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Can you hear me now? Fantastic. If you can take your seat so that we can get started for the next keynote. Um That would be helpful. I think we're still waiting a few people from one of the workshops to join us. But in view of time, I think we're going to get started. So I'm really delighted to be introducing the next keynote which is addressing the really important issue of maternal mental health, both the research elements and the clinical practice in low and middle income countries. And we've got two speakers who are going to tell us about this, Professor Robert Stuart from the University of Edinburgh and Dr Genesis Gani from Malawi and they are actually both in Malawi at the moment. So they are joining us remotely. We're hoping the technology is going to mean it all goes very smoothly. Please do put your questions into the app as we go along and we'll hopefully hear from them now over to our IT colleagues, right? Hello. Can you hear me? OK. Yeah, I'm hoping so soon. Um uh Hi. Thank you very much for the introduction and for the organizing committee for inviting and myself to speak, as you say, we're coming from L and uh just a correction is uh I'm, I'm Doctor Stuart and it's Associate Professor Choi, but we're going to give you a very whistle stop tour of perinatal mental health research and um uh practice in low and middle income countries but focusing on Malawi as an exemplar. So I'll be talking about a quick introduction to Malawi, then about the observational research into paternal mental health conditions. And then uh Guinness will talk about er interventions um and training and, and engagement with policy makers. As I say, it'll be quite a whistle stop tour. And so we'll hopefully have some questions as well. So for those who don't know about Malawi, it's a wonderful country in South eastern Africa has a population of about 20 million people, 650,000 births per year. It is a very low income country and has a compared with the, with many countries, a high maternal mortality ratio. And currently there are four psychiatrists in the country. Um And as I say, it's a wonderful place. I highly recommend visiting it mainly agricultural based economy, system, farming, but also some exports of tobacco and tea and coffee. So just to remind you about perinatal mental health conditions, um so broadly, you can see them uh categorize them into common perinatal mental health states or conditions. Um and then um some other groups including severe mental illness. So in under sort of cmd, we're thinking about distress, which is really kind of uh grief, which er, would be kind of typical, er, and not very normal responses to difficult circumstances in the perinatal period. Um but in some people, particularly those with a, a propensity to, to develop uh anxious and depressive states, they can develop depression and anxiety disorders, trauma related states. And that can be from currently from the childbirth, trauma of the childbirth itself. Um or from uh thinking back to the women's own childhood experiences of trauma that can become reactivated in the perinatal period, what we call dissociative states. Um in it, it sort of ways of people expressing their, their distress that um er and it may be in, in, in particularly sort of florid of behaviors or um er or for instance, things like loss of, of power in a limb or something like that. Um but they can occur as well. Then you have psychosis and severe mood disorders, either either preexisting such as schizophrenia, bipolar effector disorder or new onset uh and postpartum psychosis being the the kind of exemplar of that. Um And then of course, you have organic conditions um which is very important that they're not mistaken for functional mental illness. So, in terms of doing research into mental health in, in low middle income countries such as Malawi, one of the first questions is um are they do people s see the uh mental health as a as an issue in the, in the per period. Um And there have been a range of qualitative studies which suggest that people do. Um although they may see it as more of understandable response to psychosocial stress rather than a health problem. Um In this study, we did um the particular stressors, poverty, lack of support. HIV, witchcraft and child illness were identified as causes of worries. Um, husbands are expected to provide sort of levels of emotional function and practical support and when that didn't happen, and particularly when there was infidelity abuse or abandonment, they were seen as key uh stressors. Um And as I said, people would, would recognize the sort of abnormal mental states under stress. Uh And these are kind of, they're consistent with, with our understanding of common perinatal mental disorder. So that of work is very important. Then uh psychiatrists often obsess a bit about this around. How do you measure um er mental health problemss? And there's often a debate between whether you can use uh tools generated in a, in a Western setting and, and adapt them or whether you need to generate them de novo in each individual setting. And I think in general, if you are very careful with translation, adaptation and validation, then you can use um these adapted tools although they have limitations. Um and the gold standard would be a sort of a diagnostic interview. Um But then there's these range of screening measures used both in research and then there are attempts to include them in in clinical screening programs and genes will talk about that. So things like the postnatal depression scale for depression, G AD seven for anxiety city birth trauma, for PTSD, uh paternal attachment interview for for bonding. Um So that's uh part of the kind of research activity in perinatal mental health. So what about kind of prevalence and risk factors? So, perinatal common mental disorders are more common in low and middle income countries than in high income. And uh this is probably to do with a higher burden of uh psychosocial stressors. Um for instance, in, in Malawi, er one of the studies we did, we did the er in an antenatal clinics sample, major depression was prevalence of about 10% and a little bit higher in a study in a postnatal under five clinic sample community figures are probably a bit lower than that. But if you look at more broader definition of a common mental disorder, those figures are a bit higher. So what are the risk factors in Malawi and other low middle income countries in, into a part of the violence comes out as always at the top. Um It really is a, a major stressor to women in the perinatal period. Um Lack of a confiding relationship, food insecurity and physical illness, illness, both in the mother but also in the infant are major stressors. So, one of the interests. So, one of the areas of interest that has kind of raised. Mm maternal mental health up the kind of research and practice agenda is um the impact some studies from about 10 years ago demonstrating an impact of um maternal mental health on child growth uh and nutrition in, in low and middle income countries. And that's been quite sort of influential in, in increasing uh interest in and raising awareness of it is an important um maternal and child health issue. Um It's not the, it's, it's still a little bit unclear um in, in Africa, whether, whether it um is the same as in, in, in Asian settings. I mean, I think postnatally, there's good evidence that um that maternal depression can impact on infant socioemotional development in some settings on infant growth. Um And certainly you are studies a cross seal study in Malawi uh reflected um findings in other settings of uh particular effect on uh particular association with, with stunting uh in the in the infants, whether antenatal depression uh impacts on poor birth outcomes is a bit less clear in Africa. Um It certainly affects uh some birth outcomes, delayed breastfeeding initiation. Um um prolonged labor. Um But um not so clear about whether mothers who are depressed are more likely to have uh um babies born early and with low low birth weight and what you need to study those is is um uh longitudinal studies. So I'll just briefly mention one that we're doing in Malawi um in a collaboration between University of Edinburgh Glasgow, er, community, University of Health Sciences and Government of Malawi. That's being done by the Malawi Epidemiology and intervention research unit who has have two sites, one a very long, long established site up a rural site up by the lake in the north and then a new uh um urban site in the long and in both those bites, we're conducting um a uh family and birth cohort study. Um So women are being recruited from antenatal clinics and there's ultrasound dating uh which is a sort of innovation that's come in with this research and is highly valued by, by the health system. Um We'll also recruit the spouse if possible carry out a home visit and measure a range of physical and mental health measures and as well as collect and buy samples uh for a biobank. Um then just follow up at delivery and recruitment of the baby and then a postnatal check sort of checks uh uh and a home visit at four months. Um And just as an example of this, the data that's coming out of that is relates to this question about whether antinatal depression impacts on birth outcomes. And in this longitudinal interim analysis, we again found that in this setting that it doesn't. Um And there's some questions about what might explain this heterogeneity between studies. Um Is it unidentified confounding tool, validity issues? Or maybe there are different studies using methods that um then uh interact with different sort moderators. So, if you're measuring the mental health in the first trimester or the third trimester, is that important? Or is there some kind of true difference? Uh reflecting different contexts around nutrition, infectious disease, burden or culture um around that may affect um the extent to which being depressed, depressed, impacts on, on child health. And that may be an issue related to sort of shared care within the family, et cetera. But whatever, even though we found it didn't find this link. It's very important to remember that in itself, Antal depression and anxiety are distressing and disabling. And we must develop interventions for women in Africa independent of whether there is an impact on the infant's health. The other much less researched area is perinatal, severe mental illness. As you know, postpartum psychosis incidents of 1 to 2 per 1000 women in the UK. And although we don't have the figures from Malawi, we suspect it's the same characterized by a really quite dramatic onset of psychotic symptoms, confusion and mood disturbance and without adequate care, it can be very high risk in terms of suicide neglect and even infanticide. So we did a uh this is uh one of our colleagues um Gloria Kolo, who did an excellent study of um case notes of women with postpartum psychosis in one of the er in the tertiary government facility where women could be admitted with their infant as you would into a, what we call a UK mother and baby unit. But um it's er, admission, the mother's admitted to the acute ward and the baby, along with the guardian, usually the grandmother uh admitted to, to a room off the, the rehab ward. Um, and we looked at, er, case notes and found that about 3% of female admissions had postpartum psychosis and many of those as you would expect had a personal or family history of mental health problems. There was a sort of polymorphic clinical presentation um with a lot uh with sort of kind of manic symptoms or depressive or mixed symptoms um and short duration and people got better and discharged, but there was significant relapse risk. Um So we need to develop the um er further research in in severe perinatal mental illness including in women with preexisting s mis such as as schizophrenia. So that's the end of my section. So I'm gonna pass over to who will talk you through uh the rest of the talk. Uh Thank you, Rob. I will take it up from there. So, with regard to treatment, indeed, there is a huge treatment gap which exists in most African countries and uh where we are in Malawi in particular. And um that gap exists between those women who could benefit from those interventions and those who can access it. But there is a need of male approach such that we address the problem. So there is a need for health promotion and the primary and secondary prevention. Also, there is a need of identification and management to be integrated into routine maternal and child health care services. Uh As you might have noticed it, many um uh low income countries, maybe these services are not found in one place. So we may have to go from one place to the other to access the services which becomes a challenge. But also there is a need to have access to specialist mental health services which are lacking in many countries in the region, like low and middle income countries. So it becomes difficult for uh the healthcare services to meet the needs of mothers who have mental health problems. So, barriers to uh implementation include the stigma uh or stigmatizing beliefs and lack of awareness. Yeah, you agree with me that uh mental health problems are largely associated with the maybe negative characteristics of individuals and that now uh becomes a barrier for people to come out in the open or once they are identified and now uh to go and access uh the necessary services. But also the stigma comes in because people don't really know or they lack awareness that the mental illness is like any other condition. So another challenge of bar here is the low prior in government health budget. You find that there is very little or sometimes no uh funding which is specifically apportioned to mental health services if it has been apportioned, but maybe it is diverted for other health services which are deemed as necessary and pertinent. Also, there is a challenge or a barrier in terms of shortage of trained human resource. As you have heard from Rome for a country like Malawi which has got over 20 million people. It has only four psychiatrists as an example. So you would find that there is limited access to services which are offered by such uh skilled uh mental health professionals. But also the services, the psychiatric services or mental health services are generally centralized. You would find that mostly the services are found at tertiary level, very little or limited at secondary level and sometimes they are completely absent or nonexistent in the primary level. But that's where we have for the majority of the people. In this case, we're talking about women who attend Antenatal services, women who come to postnatal uh clinics. So access to mental health services is limited because of the services being centralized. Mostly. Uh it is encouraging to learn that. Uh yeah, it is happening at a global level that the World Health Organization has made efforts such that there is a recognition that these services have to be integrated. So there is the guide which is there and indeed the quality of maternal and child health services for all women can be improved by creating an environment and enabling environment where women will feel uh safe to discuss any difficulties they are experiencing in a respectful and caring environment. You agree with me that in many low and middle income countries, you find that the primary health care settings, the environment is not as conducive as we might, the women might want because there is limited space. And also you find that they usually congestion because there are too many of them requiring services and there are very few uh health workers or midwives who are supposed to provide the service. So the environment not really conducive and something has to be done. So, uh most women with mental health challenges only require low intensity mental health support and can be provided in maternal and child health care services. This is something which we need to embrace because we're talking about integration. So as I said earlier on, as a barrier that we end up going to various locations, we need to provide the services within uh the maternal and child health services. When they come to a maternity unit, they should be able to access the mental health care they uh deserve. So some women will require additional support either in maternal child health care services or specialized mental health care uh providers through referral. So it is very important that you wherever we are working, these referral pathways are supposed to be properly uh established because not all women indeed would end up requiring support from within the maternity, those with severe or complex mental disorders needed to be referred to specialized hospitals or facilities. However, those who do not require to be referred, requiring low intensity they have to receive the services or access the services within. So with the current set up in many low and middle income countries, you find that even these low intensity mental health support or interventions are not readily available. So meaning that women maybe have to be referred or else maybe completely, they don't get the services. So it is very important that uh screening is done right away in maternity health uh units. So screening should be integrated into standard care and the antenatal or postnatal contacts. They are opportunities. These are opportunities for midwives or whosoever is providing care to women to do such screening. So we have to use valid instruments already. Rob mentioned about the screening instruments, I don't need to repeat, but those instruments should be uh and psychometrically validated such that we are sure that they are able to detect and give us um results which can be uh considered as a valid. So these tools already exist like in my my country, Malawi, the validation of many tools has been done as Rob showed. But we have to also consider that this screening can be done as a multistage kind of screening because the ana or maternity uh clinics are usually uh overloaded and the the people working there sometimes might be overwhelmed. So they need at least to have some sort of distribution of workload. So a short screening instrument such as the ones which have got one or four questions can be used for initial screening. And those only those who screened positive can be referred for more detailed screening, maybe with a longer two with five or more questions. So that's what we can consider as a one of the approach for uh screening. And one of my research has demonstrated that indeed the age kind of screening would be some practical way of uh doing the screening in antenatal clinics. So successful screening requires implementation of relevant task shifting approaches to effectively deliver mental health care in local settings. So depending where we are, maybe the kind of uh health workers we have, we can design our own task shifting. For example, other in other settings, you we can use midwives, uh the other settings, they can use community health workers. So it all depends but that has to be practical and relevant to your setting. So this is a very important point. I would want to make screening should be done only where mental health services are available. Because if we do the screening, it means we are going to create demand for a service. So when you screen the the the women and you find that somebody has got uh uh are screened positive, the question would arise. So what, so it is very important that uh once we we we do the screening, then we are able to provide the interventions. So you can see one of the case records. I think this is used in South Africa. It has got specific questions which they use for screening and for Malawi, I think we are going to have our own as well, which we are going to use for screening. And I think this will be something new for uh maternal mental health care. As women come uh come to antenatal clinics, the midwives would be able to ask those questions to be able to identify those who are at risk. Ok. So psychosocial interventions are very important. So women can be given uh some sort of treatment in terms of uh low intensity as individual or as groups. So you can have problem solving therapy or group interpersonal psychotherapy or CBT cognitive behavioral therapy. So mainly uh psychosocial interventions have been used uh by researchers. So would need to also maybe have opportunities to bring this into the actual practice where they are going to be implemented. But again, the challenge is to bring them to scale. How do we scale up? So indeed, as I have said, uh the scaling up can happen possibly through task shifting. So we have an example of an intervention which has been uh tested in Malawi, the Thinking Healthy program. One of our colleagues, uh doctor Noma uh tested and the feasibility of implementing the Thinking Healthy program. And it is promising that it can be done and it is acceptable to be implemented in primary health care settings. Uh severe mental illness uh interventions, there is limited research and indeed, we still have to do more and make sure that women with such severe mental illness uh have access to appropriate care. And you want to know that there is a lot of stigma associated with that. So there is very little uh uh that has been done, but we have a huge work to do to address that aspect of stigma. So there is also a challenge to do with the medications. So we need to improve in that aspect, increasing awareness on the use of medication, but also to deal with the problem of limitations in the types of medications which are used to treat these conditions and the lack of psychosocial interventions, especially uh rehabilitation. Following an episode, we need also to address that aspect and there is a need for further training or specific training. So efforts are being made and there is an urgent need to upskill both maternal and child health and mental health staff and inclusion of this aspect of training into the undergraduate teaching and in service. So we have the EMR project uh which they are working towards developing uh a postgraduate training program in perinatal mental health in Sub Saharan Africa. But also I'm happy to mention that uh uh Rob and the other colleagues, we worked together through other institutions, Malawi Government Meru and the uh Kamuzu University to come up with the Malawi Maternal mental health manual. This manual is ready very soon. It will be available for use. So, community engagement is very important as such that uh uh there are organizations which are already working in this area, influencing policy or making efforts towards implementing the policy itself. So we have like the African Alliance for Mao Mental Health and this is really doing a good work in terms of advocacy, but also uh educating and making sure that interventions are being made. And also you would see that uh uh a study has been done on postpartum psychosis, which indeed got uh opportunity to interact with the people with live the experiences. So the public involvement perspectives across, you know, three continents. Uh we had the Malawi uh India and the UK involved in that particular study. So indeed, it is very important if we are going to make interventions which are going to inform policy, the public involvement is very important. Uh Thank you very much for listening and this slide just acknowledges all the people who are doing the good work towards very little mental health. Thank you. So thank you very much to Rob and current situation in Malawi particularly and also the ongoing work that they're trying to do to improve the situation. So, Robyn Jens, I hope you can hear me, but we've got a couple of questions which I will read out to you maybe paraphrase. So the first question is whether you could tell us a little bit more about the natural history of prenatal mental health problems and the implications for services. And this is coming from Jenny Hall who's got some experience in this where in her studies, she's found that whilst the prevalence is very high antenatally that actually poor mental health before pregnancy is really important in terms of unplanned pregnancy and postnatal mental health. So I wonder whether you could tell us a little bit about, you know, how women could be maybe be targeted prior to pregnancy to, to relieve that problem. Yes, I mean, I think important to, there was a great focus initially on sort of postnatal depression, but it's increasing awareness that levels of depressive and anxious symptoms are are high in pregnancy and in some situations if women have a have a, a successful delivery of a of a alive well baby, actually the sort of rates of mental health symptoms decline. Um But uh so so, but so we definitely know that your antenatal mental state is increases your risk of being poor of having poor mental health postnatally. Um And uh it's really an opportunity, often, often people come with pre existing difficulties and what the perinatal period it offers an opportunity for intervention. Um and for change. And it is also a time of of uh where we need to think about the mother maybe is, is in some ways, particularly sort of vulnerable um to, to what's going on in her life and, and, and to uh her interaction with the health service, which may or may not be a positive experience. Um So there, there's added vulnerabilities but also added opportunities. But then we always need to remember that the early postnatal period definitely remains a period of very high risk of severe mental illness for women. Um All the studies show that the, that it is the time that month after delivery is the time of highest risk for a woman to be admitted to a psychiatric hospital. Uh And that's, that's the case locally, I'm sure. Um So that really would be my, my answer to that, that query. Thank you. And we had a session earlier today around use of technologies and how they might be helpful. So there's a question we've got about whether digital innovations could be useful for screening for mental health problems in pregnancy and whether that might help some of the barriers to implementing some of the screening. Would you think there's a role in Malawi for digital innovations? All right. Uh Thank you. Yes, there is a a possibility for digital patients particularly uh to do with the uh screening for detection. However, I think as of now, we don't have uh I don't think any research which has been done to see how that can work, but we know a good number of people can uh do have access to uh phones like the Android phones, which maybe they can access um either the app or screening. And they actually this is one thing which maybe we need to consider much of our research has focused on clinic based uh screening and we haven't done uh a lot on community based kind of screening but to answer the question on the use of technology, yes, there is that possibility of use of technology. Thank you. Thank you. Um And then another comment and question around um perinatal mental health, which has become some more public awareness recently in the UK. But that you mentioned in your talk that there is still a little bit of a stigma around it. So how challenging is it to talk about perinatal mental health in Malawi? All right. Um The challenge to talk about perinatal mental health is that if I take mental health ill uh problem or mental illness in itself without even attaching it to pregnancy or uh period after childbirth, you would find that also there is already a lot of stigma because of the myths attached to uh the conditions. So it is really a challenge to talk about the uh mental health or mental illness per se because there is also a confusion between mental illness and mental health. People always think when you talk about mental health, you're talking about mental illness. I'll give an example in one study where we were uh doing group. OK. Uh the the nurses or, and the community volunteers, they had to teach sessions and these sessions were already prescribed. The one session which came out to be difficult for the people to uh or the nurses and uh polluters to teach was the one on mental health one. They were not sure uh how the message will be received by the women. But also they were, you know, the the language uh the is somehow difficult in terms of because some of the vocabulary which we have with the medical terms to do with the mental uh or psychiatric conditions are not readily available in the local language. So that's about a diversion to the explanation but to come back to the stigma, yes, it becomes difficult because there is already a stigma associated with the mental illness. And mental illness is usually confused with the mental health. Such that when you talk mental health, people are already talking, thinking about mental illness. And now mental illness to during pregnancy might also be co uh considered as something maybe uh that is not acceptable because for example, if we talk about the causes of mental illness, from the traditional perspective, it might some believe that it's for somebody to have a mental condition. It is a case. Uh they were case by maybe the ancestral spirits or they did something evil. So you would see that that label alone uh causes a lot of problems and uh people might not want to identify themselves uh with such kind of a label. Thank you. Thank you very much. So, we have only got a minute left and we have still got some other questions which maybe you might be able to answer online, given the timing, some really interesting thoughts about how you might be able to widen access. Given that you've only got four psychiatrists in Malawi and whether there may be other opportunities for other groups to get up skilled and able to help with this problem. But I think it's been a really stimulating and really enjoyable talk and I'm glad the technology worked and we were able to hear you and thank you very much for your presentation. Thank you. Thank you. So I'm advised that the next step is lunch. But whilst you're having your lunch, please do also take time to go and look at the posters. I also have a request that there is a short meeting, a 10 minute meeting going to be happening in the poster room, which is for anyone who's interested in fistula prevention and treatment and partnering to the Global South. So please do go along to that as well. Also, we've got our next key note back at quarter to two. So please do come back in plenty of time for that. It's around heat stress in pregnancy and very interesting. So thank you again for your engagement. Thank you for putting questions into the chat and enjoy your lunch and the posters and we'll look forward to seeing you back to two.