Enhancing Access to Mental Health Services for Antepartum and Postpartum Women Through Telemental Health Services at Wellbeing Centers in Selected Health Facilities in Bangladesh: Implementation Research

Abstract

Background: Globally, 10% of pregnant women and 13% of postpartum women experience mental disorders. In Bangladesh, nearly 50% of mothers face common mental disorders, but mental health services and trained professionals to serve their needs are scarce. To address this, the government of Bangladesh's Non-Communicable Disease Control program initiated "Wellbeing Centers," telemental health services in selected public hospitals.

Objective: This study examines implementation outcomes, including adoption, accessibility, acceptability, feasibility, usefulness, need, experience, perception, and expectations of the Wellbeing Centers, with a focus on antepartum and postpartum women.

Methods: Between January 2023 and August 2024, we interviewed 911 antepartum and postpartum women receiving mental health services and 168 health care providers at 6 Wellbeing Centers in 4 districts in Bangladesh. Data collection involved both quantitative and qualitative methods. Implementation outcomes were measured following the World Health Organization's implementation research framework. Depression and anxiety symptoms were assessed using the Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7 questionnaires. Descriptive statistics and adjusted odds ratios (aORs) with 95% CIs were used to evaluate the implementation outcomes. Qualitative information was obtained through in-depth interviews and key-informant interviews.

Results: Almost all health care providers (165/168, 98.2%) reported that the Wellbeing Centers were feasible to implement in their health facilities; however, about half (84/168, 50%) felt that trained staff to operate them were insufficient. Almost all women agreed that the Wellbeing Centers were acceptable (906/911, 99.8%), useful (909/911, 99.8%), and enhanced access to mental health care (906/911, 99.5%). Patients visiting district-level hospitals had higher odds of access (aOR 1.5, 95% CI 1.1-2.0) to Wellbeing Centers. Moreover, 77.4% (705/911) of women experienced depression symptoms, and 76.7% (699/911) experienced anxiety symptoms. About 51.8% (472/911) experienced tiredness or lack of energy, 50.9% (464/911) felt nervous, anxious, or on edge, 57.2% (521/911) felt worried, and 3.8% (35/911) had suicidal ideation almost every day. Patients visiting district hospitals had higher odds (aOR 2.6, 95% CI 1.8-3.78) of depression and anxiety symptoms compared to the patients visiting subdistrict-level hospitals. Decreasing trends in Patient Health Questionnaire-9 scores (from mean 14.4, SD 0.47 to mean 12.9, SD 0.47) and Generalized Anxiety Disorder-7 scores (from mean 13.3, SD 0.49 to mean 12.5, SD 0.48) between 2 counseling sessions indicated improved mental health in the antepartum and postpartum women. The Wellbeing Centers' services were appreciated for their privacy and being free and accessible. However, stigma, postpartum illness, and long waiting times prevented some women from using these services.

Conclusions: To our knowledge, this is the first implementation research assessing telemental health in public health facilities involving trained psychologists and psychiatrists. Our study highlighted the increased accessibility, feasibility, acceptability, and utility of Wellbeing Centers for antepartum and postpartum women in Bangladesh, supporting their scale-up in similar settings.

Keywords: Wellbeing Centers; antepartum; anxiety; depression; implementation; postpartum.

Figure 1

Study sites. DH: district hospital; UHC: upazila health complex.

Figure 2

Mental health service delivery mechanism of Wellbeing Centers. ANC: antenatal care; DH: district hospital; PNC: postnatal care; UHC: upazila health complex.

Figure 3

Logical framework of the telemental health intervention.

Figure 4

Implementation outcomes of Wellbeing Centers according to the World Health Organization guidelines.

Figure 5

Need for Wellbeing Centers according to the frequency of depressive and anxiety symptoms.

Figure 6

The usefulness of the counseling in reducing the average PHQ-9 and GAD-7 scores (n=51). GAD-7: Generalized Anxiety Disorder-7; PHQ-9: Patient Health Questionnaire-9.