatal women in the Butajira Health and Demographic Surveillance Site, we purposively selected 22 women according to their scores on a culturally validated assessment of perinatal mental distress (the Self-Reporting Questionnaire). We examined concordance and discordance between qualitative semi-structured interview data (‘emic’ perspective) and the layperson-administered fully-structured questionnaire data (‘etic’ perspective) of perinatal mental distress. We analysed the questionnaire data using summary statistics and we carried out a thematic analysis of the qualitative data. RESULTS: Most women in this setting recognised the existence of perinatal mental distress states, but did not typically label such distress as a discrete illness. Instead, perinatal mental distress states were mostly seen as non-pathological reactions to difficult circumstances. The dominant explanatory model of perinatal mental distress was as a response to poverty, associated with inadequate food, isolation, and hopelessness. Support from family and friends, both emotional and instrumental support, was regarded as vital in protecting against mental distress. Although some women considered their distress amenable to biomedical solution, many thought medical help-seeking was inappropriate. Integration of perspectives from the questionnaire and semi-structured interviews highlighted the important role of somatic symptoms and nutritional status. It also demonstrated the differential likelihood of endorsement of symptoms when screening tools versus in-depth interviews are used. CONCLUSIONS: This study highlights the importance of the wider social context within which mental health problems are situated, specificially the inseparability of mental health from gender disadvantage, physical health and poverty. This implies that public health prevention strategies, assessments and interventions for perinatal distress should be developed from the bottom-up, taking account of local contexts and explanatory frameworks.