Chile pioneered maternal mental health screening — here's what it learned

In Chile, one in five mothers has postpartum depression at some point in their life. If you’re a poorer mum, you are three times more likely than your richer counterparts to experience mental health problems after giving birth.

Faced with statistics like these, Chile knew it had to act. In 2009, the country pioneered its mental health screening program for new mothers, the first of its kind in South America.

As the program has evolved over the last ten years, it’s still facing challenges. The treatment gap between women screened and women receiving treatment for their depression is not shrinking, despite 96% of new mums receiving mental health screening.

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So even while Chile makes waves for its progressive program, it’s still learning lessons about how to best deliver its services and remove the stigma from seeking help.

“It’s all in the mothers”

Despite its focus on new mothers, the origins of the program came from its “Chile Crece Contigo” strategy (known as ChCC or, in English, “Chile grows with you”), Chile’s cross-cutting approach to child development.

ChCC aims to help all children reach their full potential, regardless of their socio-economic background. A cross-cutting body of work, the program involves three key Chilean ministries: health, education, and social development.

Matias Irarrazaval Dominguez, Director at Chile’s Department for Mental Health, described ChCC as a “comprehensive support system for children from gestation to five years old”. It takes a whole picture approach, encompassing preschool policy, child benefit provisions and health checks for children.

The program began after a recognition that the first three years of a child’s life were key to a child’s growth. “Anything you can do in that short window of development is vital,” he said.

Officials realised that mothers were the missing part of the mix. “We couldn’t start with the children without including their mothers,” Irarrazaval Dominguez continued. “Examining children is so important, but often it’s all in the mothers.”

How Chile did it

So armed with statistics and a committed, child-focused agenda, Chile began screening its mums for mental health concerns using the Edinburgh Postnatal Depression Scale to see if they were developing the symptoms for depression.

Screenings take place in their local primary healthcare centres — environments which mums know and where they already feel comfortable.

Their responses are measured, and mothers with symptoms of depression are referred onto a psychiatrist under its health warranties program, which guarantees that women will be seen as part of Chile’s universal healthcare plan.

But care differs depending on a woman’s health provider — both public and private bodies participate in the provision of healthcare services. For those in the public system, patients go through their family doctor to speak to a psychiatrist. Private healthcare recipients can go directly to their psychologist.

Costs are purposefully low, with the maximum co-payment for private treatment set at $18/year for mild or moderate depression, or $75/year for more severe cases. The costs for medication are means-tested according to income. Those on the lowest incomes pay nothing.

The program also works alongside other targeted initiatives to improve the childbirth process for new mums, such as trying to improve the relationship between child and parent.

“Mothers are often alone giving birth,” said Irarrazaval Dominguez. To isolate this feeling of loneliness, the Health Department is advocating for mums to stay with their babies for longer after they give birth, to help with the bonding process.

Overcoming hurdles

The program’s coverage across Chile is a major success story: 96% of the new mother population go to their screenings. It’s well accepted within Chilean society that new mums are expected to attend their appointment after childbirth.

But the data indicates that screening on its own doesn’t translate to admission to treatment, despite the comparatively low cost of the services to the patient. Only a quarter of mothers with post-partum depression receives psychological or psychiatric treatment after referral.

Irarrazaval Dominguez put this down to three key reasons. The first is that often mothers don’t have time to attend appointments. “If you’re from a single-parent family, it can be much harder to get childcare to come to a mental health appointment,” he said.

There’s also an educational issue. “We want to provide more information to mums on how their own self-esteem and wellbeing impacts on their child, as well as themselves,” he said.

A third is negotiating the stigma attached to seeking help. Culturally, there’s an expectation that childbirth and childrearing will be difficult, and that a new mum is no different from any other. “There’s an attitude that persists that “everyone gets blue when they have a child,” he said.

On top of these three key hurdles, new mums also encounter the same problems found by anyone using the complex Chilean health system. The public/private divide means that services can be mixed depending on the provider. And despite low costs, orienteering the bureaucracy of the health system could prove a struggle for an already weighed-down new mum.

Chile’s mountainous geography (only one-fifth of the country is flat) means it can also be difficult to even get to appointments, and regions offer different public services. It can take two to three months for a psychiatric appointment in some areas, whereas there are more psychiatrists available in large cities.

Learning lessons

Reflecting on ten years of the program, Irarrazaval Dominguez was sanguine but pragmatic. “We need to improve the promotion of our services,” he said. “With HIV, everyone knows it’s important to treat it. With mental health, it shouldn’t be any different.”

He also recognised a need to improve the articulation between different healthcare teams to deliver a joined-up service. “Providers need to follow the case,” he said. “It stops people from dropping off.”

Chile is now working to make its referral system stronger, to better follow up cases and stop its bottleneck of patients using preventative measures, like the bonding program.

On top of this, case managers are now strengthening its referral system. Their role has oversight of a large number of patients and, like Irarrazaval Dominguez suggests, they exist to follow up with their cases, rather than provide day-to-day care.

So while Chile has made huge strides in its provision for women’s mental health, it’s not complacent — there is still work to be done to close the gap between screening and treatment. Irarrazaval Dominguez’s willingness to learn and reflect on the country’s services is to be admired. — Emma Sisk

[Picture credit: Joao Pedro Vergar/Unsplash]