This document summarizes a study on perinatal depression in Nigeria. The study aims to improve detection and treatment of perinatal depression through training primary care providers. So far, the study has recruited over 2000 women and found a perinatal depression rate of 7-19%. The study is conducting interviews and assessments of primary care clinics. Challenges include low detection rates, lack of private screening spaces, and difficulties locating patients. The study is engaging with health officials and building capacity. Next steps include finalizing training materials and training trainers to scale the intervention. A related proposed study would adapt interventions for adolescent mothers, who are a high-risk group.

1. Scaling up care for perinatal depression for
improved maternal and infant health (SPECTRA)
Synergy Proposal: Responding to the challenge of
adolescent perinatal depression (RAPID)
The IRT: Prof Oye Gureje-PI; Co-PIs: Prof Phyllis Zelkowitz (Canada),
Dr Kayode Ogunniyi (Policy Maker); Co-Is: Dr Lola Kola- Co-I
(Project Coordinator), Dr Bibilola Oladeji, Dr Neda Faregh, Dr Jibril
Abdulmalik, Dr Bidemi Yusuf, Dr Saheed Olayiwola

2. Background
• Depression is a leading cause of disease burden worldwide,
• In LMIC, perinatal depression occur in between 16% and 20% of women
• Perinatal depression is associated with negative outcomes for both the mother
and their children
• Early identification and prompt interventions known to reduce these negative
consequences
• The interventions needed not necessarily specialist care
• Evidence based interventions delivered by supervised, non-specialist health and
community workers in primary care shown to be beneficial to both the mothers
and their infants

3. Overall Aim
• The overall aim of this program is to study factors that may impede or
facilitate the delivery of evidence-based intervention for perinatal
depression by front-line clinicians using the WHO Mental Health Gap
Action Programme Intervention Guide (mhGAP-IG) in routine practice.
• The knowledge so gained, including that gained in the process of
responding to barriers that may be encountered, will provide
necessary information to facilitate the scaling up of the intervention in
other parts of Nigeria and other resource-constrained settings.

4. Methods
In this implementation study we are using a mixed methods design, with a
participatory approach adopted at every stage. The study is being conducted in 20
selected primary care clinics selected across 10 local government areas in Oyo
State, south-west Nigeria
There are 4 overlapping phases
1. Formative evaluation and concept development
2. Assessment of the organizational structure and clinic profile of the primary
maternal and child care clinics and determination of current rate of detection
and treatment for perinatal depression
3. Design and implementation of training of primary care providers to provide
care for perinatal depression to achieve sustainable impact
4. Evaluating the effectiveness of the mhGAP-IG and evaluating the gaps and
bottlenecks in the provision of care

5. Results to date
We are currently implementing Phases 1 and 2
• We had a planning workshop at the commencement of the study in 2015, to
design an implementation plan for the study. The outcome of this was the
development a theory of change (TOC) map for the study.
• There have been 2 consultative workshops with the health planners in
collaboration with Directorate of Planning, Research and Statistics of the Oyo
State Ministry of Health held in May and July 2016
• We have collected data on the organizational structure in relation to providing
chronic care for the 24 primary maternal clinics selected for the study using the
Assessment of Chronic Illness Care (ACIC) tool
• We have conducted key informant interviews with 20 facility managers to assess
the needs of the providers, current levels of training, and infrastructural and
organizational needs for the delivery of quality care

7. Results to date
• We have recruited and trained
research staff
• Investigators meetings hold as
scheduled
• The first draft of the training
manual for use in phase 3 of our
implementation is completed

8. Results to date
• Recruitment of the first cohort of
patients to be used to determine
the current facility detection
rates and the interventions
provided for perinatal depression
is ongoing
• Screened:2970
• Positive: 216
• Recruited: 202
• Follow-up assessments
• 2 months post enrollment: 164
• 3 months post partum: 68 out
of 74 due for assessment

9. Key Lessons Learned
• Mental health is not captured in the current health
information routine data collection system.
• Detection of perinatal depression by primary maternal health
care workers is very low
• Mothers are hardly routinely asked questions about their
mental health

10. Policy Engagement Meetings
• Meeting with the Executive
Secretary of the State Primary
Care Board, February 2017
• MOU drafted and currently in the
process of being endorsed
• Meeting with the Honorable
Commissioner for Health, with
some of the most senior
officials of the Oyo State
Ministry of Health
• Commitment for the creation of a
mental health desk and appoint a
desk officer

11. Challenges and mitigation strategies
• There was an industrial action in the Oyo State Civil Service that lasted
10 weeks from May 9, 2016 which delayed the onset of recruitment of
participants
• Patient turn out in the primary care clinics for antenatal registration
was initially lower than anticipated
• Things later picked up and we were able to surpass the recruitment target for
Cohort One
• In some clinics we had some difficulty in getting a private space for
patient screening
• We had to provide some facilities such as furniture in some clinics to enable
research staff conduct screening and ensure the privacy of the participants

12. Challenges and mitigation strategies
• Locating the homes of some patients from the addresses
provided to the research staff is sometimes difficult
• Research assistants are trained to document not just house numbers but
description of houses with identifiable landmarks, also mobile phone numbers
provided by the participants during recruitment have been helpful
• Conduct of the key informant interviews was also slower
than anticipated due to the busy work schedule of the
clinicians
• Appointments were often scheduled for interviews outside of busy working
hours of the clinicians. We have now completed planned number of
interviews

13. Capacity Strengthening
• Working with the ministry and the Director of Planning to draft the
terms of reference for the Mental Health Desk Officer
• The project will sponsor the appointed officer to attend the 2-week
annual mental health leadership and advocacy course conducted by
the WHO Collaborating Center for Research and Training, Department
of Psychiatry, University of Ibadan
• We are using a cascade training format, to build a pool of trainers
within the primary care health force that can be used to sustain
training and delivery of mental health
• An implementation science workshop to build capacity in the conduct
of implementation research in maternal health is planned before the
end of the year

14. Next Steps and areas for collaboration
• We will continue to work with the HPRO especially to
facilitate policy uptake both at the Federal and State levels
• We will continue to engage with the National Mental Health
Action Committee
• The training manuals and other training materials as well as
the intervention guides will be completed over the next
month
• Training of the trainers is scheduled for the end of May
• Training of frontline providers by the trained trainers will
commence thereafter

15. Synergy Proposal (RAPID): Background
• Adolescent pregnancy is a pressing public health issue globally
• In Nigeria, for example, about 31% of women have had a live birth
before age 18
• Reported prevalence of perinatal depression in adolescents range
from 8% to 47% often higher than for older women
• In our earlier study, we observed a prevalence of 18.8% in adolescents
(mean age 17.8 years) compared to 6.9% in those aged ≥20 years
• Adolescent perinatal depression is associated with unique
consequences such as increased risk of further pregnancy and
problems with parenting and negative outcomes on their children

16. Background
• Adolescents with perinatal depression compared to adults
• exhibit poorer adjustment to pregnancy and to motherhood
• higher rates of pre-term birth and low birth weight
• use of aggressive parenting behaviors
• growth stunting and cognitive delays in young children
• preschool problem behavior, poorer school performance, and higher levels of
psychopathology in their children at 14 years of age
• They are less likely to receive any form of care for depression
• When they do, they are more likely to be poorly adherent
• Adolescents with depression hence require targeted interventions to
keep them engaged and adherent to treatment and enhance
parenting skills for improved infant and child outcomes

17. RAPID: Research Questions and Objectives
• RAPID is designed to fill an important gap in knowledge about how
best to respond to the needs of this vulnerable but previously
neglected population of women with perinatal depression. We will be
comparing 2 evidence based intervention packages for perinatal
depression to answer the following questions:
1. What are the contextual factors that affect the detection of
perinatal depression in adolescents and the delivery of interventions
with proven effectiveness for the condition within a routine
integrated primary maternal care service
2. When delivered within routine and integrated maternal and child
care, what is the impact of the intervention on maternal depression
outcome, user satisfaction, parenting skills and on infant
development

18. RAPID: Methods
• The study will be conducted in the same primary care clinics where
our primary implementation study is being conducted in Oyo State
• This will be a hybrid Type I (effectiveness – implementation) study
guided by the Consolidated Framework for Implementation Research
(CFIR) framework
• The study will use a mix of qualitative and quantitative methods and
involve all relevant stakeholders from planning, through execution to
ensure the likelihood of policy uptake

19. Methods
• Use of KIIs to explore the contextual issues surrounding the provision
and receipt of care by adolescents with perinatal depression who
participated in our recently concluded RCT
• Sample (10 each): adolescents who completed required treatment
and follow-up, adolescents who dropped out of treatment, midwives
who provided care and facility managers of the clinics
• Planning workshop involving all stakeholders- some already engaged,
others will be brought on board; an external health system researcher
• Guided by the results from these initial activities, we will modify the
proposed process of intervention delivery

20. Proposed Procedure
• We shall be comparing 2 groups of
• One group shall be randomized to receive interventions for
depression only (using our manual based on the WHO mhGAP-IG
• The other will receive this same intervention in addition to parenting
skills and more engagement with the primary care providers over the
mobile phone
• Patients will be screened with EPDS and complete an encounter form
after being seen by the primary care provider
• We shall aim to recruit 320 participants with moderate to severe
depression at registration for ANC and follow them up till 1 year
postpartum to collect effectiveness and implementation outcomes

21. Areas for Strategic Consideration/Collaboration
• This study will build on our existing engagement and collaborations
with policy makers and other stakeholders
• Within the Oyo State Ministry of Health,
• The State’s Primary Health Care Development Board (with which
we currently are developing a Memorandum of Understanding),
• The National Primary Health Care Development Agency
• The National Mental Health Action Committee
• Midwives and physicians working at the primary care clinics
The team is bringing on board other experts including an
obstetrician, implementation scientist with expertise in perinatal
mental health and

22. Thank you for your
attention!