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

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 We included only full-text journal publications and excluded unpublished online clinical trial results, and abstracts.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.

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

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].

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.