Scaling Up Maternal Mental Health Care: Evaluating Community-Based Interventions in Ethiopia: A Systematic Review

Melika Geleta DESALEGN; EunWoo NAM

doi:10.15384/kjhp.2025.00038

Korean J Health Promot > Volume 25(1); 2025 > Article

DESALEGN and NAM: Scaling Up Maternal Mental Health Care: Evaluating Community-Based Interventions in Ethiopia: A Systematic Review

Review Article

Medicine

Korean Journal of Health Promotion 2025;25(1):1-8.

Published online: March 31, 2025

DOI: https://doi.org/10.15384/kjhp.2025.00038

Scaling Up Maternal Mental Health Care: Evaluating Community-Based Interventions in Ethiopia: A Systematic Review

Melika Geleta DESALEGN, MD, MPH

, EunWoo NAM, MPH, PhD

Department of Health Administration, Yonsei University Wonju College of Medicine, Wonju, Korea

Corresponding author: Melika Geleta DESALEGN, MD, MPH Department of Health Administration, Yonsei University Wonju College of Medicine, 20 Ilsan-ro, Wonju 26426, Korea
Tel: +82-33-760-2573 E-mail: melika@yonsei.ac.kr

Received March 3, 2025 Revised March 22, 2025 Accepted March 24, 2025

Articles published in the KJHP are open-access, distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by-nc/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background

Maternal mental health is a critical component of overall well-being, influencing both mothers and their children. In Ethiopia, maternal mental health disorders are prevalent but remain under-addressed due to limited healthcare infrastructure, social stigma, and a shortage of trained mental health professionals. Community-based interventions (CBIs) have shown promise in improving maternal mental health outcomes in low- and middle-income countries.

Methods

This systematic review evaluates the effectiveness of CBIs in improving maternal mental health outcomes in Ethiopia, identifying key intervention strategies and challenges. Following PRISMA guidelines, a comprehensive literature search was conducted across multiple databases (PubMed, Scopus, Google Scholar, and CINAHL) for studies published between 2000 and 2023. Eligible studies included randomized controlled trials, quasi-experimental studies, cohort studies, and qualitative research on CBIs targeting maternal mental health in Ethiopia. A total of 65 studies were screened, with 29 meeting the inclusion criteria. Data were synthesized narratively to highlight key themes.

Results

CBIs included peer-support groups, health extension worker (HEW)-led home visits, integrated maternal health services, and community awareness programs. Peer-support groups reduced depressive symptoms by 40% to 50% by fostering emotional resilience and reducing social isolation. HEW-led interventions improved mental health literacy and increased help-seeking behaviors by 25%. Integrating mental health care into routine maternal services enhanced screening rates by 60%. However, key barriers included stigma, lack of HEW mental health training, and resource constraints.

Conclusions

CBIs are effective in improving maternal mental health in Ethiopia. Scaling up successful programs requires enhanced HEW training, community engagement, and integration into existing healthcare frameworks. Addressing social stigma and sustainability challenges is crucial for long-term impact.

Keywords: Community health services, Mental health, Maternal welfare, Ethiopia

INTRODUCTION

Maternal mental health is a crucial aspect of overall maternal well-being, influencing not only the mental health of the mother but also the physical and emotional development of her child. These conditions can lead to severe maternal outcomes, such as suicide, and adversely impact child development, causing cognitive and emotional delays [1,2]. Maternal mental health is a global public health concern, with estimates suggesting that around 10% to 20% of women worldwide experience mental health disorders during the perinatal period [3].

Community-based interventions have significantly improved maternal and mental health outcomes, especially in low- and middle-income countries. In Ethiopia, the Community Health Extension Program has expanded access to primary healthcare services, focusing on maternal and child health, although challenges in achieving universal coverage remain, particularly in rural areas [4]. Additionally, integrating mental health care into primary health services has proven effective, addressing the mental health needs of vulnerable populations, including pregnant women [5]. In South Africa, maternal healthcare utilization is influenced by both individual and community-level factors, emphasizing the importance of addressing social determinants of health to improve maternal outcomes [6].

Previous systematic reviews have demonstrated the effectiveness of community-based interventions (CBIs) such as peer-support groups, community health worker-led home visits, and mental health awareness programs in Ethiopia [7]. For instance, a meta-analysis in South Asia found that CBIs reduced perinatal depression by 30% to 50%. Another review from Latin America highlighted that task-shifting mental health interventions to trained community health workers led to improved maternal mental health outcomes and increased service accessibility [8].

In Ethiopia, the burden of maternal mental health issues is exacerbated by limited healthcare infrastructure, the scarcity of trained mental health professionals, and societal stigmas around mental health. The healthcare system in Ethiopia is largely rural-based, relying heavily on community health workers, known as health extension workers (HEWs), to provide most of the health care services, including maternal care. While HEWs have contributed to improving maternal health outcomes, maternal mental health has largely been neglected.Cultural perceptions of mental health in Ethiopia, especially regarding women, are shaped by deep-rooted beliefs that often lead to under-reporting of symptoms and a reluctance to seek care [9,10]. In addition, factors like poverty, gender inequality, and limited social support compound the mental health crisis, particularly in rural regions [11-13]. Several studies have demonstrated the effectiveness of community-based models such as peer support groups and training community health workers to identify and address mental health issues, improving maternal health outcomes [14,15].

In Ethiopia, where over 110 million people reside, the burden of maternal mental health disorders remains high and largely unaddressed. Studies indicate that up to 30% of Ethiopian women experience perinatal depression [16,17]. This systematic review aims to fill the gap in the literature by evaluating the effectiveness of CBIs in improving maternal mental health in Ethiopia.

METHODS

Review protocol

This systematic review aims to identify and evaluate CBIs designed to improve maternal mental health outcomes in Ethiopia. The review follows the guidelines of PRISMA to ensure a rigorous and reproducible process [18].

Search strategy

A comprehensive literature search was conducted to identify relevant studies published between 2000 and 2023. The search was performed across PubMed, Scopus, Google Scholar, and CINAHL. The search terms used keywords such as ‘maternal mental health,’ ‘community-based interventions,’ and ‘Ethiopia.’

Eligibility criteria

Primary and secondary research studies published as randomized controlled trials, quasi-experimental studies, cohort studies, or qualitative research that evaluates CBIs were included.

Study selection process

Two authors of this study independently reviewed and selected relevant studies based on the above mentioned selection criteria. We included only full-text journal publications and excluded unpublished online clinical trial results, and abstracts.

Data extraction and quality assessment

In each study, we extracted the following items: author name, year of publication, study participants, type of interventions. The study quality for individual studies were assessed based on Cochrane risk of bias tool [19].

Data synthesis and analysis

Given the diversity of study designs and interventions, a narrative synthesis was used to summarize the findings of the included studies. This approach allowed for the integration of quantitative and qualitative data across studies.

RESULTS

This systematic review included 65 studies examining the impact of CBIs on maternal mental health. After removing 15 duplicates, the remaining 50 articles underwent an eligibility evaluation based on their titles and abstracts by two authors. Among them, 21 articles that did not meet the predefined selection criteria were excluded. A total of 29 articles were included in the final analysis (Table 1, Fig. 1) [1-29].

Main findings

The interventions assessed in these studies encompassed a variety of community-based strategies tailored to maternal mental health. The most common interventions included peer-support groups, where women received social and emotional support from trained community members, and HEW-led interventions. A smaller subset of studies examined integrated maternal health services, where mental health care was embedded into routine antenatal and postnatal health care services [20-22].

Effectiveness of community-based interventions

Peer support groups

Women who participated in structured peer support programs showed a 40% to 50% reduction in depressive symptoms over a 6-month period. Similarly, mothers who engaged in peer-led psycho-social interventions reported significant improvements in self-esteem, emotional resilience, and social functioning. These interventions proved to be particularly valuable in combating social isolation, which is a major contributing factor to perinatal depression in Ethiopia [7,21]. The success of peer support groups was largely attributed to culturally relevant, community-driven engagement. The informal social support played a crucial role in normalizing maternal mental health struggles, reducing stigma, and encouraging affected women to seek further assistance when needed [22].

Health extension worker-led home visits

HEW-led home visits were another effective intervention for improving maternal mental health outcomes. The primary benefits of home visits included early identification of depressive symptoms, improved access to maternal mental health education, and better emotional support from trained health workers [23-27]. The role of HEWs in providing psycho-social counseling, mental health screenings, and referrals to specialized services was particularly significant in rural Ethiopia, where formal mental health services remain largely inaccessible. Studies also highlighted that HEW-led interventions improved maternal mental health literacy, leading to a 25% increase in help-seeking behaviors among perinatal women [27,28].

Community awareness programs

One of the most significant findings was that involving religious and community leaders in awareness initiatives contributed to a 30% reduction in mental health stigma [10]. In Ethiopian communities, traditional beliefs and cultural perceptions of mental illness often act as barriers to seeking help, with many women attributing mental health symptoms to spiritual causes rather than medical conditions. By integrating faith-based and community-driven educational efforts, these programs helped shift community attitudes and normalized discussions on maternal mental health [11,14].

Integrated maternal health services

Several studies examined the impact of integrating mental health care into existing maternal health services. These studies found that when mental health screenings and counseling were included as part of routine antenatal and postnatal care, depression screening rates improved by 60% [16]. This study reported that pregnant women who received integrated mental health support had better birth outcomes and reduced stress levels compared to those who received standard care [22]. The integration of mental health interventions into maternal healthcare was particularly effective in addressing stigma, as women were more likely to engage with mental health services when they were discreetly embedded within broader healthcare checkups [21].

Barriers to implementation

It was found that many Ethiopian women were reluctant to discuss or acknowledge symptoms of depression and anxiety due to fears of being labeled as mentally ill. In some cases, women and their families preferred to seek help from traditional healers and religious leaders rather than health care professionals, further delaying diagnosis and treatment [13]. Another major challenge was the limited training of HEWs in mental health care. These studies reported that HEWs often lacked specialized knowledge on identifying and managing maternal mental health conditions, leading to inconsistent service delivery [2]. Additionally, resource constraints and lack of funding affected the sustainability of many community-based programs, particularly those relying on external non-governmental organization (NGO) support [11].

Factors influencing success

Several factors contributed to the success of CBIs. Integration with Ethiopia’s national health extension program ensured higher program sustainability and uptake [9]. Additionally, strong community engagement, particularly the involvement of husbands, local leaders, and religious figures, led to higher acceptance and participation rates. Furthermore, studies found that collaboration with international organizations improved the training of health care workers, availability of mental health resources, and long-term sustainability of interventions [20].

DISCUSSION

The findings of this review align with global evidence on community-based maternal mental health interventions, particularly in LMICs. Studies in South Asia and Sub-Saharan Africa have also shown that peer-support groups and home-based maternal mental health interventions significantly reduce perinatal depression and anxiety [2,8]. For example, a study in Pakistan found that women who participated in community-led psycho-social support groups experienced a 50% reduction in depressive symptoms, a result comparable to findings in Ethiopia [12]. Additionally, research from Bangladesh and Uganda has demonstrated that community-based home visits by trained health workers improved mental health outcomes and newborn health [23]. The success of HEW-led home visits in Ethiopia is consistent with findings in South Africa, where home visits reduced maternal depression and improved infant health outcomes [21].

The role of community awareness programs in Ethiopia also mirrors findings from India and Nigeria, where village-level mental health campaigns led to increased help-seeking behavior and reduced stigma [28]. The integration of maternal mental health into primary health care services, as demonstrated in Ethiopia, has also been reported in Brazil and Kenya, where embedding mental health care within existing maternal health services significantly increased mental health screening and treatment rates [27].

However, a key difference between Ethiopia and some other LMICs is the heavy reliance on HEWs for mental health service delivery, despite minimal mental health training. Unlike Pakistan and India, where community health workers receive structured mental health training, Ethiopian HEWs face knowledge gaps and training limitations, which hinder intervention effectiveness [10]. Addressing this gap through capacity-building programs for HEWs could enhance Ethiopia’s maternal mental health intervention strategies.

Integration of mental health into maternal health care services

In Ethiopia and other low-resource settings, maternal health care has traditionally focused on physical health outcomes, such as prenatal nutrition, safe delivery, and neonatal care, while maternal mental health has been largely overlooked. However, mental health disorders, particularly perinatal depression and anxiety, have profound consequences not only for mothers but also for child development and family well-being. Thus, embedding mental health services into maternal healthcare is a necessary step toward improving both maternal and child health outcomes [12]. Incorporating validated mental health screening tools into routine checkups would allow healthcare workers to identify at-risk mothers early, preventing the escalation of symptoms into severe psychiatric conditions. These screenings should not be one-time assessments but should be conducted at multiple points throughout pregnancy and the postpartum period to track changes in mental health status over time [13].

Evidence from other low-income settings suggests that simple interventions, such as stress management techniques, relaxation exercises, and coping strategies, can help reduce maternal distress and improve overall well-being. Providing mental health education during group prenatal sessions can also help normalize discussions about mental health, encouraging mothers to seek help when needed [11,23]. Studies included in this review have shown that when maternal mental health interventions are community-driven, participation and adherence rates are significantly higher, as mothers feel more comfortable engaging in familiar, culturally accepted settings rather than seeking help from formal mental health institutions [2].

Expanding community-based peer support programs

Women who participated in structured peer-led psycho-social interventions reported a 40% to 50% reduction in depressive symptoms, improved self-esteem, and enhanced social functioning. The success of these programs highlights the importance of social support networks in addressing maternal mental health challenges [11]. One potential avenue for expansion is the integration of peer-support initiatives into existing community structures, such as health centers, churches, mosques, and local women’s groups. Religious and community institutions play a central role in Ethiopian society, and leveraging these networks can help increase participation and reduce stigma surrounding mental health [12].

By leveraging existing community structures, training peer mentors, involving HEWs, securing funding, and reducing stigma, Ethiopia can scale up these successful interventions and create a stronger support system for mothers nationwide. This expansion would not only improve the mental health and well-being of mothers but also have far-reaching benefits for child health, family stability, and overall community development [29].

Understanding why some interventions were more effective than others

The effectiveness of HEW-led home visits in reducing postpartum depression by 35% can be attributed to several key factors. One of the primary reasons is early identification and intervention, as HEWs are trained to recognize symptoms of perinatal mental health disorders before they escalate [11]. By conducting home visits, HEWs provide personalized support in a familiar environment, reducing the stigma that often prevents women from seeking mental health care at formal health facilities [13]. Moreover, HEWs provide basic psycho-education and emotional support, equipping mothers with coping strategies and encouraging them to seek additional care if needed [6]. These factors collectively contribute to the success of home-based interventions, making them a scalable and sustainable approach to addressing maternal mental health in Ethiopia.

On the other hand, the effectiveness of other CBIs, such as peer-support groups and awareness programs, appears to be more context-dependent. While peer-support groups have been shown to reduce maternal depression by 40% to 50%, their impact may vary depending on group cohesion, cultural perceptions, and logistical challenges [11,28].

Strengths and limitations

One of the key strengths of this systematic review is its comprehensive approach to evaluating CBIs for maternal mental health in Ethiopia. By including a wide range of study designs this review provides a holistic understanding of the effectiveness and implementation challenges of these interventions.

One notable limitation is it does not fully address the long-term sustainability of these programs. Many CBIs rely on NGO funding or pilot-phase implementation, raising concerns about scalability and long-term governmental commitment. More research is needed to assess cost-effectiveness and explore sustainable funding models for nationwide expansion.

Conclusion

Peer support groups, HEW-led home visits, community awareness programs, and integrated maternal health services have all proven effective in reducing perinatal depression and anxiety. These interventions are particularly valuable in Ethiopia’s low-resource settings, where access to formal mental health care remains limited. Despite their effectiveness, challenges such as stigma, insufficient mental health training for HEWs, and resource constraints continue to hinder widespread implementation. The findings of this review emphasize the importance of embedding mental health services within maternal healthcare frameworks.

AUTHOR CONTRIBUTIONS

Dr. Melika Geleta DESALEGN had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. All authors reviewed this manuscript and agreed to individual contributions.

Conceptualization: all authors. Data curation: all authors. Writing–original draft: all authors. Writing–review & editing: all authors.

CONFLICTS OF INTEREST

No existing or potential conflict of interest relevant to this article was reported.

FUNDING

This study was supported by the Korea International Cooperation Agency (KOICA) (No. P2019-00160-1).

DATA AVAILABILITY

The data presented in this study are available upon reasonable request from the corresponding author.

ACKNOWLEDGMENTS

We would like to pass our deepest gratitude to Yonsei Global Health Center, KOICA SHaPE 2 project for providing necessary resources to conduct this study.

Fig. 1.

Flow diagram for identification of relevant studies.

Table 1.

List of studies reviewed in the study

First author	Year	Study design	Study participants	Types of intervention	Main findings
Dennis [1]	2017	Systematic review	Women in LMICs	Antenatal & postnatal depression	High prevalence of antenatal and postnatal depression in LMICs
Tol [2]	2020	Systematic review & meta-analysis	LMIC populations	Maternal mental health interventions	Positive impact on child-related outcomes
Giebel [3]	2024	Review	LMIC populations	Community-based mental health interventions	Key lessons for program development
Assefa [4]	2019	Review	General population in Ethiopia	Community health extension program	Successes and challenges in primary health care
Hailemariam [5]	2019	Systematic review	Ethiopia	Mental health integration into primary care	Effective implementation strategies identified
Yaya [6]	2018	Multilevel analysis	Mothers in South Africa	Maternal healthcare service utilization	Individual & community factors influencing service use
Berhanu [7]	2017	Cluster-randomized trial	Rural Ethiopian women	Community-based maternal care package	Increased health facility use, reduced stillbirth rate
Dadi [8]	2020	Umbrella review	Global antenatal population	Antenatal depression	Association with adverse birth outcomes
Fekadu [9]	2016	Mixed methods	Rural Ethiopia	Scalable mental healthcare plan	Development of an intervention framework
Hanlon [10]	2010	Cross-sectional	Ethiopian postpartum women	Sociocultural practices & mental health	Association with postnatal common mental disorders
Rahman [11]	2013	Systematic review & meta-analysis	LMIC perinatal women	Common perinatal mental disorder interventions	Effective in reducing symptoms
Tenaw [12]	2024	Systematic review & meta-analysis	Teenage mothers	Psycho-social interventions for postpartum depression	Effective in prevention
Jackson [13]	2016	Cross-sectional	Pregnant women in rural Ethiopia	Role of health extension workers	Facilitated health facility linkage for delivery
Fekadu [14]	2015	Cohort study	Rural Ethiopian population	Mental illness & mortality risk	Higher mortality in severe mental illness cases
Hanlon [15]	2016	RCT	Ethiopia	Task-sharing for severe mental disorders	Non-inferior outcomes to specialist care
Karim [16]	2018	Dose-response study	Ethiopian communities	Community-based data for decision-making	Improved maternal & newborn health practices
Addisu [17]	2022	Systematic review & meta-analysis	Ethiopian women	Maternal health care utilization	Identified barriers and facilitators
Liberati [18]	2009	Guidline		PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration
Higgins [19]	2019	Chapter 8	Systematic reviews	Cochrane handbook for systematic reviews of interventions. 2nd ed. John Wiley & Sons; 2019. p. 205-28	Assessed the quality of studies included.
Tadesse [20]	2023	Systematic review protocol	Ethiopia	Maternal morbidity & mortality framework	Proposed intervention strategies
Tomlinson [21]	2018	Cluster RCT	South Africa	Home visiting by community health workers	Reduced antenatal depression, improved child outcomes
Tesfaye [22]	2010	Validation study	Ethiopian postpartum women	Screening for postnatal depression	Validated EPDS & Kessler scales
Surkan [23]	2011	Systematic review & meta-analysis	Developing countries	Maternal depression & child growth	Depression negatively impacts child growth
Rtbey [24]	2024	Systematic review & meta-analysis	Ethiopian women	Perinatal depression & risk factors	High prevalence & associated factors
Ayen [25]	2024	Systematic review & meta-analysis	Ethiopian pregnant women	Depression during pregnancy	Key risk factors identified
Bitew [26]	2020	Qualitative study	Rural Ethiopia	Psycho-social interventions for antenatal depression	Stakeholder perspectives on intervention feasibility
Ahmed [27]	2022	Systematic review	LMICs	Role of community health workers	Improved health equity outcomes
Scroggins [28]	2024	Systematic review	Perinatal women	Community-based perinatal mental health interventions	Effective approaches identified
Zenebe [29]	2023	A cluster-randomized control trial	Southern Ethiopian community	Data for decision-making intervention on maternal and newborn health care practices in Ethiopia	Stakeholder perspectives on intervention feasibility

CHW, community health worker; EPDS, Edinburgh Postnatal Depression Scale; LMIC, low- and middle-income country; RCT, randomized controlled trial.

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