**3. Ethics of screening**

Health professionals, including midwives, are required to deal with diverse ethical issues when new intervention strategies are developed because they may be unfamiliar with the ethical standards associated with the new practice [91]. It is documented that screening may do more harm than good and it is ethical for clinicians to ensure that the benefits from the screening of each individual must outweigh the harm [39]. Potential harms from routine screening for depression include the treatment of depression in individuals who are incorrectly identified as having the condition, and the treatment of mild symptoms that would often resolve without intervention [38]. As such, clinicians must be open and honest in telling their clients about the accuracy of screening instruments [91] in detecting antenatal depression. According to Sjögren [72], screening instruments are generally limited in their accuracy and interpretation of their results may lead to incorrect conclusions such that if the result is falsely negative, the individuals will consider themselves healthy, when they are actually ill, or if the result is falsely positive, a healthy individual will leave the practice with a false diagnosis.

#### **3.1 Ethics of screening for depression**

Screening for depression should include the provision of depression care support apart from those targeted at improving the effectiveness of treatment [92]. It should also ensure that an individuals' rights to informed choice, confidentiality and autonomy are respected by clinicians [39]. It is important that individuals should provide fully informed consent and be assured of confidentiality before they are screened for [91] depression. Literature suggests that screening and referral for depression within the clinical settings makes it difficult for clinicians to maintain confidentiality [93] about a client's information. Clinicians have an ethical responsibility to ensure that the findings of screenings are not misunderstood or misused in manner that is detrimental to their client's well-being by the clients themselves, their families, community, other clinicians or policymakers [91].

*Screening for Antenatal Depression by Midwives in Low Resource Settings in Primary Care… DOI: http://dx.doi.org/10.5772/intechopen.97411*

### **3.2 Ethics of screening for depression in antenatal clinics**

Screening for depression during pregnancy may evoke a lot of ethical questions that need to be answered before midwives start implementing screening programmes. For instance, false positives may be of ethical concern because they may add a burden to pregnant women and to clinical services. Screening may result in the use of medications, many of which can cause adverse effects [94] in pregnant women who are falsely detected as having depression. As such, a screening programme must be socially acceptable and must be at an acceptable cost [95] to pregnant women and their families. It is possible that some pregnant women may be placed on anti-depressant medications unnecessarily and will consequently be exposed to the negative side effects associated with these drugs [38]. However, when screening for antenatal depression, a higher level of false positives may be considered acceptable as, ethically, it would seem better not to miss a pregnant woman who needs treatment and support. As described in literature, it is possible for clinicians to exclude false positives from unnecessary treatment by conducting a further diagnostic assessment (gold standard) on all individuals, who screened positive, to confirm the presence of the disorder [94, 96, 97]. This is corroborated by Thombs, Coyne [38] who asserted that individuals who screen positive for depression need further assessment and, if confirmed, should be offered treatment.

A drawback is that the infrastructure and human resources required to implement an effective screening programme can be so costly that allocation of scarce resources demand the appropriate application of ethical principles of justice and equity [39]. It is documented that it is unethical to screen individuals without providing them with relevant interventions because it deprives them of rights to control their own lives and access to treatment [91]. Pregnant women who are diagnosed with depression may be discriminated or socially rejected by society [98]. It is an ethical concern that after screening, a substantial proportion of women diagnosed with false positives may experience discrimination, self-stigma, and stress for unjustifiable reasons [91]. Although little is known about the possible "nocebo effect" of telling individuals who are otherwise not specifically concerned about their mental health that they have depression [38], a label of antenatal depression may negatively affect personal identity, relationships and the selfesteem of pregnant women [91]. The "nocebo effect" occurs when verbal suggestions of an adverse outcome can lead to the onset or exacerbation of symptoms [99].

The new label of having antenatal depression may influence the future goals of individuals and the type of support they may receive from significant others [91]. It is documented that individuals labelled with mental illness may lose their sense of entitlement to participation in community activities [98]. It is possible that pregnant women, who screen positive for depression, may start distancing themselves from others, in anticipation of the associated stigma of depression, and this may negatively impact on their utilisation of antenatal and other social services. There is evidence which shows that stigmas due to a diagnosis of depression is one of the barriers to treatment among women [100]. However, opposing evidence showed that pregnant women who participated in screening for antenatal depression did not feel stigmatised, labelled or distressed by the screening process [101]. This is corroborated by Siu, Bibbins-Domingo [51] who asserted that the negative effects of screening for depression in adults is small or sometimes non-existent.

## **4. Cultural aspects of depression and treatment in Malawi**

In Malawi, all communities have their own explanations for illness. It is believed that mental disorders such as depression is caused by witchcraft, possession by

spirits and 'evil eye' (punishment directed at a person by another person or a supernatural being) [102]. In addition, 'Chauta' (God) may punish wrongdoers who violate taboos [102]. Mental disorders may be caused by parents performing culturally disapproved forms of sexual intercourse such as not abstaining from sexual activity from seventh month of pregnancy until six months after delivery to prevent the child from suffering from mental disorder [103]. This shows that cultural beliefs should be considered as one of important factors which influence mental health interventions [104].

People may have negative cultural beliefs about mental disorders embedded in their community. Cultural beliefs related to mental disorders may affect the way the mentally ill person is handled locally [102]. Explanations of mental disorders, be it witchcraft, angry ancestors, will of God determine the acceptance of affected person's condition [103]. People who believe in witchcraft as a cause of mental disorders may have no hope about recovery in the absence of traditional medicine [104]. It is believed that pregnant women should avoid conflict with others because they may bewitch her to cause delay and complications in labour [105]. It is documented that people who fear witchcraft avoid offending other people who might use magical charms to retaliate [102]. Stewart, Umar [105] found that witchcraft was considered as a very real danger that makes a pregnant woman and her unborn baby vulnerable to illness.

Traditional healers use charms, herbs or mental suggestions to treat mental disorders [102]. However, stigma towards mental disorders exists in Malawi [106] such that treatment may not be sought for an individual with depression who is not causing any trouble [102]. Furthermore, when people are sick, they want to know cultural explanations of their sickness such that they consult traditional healers before going for western medicine, or use both to be on the safe side [102]. This may suggest the need for developing culturally appropriate mental health interventions [106] for screening and treating of depression in pregnant women and other populations in the country.

There is evidence that the pathway to psychiatric care for patients with psychological problems in Malawi is comparable to other developing countries whereby traditional healers and paramedics play a significant role [107]. However, many cultural beliefs related to mental disorders are being challenged [102] and there is high utilisation of health services for people with common mental disorders in the local Primary Health Care settings [108]. This may suggest that screening for depression in local antenatal clinics may be feasible despite the prevailing cultural beliefs on mental disorders. In Malawi, mental health services are provides in all health centres, district hospitals and central hospitals across the country [17].

## **5. Task shifting in screening of antenatal depression in low resource settings**

Mental disorders are underdiagnosed by primary care health workers in low resource settings, where mental health specialists are scarce [31]. This poses a challenge to integration of screening of depression into antenatal care. However, literature suggests task shifting approaches could be used to effectively deliver mental healthcare in primary health care settings [109]. Task shifting refers to the rational redistribution of tasks among health workforce teams, with specific tasks moved from highly qualified health workers to health workers with shorter training and fewer qualifications in order to make efficient use of the available human resources [110]. In task shifting, tasks are shifted from health workers with more general training to workers with specific training for a particular task [111]. For

#### *Screening for Antenatal Depression by Midwives in Low Resource Settings in Primary Care… DOI: http://dx.doi.org/10.5772/intechopen.97411*

instance, non-specialist health professionals or lay workers able to detect, diagnose, treat, and monitor individuals with mental disorders after receiving brief training and appropriate supervision by mental health specialists [109]. This may help to mitigate the impact of health worker shortages an may provide an opportunity for establishing equitable and sustainable health systems in low resource settings [110].

Task shifting aims at increasing the number of healthcare services provided at a given quality and cost, or providing the same level of healthcare services at a given quality at a lower cost [111]. As such, task shifting may be of essence in this study because it proposes the inclusion of screening of depression in antenatal services which requires midwives to take up new tasks of detecting and treating of antenatal depression. In Uganda, nurses who run health centres diagnose and prescribe in addition to their usual nursing and midwifery duties [110]. Similarly, anecdote reports indicate that task shifting makes nurses/midwives in Malawi, especially those deployed in health centres, to operate beyond their scope of practice because circumstances demand that they do patient assessment, diagnosis and prescribing. This underscores the importance of having relevant policies and legislations to regulate the implementation of task shifting without compromising quality of care [110] in antenatal clinics.

In line with task shifting, the WHO recommended that the provision of mental health services in primary care should be the responsibility of primary care workers such as nurses and midwives who must receive ongoing training and supervision from specialist mental health specialists [112]. This is corroborated by Honikman, van Heyningen [16] who found that midwives were able to screen for depression and refer pregnant women appropriately after receiving some training in South Africa. Non-specialist health workers can effectively detect, diagnose, treat, and prevent common and severe mental disorders [109]. It is documented that taskshifting mental health interventions from specialised to non-specialised health workers to treat common mental disorders could expanding access to mental healthcare [112]. Furthermore, task shifting can substantially reduce the expected number of healthcare providers otherwise needed to close mental health service gaps at primary health care level in low resource settings [113].

However, task-sharing should not be viewed as an "outright solution" to the human resource crisis in low resource settings because specialist services will always be required regardless of the innovativeness and effectiveness of task shifting approaches in reducing the mental health treatment gap [112]. Considering that midwives in antenatal clinics in low resource settings are overburdened with increased workload [19], there is a need to ensure that task shifting happens in a team, based on which cadres are available, which tasks need to be undertaken and who has which competencies [110]. This study proposed that midwives who are readily available in antenatal clinics and mental health specialists-though scarceshould collaborate when screening for antenatal depression.

In Malawi task sharing initiative which involved lay health workers in providing mental health services led to the establishment of a new service within the community which increased access to mental health services [114]. The lay health workers received mental health training and were supervised by health professionals. There was increase in detection of people with severe mental illness by lay health workers. Lay health workers were also able to treat or refer patients with distress based on their assessment. However, the decision to refer patients to a district hospital was made by professional health workers. This is a local mental health initiative on which may inform successful implementation of the proposed screening protocol for antenatal depression in the country.

Best-buy interventions may be another approach of implementing mental health services in antenatal clinics. These interventions emphasise cost effectiveness,

feasibility, affordability and scalability [115]. Implementation of buy-in interventions depends on appropriateness of setting, capacity of system to deliver a given intervention to a targeted group of people, technical complexity of intervention and acceptability. It is hoped that screening of depression using the proposed screening protocol would be best-buy interventions because it will be integrated in usual antenatal care provided by midwives. However, mental health specialists remain key in screening of antenatal depression due to complexity of its diagnostic assessments and treatments. This may suggest the importance of utilising task sharing when providing best buy-interventions.

Mantal health services have traditionally been offered in psychiatric institutions. Nonetheless, the proposed screening protocol for antenatal depression suggests provision of mental healthcare to pregnant women in unconventional settings of care. Interventions in unconventional settings model focuses on expanding care beyond traditional locales of service into settings where individuals attend [115]. Provision of care in unconventional settings open multiple opportunities to reach out to individuals or populations not otherwise served. However, implementation of this approach in local antenatal clinics may increase workload for midwives who are already burdened.
