Simone Honikman

Simone works with public healthcare workers and enables them to engage empathically, identify and treat common mental illnesses in pregnant and postnatal women. She founded and directs the Perinatal Mental Health Project which empowers pregnant women and new mothers from disadvantaged communities in South Africa.

Pregnancy and the postnatal period is a psychologically distressing period for many women, particularly those facing other social challenges in their lives like poverty, gender-based violence and HIV/AIDS. The burden of maternal mental illnesses (including pre and post-natal depression and anxiety) in low-income communities is very high. When they are left untreated, the results can be fatal and contribute to maternal mortality and poor maternal and child health. In response to this problem, Simone started the Perinatal Mental Health Project (PMHP), which was registered in 2008 as a fully operational nonprofit organization. PMHP’s vision is to ensure that all women have access to high quality perinatal mental health care (during pregnancy and one year after delivery) as a regular service integrated into the public health system.

Simone’s idea is built on four main components (screening, counseling, referral and training), which together form the foundation of an innovative model for maternal mental healthcare. Based on strategic partnerships with public healthcare centers, the model ensures that 100 percent of women visiting public hospitals for ante and post-natal healthcare get access to maternal mental healthcare as well. Thus, PMHP’s activities are physically and operationally embedded into healthcare centers to ensure a holistic perinatal healthcare package through public health institutions. The screening process is done hand in hand by PMHP and the healthcare center’s midwives and nurses who are specifically trained by PMHP to understand the symptoms and risk factors for maternal mental health illnesses. Those women identified as ‘at risk’ or who present symptoms of mental health illnesses are referred for counseling that is provided by professional counselors employed by PMHP. This is structured to provide individualized emotional support and enable the patient to understand the context of her mental health problems and explore practical solutions for coping with them. This ensures the patient has the right mindset, knowledge and support system to deal with risk factors in the environment and the symptoms of mental health disorders.

Simone understands that there are different social problems that either cause, or make pregnant women vulnerable to, mental health illnesses in poverty stricken communities. Consequentially, PMHP has developed partnerships with various public and citizen sector organizations (HIV/AIDS clinics, psychiatrists, religious and community leaders, gender-based violence organizations, various alcohol and drug support groups) that refer the patients that need assistance to PMHP. This referral renews the patients’ hope because they understand that there is practical help available to them.

The model also includes a training component in addition to the screening, counseling and referral system. Simone trains health care workers (public, private and students) on perinatal mental health issues and how they can be effectively dealt with. Furthermore, through research and advocacy, Simone creates awareness of the existence of perinatal mental health illnesses and how they can be dealt with in communities and within healthcare departments. PMHP currently works directly in four public obstetrics healthcare centers in the Western Cape, reaching almost 55,000 pregnant women. Furthermore, Simone has developed operational guidelines that she uses to train other public healthcare centers in South Africa and beyond (Malawi, Zimbabwe, Zambia, Mozambique and Lesotho) to adopt her model and incorporate it into their systems. This ensures rapid scaling even without PMHP’s physical presence.

The World Health Organization predicts that globally, unipolar depression constitutes the third highest burden of disease. (WHO, The global burden of disease: 2004 update). About one third of pregnant women living in South Africa experience a common mental disorder (depression or anxiety) - more than double the prevalence reported in developed countries (Hartley et al, 2011; Rochat et al, 2011). There is extensive evidence on the adverse effects of untreated common perinatal mental disorders (during pregnancy and the first year following child birth) on the mothers’ health, as well as on the health and development of their children (Meintjes et al, 2010). Stigma and poor mental health literacy mean that very few women seek mental health care, even when mental health services are available (Saxena et al, 2007).

In South Africa, approximately 75% of individuals suffering from a common mental disorder do not receive any form of mental health care (Seedat et al, 2008). In part, this is linked to the shortage of mental health specialists in the country, with only 7% of psychologist working in the public health sector (Day & Gray, 2011). Further, health workers in maternity settings have low mental health literacy and hold stigmatizing attitudes towards those with mental illness (Rahman et al, 2013). Yet, these health workers are the primary interface between vulnerable women and health care. Current health worker training in South Africa does not adequately equip nurses to manage emotional wellbeing, nor are they equipped to manage the stress they experience in the professional setting, with little or no support available to them. It is well documented in South Africa, that health staff is often emotionally and physically abusive towards women in sexual and reproductive health services, especially during labor (Jewkes et al, 1998; Kruger & Schoombee, 2010). With healthcare services already strained by chronic diseases, limited infrastructure and lack of resources, the problem is exacerbated by understaffing, poor training and low morale among health workers.

Mental illnesses result in a range of negative consequences for the mother, the baby and the community at large. Mental illnesses in pregnant mothers increase their vulnerability to abandoning their babies, suicide (especially in teenagers),, substance abuse, HIV infection, the loss of employment, complicated pregnancies, reduced baby-mother bonding and infant malnutrition, diarrheal disease and mortality. Studies indicate that about 80 percent of infants in children’s homes in Western Cape were abandoned and about 2,000 babies were abandoned in Johannesburg between 2007 and 2010 (Child Welfare South Africa, 2010). Furthermore, depression in pregnant women is associated with lowered adherence to antiretroviral medication and poor use of antenatal care, thus exposing both the mother and the baby to additional health risks (Journal of Affective Disorders, 2011).

Although mental healthcare is attracting more attention, maternal mental health still remains ignored in most developing countries. About 95 percent of pregnant women in South Africa obtain antenatal care from public health facilities. However, these are not adequately resourced to incorporate mental healthcare in their services. In addition, health care workers have low levels of knowledge and skills for addressing common mental illnesses and generally hold the view that only psychiatrists can treat these cases. Moreover, because of this misunderstanding and their challenging working conditions, these health workers can often be impatient and aggressive towards pregnant women. The lack of knowledge about mental illness is also prevalent at the community level, and people displaying symptoms of mental health illnesses are stigmatized and thought of as “crazy people” who are of less value to society.

The PMHP has four complementary programs: service delivery, training, research and advocacy. These components work together and alongside existing maternal healthcare to advocate for a holistic support system for pregnant women and new mothers.

The PMHP aims to address the high prevalence of perinatal mental disorders and the shortage of mental health specialists in South Africa, by integrating maternal mental health care into routine antenatal and postnatal health care, through the use of a collaborative stepped-care approach and task-sharing strategies. This integrated approach is unique in that mental health care is typically regarded as a specialist, vertical component of healthcare and is thus inaccessible to those with common mental disorders who may not overtly manifest the symptoms or associated functional disabilities.

The point of contact is when the majority of women access primary health services for maternity care. The strategy is preventative as well as curative, and routine integration allows women to access care without their incurring the additional costs of extra appointments and without exposure to stigma.

Every pregnant woman who comes through the health center for maternal health services is screened for the risk factors and symptoms of mental illnesses. Women flagged for further attention are referred to PMHP trained counselors for counseling. Counselors build supportive relationships with the patients and empower them to find practical solutions to their problems. Counseling involves a series of one-on-one sessions and also group or family sessions, where necessary. The counselor informs, educates and explores with the mother alternative solutions to the problems she faces during pregnancy and beyond. Counselors ask patients about their emotions,, desires and challenges and particular contexts. This helps each mother identify priority problems and develop strategies for how to address them. PMHP has established partnerships with many community-based, public and citizen sector organizations, clubs and support groups to which patients are connected for help. For instance, unemployed, single mothers are linked to the Department of Social Welfare and signed up for a social welfare grant; victims of abuse are referred to women’s rights and gender based violence organizations; and those in need of psychiatric treatment are referred to mental health facilities to be reviewed by psychiatrists for relevant treatment. However, the beneficiaries still remain engaged with PMHP even after being referred to other organizations for assistance. The referral only serves to complement the solutions that PMHP provides in preventing and overcoming mental distress.

PMHP also focuses on advocacy work to improve awareness of the existence of common maternal mental illnesses, to both service providers and the community at large. PMHP organizes workshops for community stakeholders to share information and strategies to address maternal mental distress. Flyers and brochures are developed in local languages to help increase mental health literacy of the service users and the public. The PMHP is also influencing policy formulation to affect government systems and ensure that the Mental Health Act that was passed in 2002 to incorporate maternal mental health into public health systems is translated into policies that can be implemented.

Due to PMHP’s strategic positioning within the University of Cape Town, Simone has managed to consolidate partnerships with top level local and international institutions and researchers in the field of public health, mental health and maternal mental. This has enriched PMHP’s work and has also enabled its research outputs to impact on policy and practices in places as far afield as the Northern Territories of Australia, Zimbabwe, Ethiopia and India. In fact, the Empathic Care Training module, created by Simone for healthcare workers to better deal with distressed mothers, has been delivered to multidisciplinary teams from Malawi, Lesotho, Rwanda, Botswana, Zimbabwe and other African countries. This “Secret History” training module is based on storytelling and group role-playing and has now been taken up in the School of Nursing in Iowa, USA.

The PMHP is currently operating in three public obstetric facilities in Western Cape and has so far directly reached out to more than 55,000 pregnant women with various services and interventions relating to maternal mental health. Over 70 percent of the patients engaged through PMHP services show improved mental health and are better able to cope with pregnancy, child birth and the postnatal period. Since launching the training program in 2008, 2,237 health workers and students across South Africa have been trained in maternal mental health. Now, Simone is also making her educational materials, through story-telling, available to teenagers via Mixit, a popular cellphone-based social media for youth. The first story, about pregnancy during the teenage years, has been shared with over 30,000 youth using this platform. Other stories are to be released to continue to raise issues about maternal mental health with adolescents.

Simone grew up in a typical middle class, white family in apartheid South Africa. However, her parents were against the principles of the apartheid regime. She was taught from an early age to question authority and understand why things were going wrong. Simone believes that this is what stirred her curiosity to learn more about the inequalities and injustices around her ‘protected’ world. She was inspired by the strength and resilience of the disadvantaged women around her and the numerous responsibilities and burdens they were expected to bear. At age 12, she decided to become a doctor and knew she wanted to work in disadvantaged communities. While studying medicine at the University of Cape Town (UCT), Simone realized that her fellow students were emotionally struggling with the stress of medical studies. There were many cases of depression and emotional breakdowns that no one seemed to do anything about it. Simone started a student advice and support center next to the school’s canteen to assist students that were emotionally stressed and needed psychological help or counseling. After finishing her studies, she worked as a medical officer in the public sector in obstetrics, pediatrics, internal medicine and psychiatry. She was employed to manage the Khayelitsha Cervical Cancer Screening Project in Cape Town.

In early 2002, Simone came across research that indicated that one in every three postnatal women in Khayelitsha (an informal settlement outside Cape Town city area) was depressed. At the same time, her colleague, (a doctor working in private general practice, shot herself and died, eight months after the birth of her daughter . This was a catalyst for the development of the concept of the PMHP at Mowbray Maternity Hospital in 2002. In 2008, the PMHP became a founding partner of the Centre for Public Mental Health at the University of Cape Town. Although the PMHP is located within UCT, it sources funding independently. Simone is committed to ensure that the model is scaled out beyond the Western Cape to other South African provinces in order to reach as many beneficiaries as possible.