Screeeech! The piercing sound jolted Esther Olawale, a 29-year-old mother, back to reality. She had stepped carelessly onto the highway, lost in thought, and would have been knocked down by an oncoming vehicle,if not for the driver’s quick reflexes, who slammed the brakes just in time.
Olawale’s woes began a few weeks after the delivery of her four-month-old baby, who was diagnosed with a hole in the heart, at the Mercy Street Children’s Hospital. A surgery of over three million naira has been recommended for the child, but the parents have not got the money.
“No one told me. And I never imagined it could be this bad!” Mrs Olawale broke down in tears. “If motherhood is all about what I’m going through at the moment”, she continued, “I think no woman would like to become a mother,” she spoke in anguish of soul.
Prevalence of PPD in Nigeria
Postpartum depression (PPD), according to the World Health Organisation (WHO) ,is a significant mental health issue affecting women after childbirth. It is a type of depression that can occur during pregnancy or after childbirth, with symptoms similar to those of other depressive episodes.
Globally, available records show the prevalence of PPD to be between 10-15 per cen,t but ranges from 10 -35.6per centt in Nigeria, according to different studies. With the increase in prevalence of this condition notwithstanding, the fear of being stigmatised leads to denial in many women, which keeps care away from them, thereby worsening their conditions.
“From sleepless nights, to difficulty in breathing, and other terrible symptoms,” Olawale narrated, “my baby’s condition deteriorated fast until she was diagnosed. Then the race to raise the funds for her survival, amidst our financial limitations ,began!”
Following this sad reality, Mrs Olawale, whose husband is a roadside trader, has been traumatised and perplexed, with no idea of how they will get the huge amount of money. “In fact, several thoughts had run through my mind on getting rid of the baby, to relieve myself of the untold pressure, but my husband kept expressing optimism in getting her,” she further disclosed her perplexity.
With prevalence rates varying from state to state, the country’s lack of specialised maternal mental healthcare units in public hospitals, due to poor implementation of the National Mental Health Act of 2021, exacerbates the condition in women, with associated stigma and discrimination.
Temitope Obayendo visited some antenatal and postnatal clinics in Lagos State- Ikeja, Ikorodu, Epe, Badagry, and the Island axis of the state to document the impacts of PPD in the lives of women. Her findings reveal critical gaps in the state healthcare delivery system, which ironically boasts of a robust mental health service unit, but a large number of nursing mothers groan silently under the burden of PPD.
More cases of mothers suffering PPD
Unlike Olawale, Alice Nwankwala, a 23-year-old single mother, experienced psychological trauma from pregnancy due to spousal neglect. “My initial plan was to complete my tertiary education before settling down for marriage,” she told the reporter. “But somehow along the line, pregnancy set in, and my fiancé abandoned me in that state, due to his financial incapability”, Nwankwala recalled with teary eyes.
Nwankwala narrated how healthcare providers at the Island Maternity, where she had her antenatal, and the Mercy Street Children’s Hospital, where she attended for post-natal clinics, neither lectured nor provided care for them on PPD. “So it was a totally new experience for me. If not for my dear friends, I wouldn’t know what would have become of me and my baby today”.
Mrs Ada Kalu, a grieving mother whose three-month-old baby boy had just died from severe neonatal sepsis, wailed uncontrollably for hours. After five long years of waiting and hoping, her miracle child was gone.
“I want my baby back alive”, she cried. Her voice breaks under the weight of despair, as seen at the front of the Maternal and Child Care of the Ikorodu General Hospital. Hers was a double jeopardy of traumatic, long weeks of sleepless nights of care for her newborn, coupled with the eventual loss of the child.
Challenges of child care
Child care comes with lots of responsibilities and challenges for mothers, from pregnancy to labour pains, delivery, breastfeeding, general care, sleepless nights of nursing, caring for sick or deformed babies, trying to understand the needs of newborns at each developmental phase, baby blues, etc. Besides, mothers have other obligations to other members of the family and themselves.
The common manifestations of PPD, according to experts, range from emotional to physical symptoms, cognitive, and social symptoms. These signs and symptoms can appear within the first few weeks after childbirth but can also begin earlier, during pregnancy, or later, and last up to a year after birth.
The Lagos State Mental Health Policy and Law
Interestingly, in a bid to curb the incidence of mental disorders among the population, the Lagos State Government, through the Ministry of Health, introduced the Lagos State Mental Health Policy in 2011,a nd Mental Health Act 2019, far ahead of the National Mental Health Act of 2021, which highlight the goals of the state government in protecting the rights and caring for the mentally challenged and persons suffering from substance abuse; integrating mental services into the primary and secondary health institutions, towards ensuring adequate mental health services even at the primary health centres.
The policy document, which is divided into six areas, has the following sub-headings: Mental health promotions; primary care and access to services; treatment guidelines at primary care levels; services for people with severe mental health illness; reduction of workplace stress and the risk of success; and human resources for mental health.
Weak implementation of Mental Health Policy, Law
In implementing this policy, according to the Mental Health Act 2019, the Ministry of Health, established the Lagos State Mental Health Development in 2019.
(LagosMiND), a non-profit, governmental organisation for the promotion of mental health services through advocacy, education and collaboration with NGOs for partnerships and support.
According to the LagosMiND on its website, it provides services including: Tele-behavioural mental healthcare, virtual psycho-social support, virtual counselling, referrals to on-site mental healthcare hospitals, community-based mental health awareness campaign, training, policy writing and development and advocacy programme.
Also in 2024, the Lagos State Government introduced a new mental health helpline, called “the Lagos Lifeline Smart Number: 0700 000 MIND (0700 000 6463), to expand access to mental healthcare. However, this reporter called these lines twice as a patient seeking mental health care, but no specific care or referral was given.
Critical gaps in Lagos Mental Health Policy, Law
However, fourteen years down the line, the state has failed to significantly deliver on its objectives, due to what it tagged several challenges, including stigmatisation and poor literacy level ofthe affected population. A major aspect of its failure is the absence of functional maternal mental health units at general hospitals and primary health centres. Unfortunately, six years after the enactment of the law, there is a rather an increase in PPD, as more pregnant and nursing mothers are battling PPD all alone, without mental health care at both antenatal and postnatal clinics as stipulated in the mental health policy and law.
Absence of psychiatrists at health centres and general hospitals
Our investigation on the provision of mental health services at the general hospitals and health centres,went beyond mothers to caregivers who spoke on the ground of anonymity when asked about the level of care provided for individuals with mental health conditions. When this reporter asked a pharmacist at the Ipaja Primary Healthcare Board on the appropriate health centre to seek care for her cousin with PPD, she responded thus,” I will advise you to take her to LASUTH for proper treatment, because we have not started providing mental health services here. Of course, we have been trained, but the service has not commenced at health centres, because we don’t have psychiatrists here yet.”
The correspondent went further to speak with a nurse at the Ogolonto Primary Health Centre, who prefers anonymity, on the appropriateness of bringing her cousin experiencing PPD for treatment. The nurse, just like the pharmacist, referred this reporter to LASUTH for care because there are no psychiatrists deployed to provide mental health care at the facility presently. “We don’t have psychiatrists in this centre yet
; you should take your cousin to LASUTH.”
The reality of PPD and other mental health illnesses
The World Health Organisation (WHO) affirms that mental disorder is a global health concern, with 1 in every 8 people around the world living with one mental disorder or the other. It highlighted anxiety disorder, depression, bipolar disorder, post-traumatic stress disorder (PTSD) and schizophrenia as the common types of mental health conditions. However, findings from Nigeria identify stigma as a significant barrier to treatment, with causes including spiritual beliefs and societal misinformation, and effects such as discrimination in employment, housing, and social interactions.
The apex global health institution further recognises the days and weeks following childbirth as the postnatal period as a critical phase in the lives of mothers and newborns, as most maternal and infant deaths occur during this time. Sadly, it observes that with the extensive documentation of PPD in high, middle and low-income countries, the condition is still largely underdiagnosed and undertreated in many low- and middle-income nations, Nigeria inclusive.
According to a study in the European Journal of Medical and Health Sciences (EJMED), the average prevalence of PPD is 15.4 per cent in the USA, 38.1 per cent in Italy, 17.1 per cent in Germany, and 22.5 per cent in Ireland. With a prevalence of 45.1 per cent in 2011, 49.3 per cent in 2014, and 50.3 per cent in 2015, as well as a prevalence of 57.14 per cent in 2020.
It also recorded the prevalence of PPD in South Africa to be 10.4 per cent for serious PPD and 14.6 per cent for low to medium PPD in a South African study. Depressed women often neglect healthy habits and postnatal care, leading to adverse effects such as maternal mental health decline, family strain, and long-term psychological and developmental problems for their children.
Effective integration of maternal mental healthcare into antenatal, postnatal clinics as panacea
To checkmate this culture of negligence, the global health agency released a Postpartum care guide for the mother and newborn some years back, which recommends that clinics integrate maternal mental healthcare into their services, including screening for PPD at postnatal visits, and provision of psychosocial support. Identification of women at high risk, offering psychological interventions, and ensuring access to mental health services were a pivotal part of the guide.
Speaking exclusively with Pharmanewsonline, Chief Consultant Psychiatrist at the Federal Neuropsychiatric Hospital, OshodiAnnexex, Dr (Mrs) Funmi Akinola, echoed the views of WHO in situating mental health clinics within health centres. “I want to categorically state that mental health should be incorporated into primary healthcare. Other practitioners used to say mental health is number nine on the primary healthcare agenda. But is it implemented? Are there staff deployed for the service at the health centres? What is the essence of all these laws without implementation?
“I will recommend that the Lagos State Government ensure that inside each local government secretariat, there is a mental health desk. There should be, even if it’s not a doctor, a psychiatric nurse employed in each of the local governments?” she advised.
A Clinical Psychologist and Founder of Postpartum Support Network Africa (PSN Africa), Onyedikachi Ekwerike, confirmed PPD as a critical public health concern that motivated his founding of the support network for mothers suffering from the condition. Of particular interest to him is the need to shatter the indifference and negligence usually attached to the condition, while developing cases for the seriousness it deserves.
Ekwerike, who spoke in a report published by the Nigerian Health Watch on PPD, said, “I got interested in maternal mental health in 2014 after a relative suffered postpartum psychosis. The whole confusion that it caused within the family and how poorly it was handled got me really frustrated with the lack of access to care for her,” Ekwerike said.
Adeyemo E.O., Oluwole E.O., and others in an investigation titled “Prevalence and predictors of postpartum depression among postnatal women in Lagos, Nigeria”, found a 35.6 per cent prevalence of PPD in Lagos with predisposing factors such as delivery by cesarean section, mother being unwell after delivery, and not exclusively breastfeeding the baby. Although they recommended a viable social support for women both in the pre- and postnatal periods and routine screening of women for postpartum depression for early detection and immediate intervention as far back as five years ago, yet, the situation remains unchanged.
In a related study conducted in Enugu, South-East Nigeria, “Postpartum depression among mothers as seen in hospitals in Enugu, South-East Nigeria: an undocumented issue.” It established the significant impact of PPD on families, which may coexist with child abuse and neglect, marital discord, divorce and family violence. It emphasises the need to tackle the maternal mental disorder early to avert it from snowballing into severe mental disorders.
More cases of PPD
For Basirat Hussein, a new mom and civil servant, her experience is more of emotional and physical symptoms than cognitive, as her inability to regain her bodily shape, four months after having her baby, has plunged her into sadness, anxiety and worthlessness. “Why would I just change drastically from being a plump woman to a very slim person? It’s making me feel very uncomfortable with myself. I see a lot of changes in my body, which depresses me, ” she said.
The fact that she is breastfeeding further compounds her case, as she can not embark on any supplement except those prescribed by the physician. This was what brought her to the Maternal and Child Care Centre of the Epe General Hospital, where this correspondent met her.
She expressed her frustration further, “Since I had my baby four months ago, everybody kept asking what was wrong with me. Sometimes, even my siblings will ask, Aunty Bee, what happened? When will you recover? I just tell them, maybe it’s because I’m exclusively breastfeeding. But they’ll say, well, it’s not like that.”
Hussein, who is already four months into her six-month maternity leave, wonders when and how she will regain her former plump shape, if that has not happened presently. Although she acknowledged that health practitioners mentioned postpartum depression during the health talk, she did not dwell much on it, to their understanding. Thus, she continues living in despair despite nursing a bundle of joy.
Another mother, at the Lagos State University Teaching Hospital (LASUTH), Mrs Bilkis Ahmed, expressed her frustration in caring for her baby with Down syndrome. She narrated how the one-year-old’s retarded development continuously makes her miserable, coupled with the additional stress of his inability to talk and walk at the appropriate time, which makes him mess himself up most times. “I’m usually perplexed most times as I wonder when I would be free from the burden of nursing this baby, coupled with a load of other responsibilities of mine.”
Findings from survey on the provision of mental health services
Despite the stipulated provisions of the Lagos State Mental Health Policy of 2011 and Mental Health Law,2019, toward integrating mental healthcare into general hospitals and primary healthcare centres, since 2011 and 2019 respectively, our findings on the provision of mental health care to pregnant women and nursing mothers revealed that 14 years after, there is no significant provision of mental health services in the state public health facilities, except for tertiary health institutions.
The survey sampled 55 nursing mothers and pregnant women from seven public hospitals and five primary health centres – Ikorodu General Hospital; Epe General Hospital; Badagry General Hospital; Island Maternity; Mercy Street Children’s Hospital; General Hospital, Odan; Lagos State University Teaching Hospital; Epe Primary Health Centre; Mende Primary Health Centre; Ilado Primary Health Centre, Ogolonto Primary Health centre, and Agege Primary Health Centre, from the antenatal and postnatal clinics of the facilities using questionnaires.
It is important to state here that the process of data collection nearly stalled when the FOI Desk of the Lagos State Ministry of Health declined to respond to the FOI request sent by this investigator.
Additionally, restrictions from nurses and other hospital officials made it impossible to openly administer questionnaires to mothers during clinic sessions. Nevertheless, the correspondent’s resilience kept the study on course, as she went undercover, posing as a patient in several clinics, to obtain information from mothers, though the process remained rigorous.
Out of the 55 respondents who completed and submitted the questionnaire, we found that the age group that suffers PPD the most are mothers between the ages of 31 to 45. Contrary to previous limited awareness about the condition, our findings revealed that there is increased awareness of PPD among mothers, as 90.9 pper centof respondents affirmed that they are aware of the condition, while 63.64 pper centconfirmed that to are survivors of PPD. Again, our investigation showed that thosewhot had the experience after their first child were more in number, 27.27per centt, while those witha second child were 18.18, those after the third issue, were 10.91per centt, those with others were . 27 per cent, this makes the total of respondents who had depression after childbirth to be 63.64 in total. The indication of this is that PPD is more prevalent among new moms. The survey further revealed that the stress of child care is the most predisposing factor to PPD, with 32.76 per cent of respondents indicating it.
On the accessibility of care for PPD, a greater percentage of the respondents, 40 percent indicated that they received treatment for their conditions in private facilities, while an insignificant proportion of them, 16.36 percent, I.82 percent and 5.45 percent, noted that they got care from general hospitals, primary health centres, and teaching hospitals, respectively, while the remaining 36.38 percent relied on faith in God to scale the challenge.
Stakeholders corroborate the situation.n
Affirming the prevalence of PPD in mothers, Chief Consultant Psychiatrist, Dr (Mrs) Funmi Akinola, further highlighted more symptoms of PPD to include socio-economic induced pressure,
which could lead to lack of sleep, anxiety disorder, loss of appetite, indifference to the baby’s condition, tearfulness, and inability to breastfeed, among others.
Dr Akinola, who is also a partner to Mental Health Foundation Nigeria, a non-governmental organisation and a social enterprise that engages in mental health advocacy, pointed out the ignorance of most mothers about their experience, which explains why they don’t seek care for it. “It’s just that most mothers don’t understand what is happening to them. So, if they don’t understand what is happening to them, the likelihood is that they might not seek help on time.
“The important thing is, as long as mothers attend antenatal clinics, it should be part of the topics that are featured in health talks. So, the nurses should start talking about mental health, depression during pregnancy, and depression after delivery, to reduce the incidence.”
Prof. Olurotimi Coker, a consultant psychiatrist, also shared his views in an exclusive interview with Pharmanewonline. He highlighted factors that predispose women to PPD to include personal or family history of mental disorder or depression, stressful negative life events during pregnancy, including financial problems; lack of social or family support; unwanted pregnancy or relationship problems with the spouse, complications in pregnancy or newborn, such as birth complications, or newborn baby with special needs.
Experiences of mothers with special needs children, his reporter interacted with- Mrs Esther Olawale, Mrs Ada Kalu, and Mrs Bilkis Ahmedz validated Prof. Coker’s diagnosis of predictors of PPD.
The Professor of public mental health, however, er assured of means of curbing the likelihood of PPD, noting it could include “planning of the pregnancy; as it has been observed that women who plan their pregnancies may be better prepared emotionally and psychologically for the postpartum period, potentially reducing their risk of PPD. Having a supportive spouse who accompanies their wife during labour and delivery, along with strong family support networks, can prevent the risk of PPD. Early skin-to-skin contact between mother and baby, immediately after birth, has been shown to have protective effects against PPD.
Similarly, breastfeeding has been associated with a lower risk of PPD, likely due to the hormonal and physiological benefits it provides to the mother. Most importantly, having strong social support from the nuclear and extended family of both parents and close friends can help mitigate the risk of PPD. Screening for depressive symptoms during pregnancy and postpartum can help identify women at risk and enable early intervention and treatment.”
Critical gaps in the Lagos State Mental Healthcare system confirmed
In an exclusive interview with the Director/Head of Special Projects & Mental Health at the Lagos State Ministry of Health, Dr Tolu Ajomale, he acknowledged the growing concerns for adequate mental healthcare in the state, noting that 25 per cent of Nigerians are estimated to experience a form of mental illness in their lifetime, with Lagos having a prevalence of 3.5 to 5.5 percent of residents living with anxiety disorders and depression respectively. These figures, he said, tend to be higher among vulnerable groups like young adults and women.
Contrary to the numerous provisions of mental healthcare highlighted in the Lagos State Mental Health Policy and the Lagos Mental Health Law, Ajomale concurred with our findings from interactions with nursing mothers from public health facilities that the majority of healthcare providers in government hospitals are still lacking the required skills to diagnose and treat mental health conditions, in this case, PPD.
Reasons for delay in implementation of Mental Health Policy, Law
The only reason he attributed to the delay in the effective implementation of Mental Health policy and law is the shortage of skilled mental health personnel in the country.
“The challenge has been that healthcare providers haven’t historically been trained to screen for or talk about mental health during routine postnatal check-ups, so these issues are often overlooked, leaving many women struggling in silence. In practice, a mother attending a postnatal clinic might be asked about her wound healing or the baby’s nutrition, but not about her mood or sleep, even though those are just as important to her well-being.
“In my view, addressing PPD is critical for both mother and child. Untreated postpartum depression not only causes deep suffering for the mother, but it can also affect the baby’s development and the mother-child bond. Mothers with severe depression may have difficulty caring for their newborns, and the infants in turn may have feeding or bonding issues. So this is an area we take very seriously,” he asserted.
Responding to the absence of psychiatrists at health centres and general hospitals as disclosed by health workers and nursing mothers, the head of the mental health unit, citing the shortage of mental health professionals in the country as a defence, with only 250 psychiatrists for 200 million people, while Lagos has a good share of them.
Plans to bridge gaps
In bridging this gap in mental healthcare services to mothers, Dr Ajolmale hinted at the plan of the state health ministry in actively raising awareness about PPD in all general hospitals and primary health centres. Some of the activities he mentioned include training of nurses, midwives, and doctors to recognise the signs (like persistent sadness, withdrawal, extreme fatigue, feelings of hopelessness) and to respond with empathy and referral to appropriate care.
In addressing the issue, he said, “We are adopting a multi-pronged approach, with an underway plan through the LagosMiND programme, which will enable frontline health workers to screen mothers for depression or anxiety and provide initial counselling or referrals.” This implies that there is currently no provision of mental healthcare in Lagos State health facilities for mothers suffering PPD, irrespective of the adoption of a mental health policy, and the Mental Health Law 14 and 6 years back, respectively
Reflecting on the gross neglect of nursing mothers experiencing PPD in the state, Ajomale promised a turnaround of the condition in the next year. “Within the next year, you will see dedicated mental health personnel assigned to maternal and child health centres as part of our pilot programmes.”
This report was supported by the Wole Soyinka Centre for Investigative Journalism (WSCIJ) under its Report Women Female Reporters Leadership Programme (FRLP)
