Johns Hopkins Bloomberg School of Public Health Maternal Mental Health in Post-Conflict Settings:...

Johns Hopkins Bloomberg School of Public Health

Maternal Mental Health in Post-Conflict Settings: Findings from Timor-Leste

Wietse A. Tol, PhD

wtol@jhu.edu wtol@pcaf.org

Lots of debate:• In post-conflict settings, which experiences are critical for mental health?

• Past conflict traumavs.

• Ongoing stressors

Why focus on maternal mental health in post-conflict settings?

1. Important concern in its own right: in LMIC maternal depression 15.6% prenatal, 19.8% postnatal; depression 2nd largest contributor DALY in women aged 15-44)

2. Key risk factors highly present: poverty, intimate partner violence, lack social support, negative life events

3. Negative impact on children: suboptimal growth, diarrhea, febrile episodes, suboptimal breastfeeding and immunization

Timor-Leste

• 1.2 million people• Low development: 147/

187 HDI (UNDP, 2011)

• 49.9% under poverty line

• 35% spousal physical/ sexual violence

• 33% children under 5 severely stunted; 15% severely underweight

Timor-Leste Timeline

1600’s – 1975 Portuguese colony

1975 – 1999Indonesian occupation

- 200,000 killed- Human rights violations on large scale1999 referendum: 78% vote for independence from Indonesia; followed by large-scale violence;

destruction of infrastructure2006 violence

2008 assassination attempts

Current studyIn preparation for birth cohort study

Objectives:

– Check recruitment methods– Feasibility/properties of

instruments in this specific group

– Initial exploration of cross-sectional relationships

Current study2 districts; 8 suco’s (mix rural/urban)Sample recruitment through:

– 1. Visit chefe and health post– 2. Liaise with partner NGO (Safe Motherhood

Program) and SISCa volunteers– 3. Door-to-door

Aim to find all pregnant women and those with 4-5 month old infants

Socio-demographic characteristics

Which stressors?• Daily stressors (between 20% and 30%):

• no clean water• not enough money (school fees, clothes)• Lia

• Intimate partner violence (39% prenatal, 29% postnatal)

Maternal Mental Health

Relationships between adversity and maternal mental health

Header/Full Bleed Image

Name/Subject Subhead Title/captionTitle/caption

PTSD symptoms

Perinatal Depression

Human Rights trauma

Witnessing murders

Extreme deprivations

PAST CONFLICT TRAUMATIC EVENTS

Intimate partner violence

INTIMATE PARTNER VIOLENCE

Ongoing adversity

ONGOING ADVERSITY (DAILY STRESSORS)

PTSD symptoms

Human Rights trauma

Witnessing murders

PTSD symptoms

Human Rights trauma

Witnessing murders

Result #1

Traumatic events and IPV predict both PTSD and perinatal depression

conflict events and IPV should be taken into account for maternal mental health

PTSD symptoms

Ongoing adversity

Result #2

Ongoing adversity predicts PTSD and depression

Treatment of symptoms alone will not be effective on the longer term if ongoing adversity is not addressed

PTSD symptoms

Ongoing adversity

PTSD symptoms

Human Rights trauma

Witnessing murders

Ongoing adversity

Result #3

Traumatic events predict both ongoing adversity and psychological symptoms

conflict events are carried over into the present (‘caravan of loss’)

PTSD symptoms

Human Rights trauma

Witnessing murders

Ongoing adversity

Result #4

PTSD is strongly related to depression

Need to think of maternal mental health beyond depression symptoms

Coming back to beginning: which is more important?

Current debate over-simplifies: BOTH past traumatic events and ongoing adversity are important for post-conflict mental health

They influence each other in complex ways

AcknowledgementsUniversity of New South Wales, Sydney, AustraliaDerrick Silove, MDSusan Rees, PhDNatalino TamLazaro Lelan Sila

The Alola Foundation, Dili, Timor-LesteTeresa Verdial

Universidade de Paz, Dili, Timor-LesteNelson Martins, MD, PhD

Funding: National Health and Medical Research Council, Australia

MeasuresADVERSITY

Daily stressors Locally constructed

Domestic violence Based on WHO survey

Traumatic events Harvard Trauma Questionnaire

MATERNAL MENTAL HEALTH & DISABILITY

Psychological distress Kessler Psychological Distress Scale (K10) + additional items

PTSD Harvard Trauma Questionnaire (HTQ)

Anger Locally constructed .76

Perinatal depression Edinburg Postnatal Depression Scale (EPDS)

Disability WHO Disability Assessment Schedule (WHODAS) 12-item

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