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Whether women are being referred to a professional counsellor, nurse, social worker or any kind of caregiver, there are a number of special issues which should be considered when caring for mothers with social issues.
Women living in poverty are at greater risk of developing a mental illness, and those with mental illness are more likely to slide into poverty, or stay poor. Current studies show that as many as 1 out of any 3 women living in poverty in South Africa experience depression during or after their pregnancy.
There are many issues associated with poverty which can negatively affect a woman’s mental health, such as:
Women living in poverty are at greater risk of developing a mental illness.
When helping and supporting a woman to identify the resources that are available, it must be kept in mind that women living in poverty face significant challenges. There may be fewer resources available to them and their situation might make it more difficult for them to get help that is available. However, it is important to be aware that the ‘vicious cycle’ relationship between poverty and mental ill-health can be broken, if the correct interventions are put into place.
Without support, women can feel lonely and overwhelmed, and may be less likely to get the help needed during pregnancy. This is why they are more likely to experience psychological problems.
Even women living in busy or overcrowded settings can feel completely alone and in despair.
Poor women may not find emotional and practical support because:
Signs that a woman may not be supported are:
Listen to her. Being heard and having someone provide emotional support can be very helpful. Are there any support groups in the area that can assist with finding resources? Can she be linked into accessing a social grant or work skills?
Women value the support that comes from the people close to them. Women may feel supported if practical help or financial assistance is given. Emotional support is also considered extremely important to mothers.
Emotional and practical support is important to maintain mental health.
Pregnant teenagers are at greater risk of developing mental illness. Also, young women who are depressed are more likely to become pregnant during their teenage years. Health workers should keep in mind that adolescence is a time when a number of physical and emotional changes take place. Adolescent girls are vulnerable, and may have difficulties dealing with crises or recovering from trauma. They also may experience pressure to engage in sex or use alcohol and drugs. Pregnant adolescents need special attention that is non-judging and supportive.
‘Typical’ teenage behaviour, such as aggression or withdrawal, may be the natural ‘fight or flight’ responses to the terrifying situation in which the adolescent finds herself.
Do not judge her or show anger. This may cause the girl to reject the care you offer her out of fear. A health worker explaining that her fear is natural and showing empathy, can make a positive difference to the outcome for the girl and the pregnancy. Kindness and acceptance from health workers may help the fear and help with the difficult behaviours that some teenagers display in health care settings.
Pregnant teenagers are at greater risk of mental illness.
About 60% of all pregnancies in South Africa are unintended (unplanned). Of these, one out of three is unwanted. The decision to either terminate or continue with the pregnancy is a very difficult one for most women and may cause severe distress.
For some women, termination of a pregnancy is the decision they arrive at after weighing up their options, and this needs to be respected as their decision. Other women, however, will, even in adverse social circumstances, decide to continue with the pregnancy and this needs to be supported. It is important not to make a woman who faces an unintended pregnancy feel guilty about her decision. She is already in a crisis situation which will be made worse if she is judged for her choice.
For some women, the choice to terminate a pregnancy may have negative mental health consequences, and for others, the choice to continue with an unintended pregnancy also has mental health consequences, both for the mother and for the child. They may be stressed or worried that they will not be able to provide for this child. They may feel anger at a partner who has abandoned them or denied paternity. The timing of this pregnancy may disrupt schooling, studies or work plans – all of which may negatively affect others in the family or home. There are many reasons why an unintended pregnancy can cause mental distress.
Unplanned and unwanted pregnancies are common in South Africa and may result in mental illness.
Any women experiencing distress needs non-judgemental support and kindness to help them to make the best decision for themselves. Persuasion by a health or social worker to make a decision either way may be damaging for the mother.
Health workers are legally obliged to provide information on Termination of Pregnancy (TOP) services for those who seek this, whatever the personal beliefs that the staff may have. A health worker who is approached by a woman for a termination may decline to do so, but is obligated by law to inform the woman of her rights and refer her to another health worker or facility where she can get a termination.
The Choice on Termination of Pregnancy Act, 1996 (Act No. 92 of 1996) is the law governing terminations in South Africa. During the first twelve weeks of a pregnancy, a termination may be performed at the request of the woman. From the thirteenth to the twentieth week, a pregnancy may be terminated if it endangers the woman’s mental or physical health, if the fetus could suffer from a severe mental or physical abnormality, if the pregnancy resulted from rape or incest, or if it would significantly affect the woman’s social or economic circumstances. After the twentieth week, a pregnancy may only be terminated if it could endanger the woman’s life, if the fetus is severely malformed, or if there is a risk of severe illness to the fetus.
Certain state hospitals or clinics perform free terminations, although sometimes only if the woman is referred by a health worker. Problems with access to early and safe TOP services mean that women can face a range of physical and mental health complications. Part of the poor access to services may relate to judgemental attitudes of health workers or to a lack of information given by health workers. Stigma and fear often make women have unsafe and dangerous illegal abortions. Backstreet abortions, often using the drug Misoprostol, can lead to septic infections, damage to internal organs or the most common effect is a continued pregnancy. Termination services have dramatically reduced both the number of and deaths from illegal abortions.
The option of a termination of pregnancy must be available for unwanted pregnancies before twelve weeks gestation.
Women who have booked at an antenatal clinic may have accepted that they are having the baby, but it may still be unwanted. Women may want to explore the option of having the baby adopted.
Adoption is the legal act of permanently placing a child with a parent or parents other than the child’s birth/biological mother or father. A legal adoption order terminates the parental rights of the birth mother and father, while ‘handing over’ the parental rights and responsibilities to the adoptive parents. The adopted child is then regarded as the child of the adoptive parents. In a Disclosed adoption, the identity of the biological parents and the identity of the adoptive parents are known by both parties. This form of adoption may include a post-adoption agreement that provides for future contact or the exchange of information. In a Closed adoption, no identifying details are available or exchanged between the adoptive parents and biological parents.
Adoption proceedings are handled by social workers at accredited and designated child protection organisations. Some organisations may charge a fee relating to adoption. See further information about adoption agencies in the Resources section.
Consenting to the adoption of a child is a difficult thing to do and child protection organisations and the Department of Social Development provide support services to assist with the process.
Women should be helped if they are considering having their baby adopted.
Women who have had to leave their home countries, because of war or economic difficulties, experience high rates of emotional and physical trauma. They may have experienced violence during war or during their travels to other countries. Refugee women are also particularly vulnerable to being raped. In addition, they are often living in poverty and may find it difficult to access health care.
Figure 6-1: Refugee women may have experienced economic difficulty, violence, emotional and physical trauma and are often living in poverty.
Because refugees have been separated from their families and communities, they often have very few sources of support or no support at all. They may find it difficult to communicate in the local language. Some communities are violent toward refugees, so refugee women may also face social isolation, discrimination and ongoing physical danger. These experiences, on top of the previous trauma of violence, economic hardship, the death of loved ones, torture or rape, can lead to very poor mental health among refugee women. Counselling a refugee woman can be difficult, as she may:
Be gentle and understanding. If she is unable to speak the local language, try to get someone that she trusts to act as an interpreter. Try to explain what is happening and how the clinic works in simple language. Check that she understands before you examine her.
Refugees often suffer many difficulties and are at risk of mental illness.
Domestic abuse is defined as abusive acts that threaten another person’s physical safety, freedom, health and emotional wellbeing. Abusive acts can be physical, sexual, emotional and financial. These are committed by someone the person lives with, or used to live with (a domestic relationship), e.g. a partner or ex-partner, boyfriend/girlfriend, parents, children, family member or a person sharing the same home.
Domestic abuse often takes place in the home.
Domestic violence is abuse which often has a specific purpose in mind. It is used by someone to gain and maintain control over another person. This control is designed to make the person feel fearful of the abuser, so that control over the person’s life can be maintained.
There are very high rates of rape and violent assault in South Africa: it has the highest rate of violence against women in the world.
Experiencing domestic violence is common in South Africa, and domestic violence is likely to increase during pregnancy. It is important for a health worker to pay special attention to these situations as they can affect a woman’s mental and physical health.
Domestic violence is common in South Africa and can affect a woman’s mental health.
Intimate partner violence (IPV) is defined as threatened, attempted, or completed physical or sexual violence or emotional abuse by a current or former intimate (sexual) partner. IPV can be committed by a spouse, an ex-spouse, a current or former boyfriend or girlfriend, or a dating partner.
Emotional abuse is the repeated use of controlling and harmful emotional behaviour by a partner to control a person.
As a result of emotional abuse, a person may live in fear and have altered thoughts, feelings and behaviours, as well as deny personal needs, to avoid further abuse. Emotionally abusive behaviour by someone’s partner may include:
The abuser uses emotional abuse to damage someone’s feelings of self-worth and independence. People who have experienced emotional abuse may feel that there is no way out of their relationship, or that ‘they are nothing’ without their abusive partner. They will often blame themselves for the abuse.
Physical abuse is physical injury inflicted on a person, on purpose, with the intention of being cruel or hurtful. Physical abuse can refer to punching, beating, kicking, biting, burning, shaking, or any other way of harming someone’s body physically. Physical abuse can happen just once, or can be ongoing.
Sexual abuse is any sexual contact or interaction (physical, visual, verbal or psychological) between one person (the victim) and another who is in a position of power (the abuser). The difference between rape and sexual abuse is that sexual abuse can be any act which uses someone for sexual stimulation. It can happen just once, or be ongoing. When physical sexual abuse is committed by a person who is a blood or legal relative, this is incest.
Rape is any sexual act which has been forced onto another person. It can include, but is not limited to, acts of sexual penetration into the vagina, anus or mouth of another individual without their consent. A person can be raped by their partner, a family member, a friend, someone they know, a stranger, or by several people. Rape may be committed by a person who is a blood or legal relative. Rape is a violent, traumatic and life-changing experience that can happen to anyone, female or male. It can create stressful situations within a person’s relationship, family and community.
Financial abuse is a way of exercising control over another person. Financial abuse may include:
There are many forms of abuse and each can affect mental health.
There are many reasons why women stay in abusive relationships. A woman might:
Domestic violence often occurs in a cycle.
The cycle usually repeats itself as the woman hopes that the abuser will change and go back to being the person she once knew.
Figure 6-2: The cycle of violence.
Women are not all the same, yet there are some common signs that women show when they are experiencing abuse. Rape and other forms of abuse can have a range of effects on women, such as:
Physical effects: shock, physical injury, nausea, tension headaches, disturbed sleeping and eating patterns, HIV or other sexually transmitted infections, pregnancy
Behavioural effects: crying more than usual, difficulty concentrating, restlessness, listlessness, withdrawing from people, relationships and social situations, not wanting to be alone, being easily frightened and jumpy, being easily upset, irritability, fear of sex, loss of sexual pleasure, changes in lifestyle, increased substance misuse and behaving as if the rape did not occur (denial)
Psychological effects: anxiety and fear, guilt, helplessness, humiliation and embarrassment, shame, low self-esteem, anger, feeling alone and misunderstood, losing hope for the future, numbness, confusion, aggression, personality changes, loss of memory, having flashbacks of the rape, nightmares, anxiety, depression and suicidal thoughts
However, if a woman does not show any of these reactions or symptoms, it does not necessarily mean that she has not been abused. She may be hiding the effects.
Women who are experiencing abuse by their partner may:
Warning signs of physical abuse can include:
Warning signs of isolation and emotional abuse can include:
Women who are suffering from domestic violence can feel very vulnerable and alone. So, it is particularly important to support them emotionally and provide practical support. This can be done by helping them understand their situation and what their options are, and refer them to community organisations for legal and social support.
Many health workers avoid asking about abuse, perhaps because they are worried it will take a lot of their time and energy to deal with, they do not feel properly trained to help, or because they do not know about options for care.
In extreme situations, a woman may have to remove herself from immediate harm, and stay in a shelter or at a friend’s or relative’s home.
This is a difficult and important step for a woman victim of domestic abuse: it is essential that she is shown empathy and emotional support. You may be able to develop a safety plan with her. This will include ensuring secrecy of the location of where she is going, packing (sometimes secretly storing, over time) important documents, ID documents, valuables, clothing and food necessary for the woman and her children to leave.
A woman may deny she is being abused when she is asked about it. However, by simply asking, you are showing the mother that you care. She will appreciate that, and may feel safe to disclose at a later stage.
Women who are being abused may have also witnessed abuse of their children. Often more than one person is being abused in a home. The woman herself may be abusing her children. The decision to stay or leave an abusive relationship may be influenced by whether her children are also being abused.
Child abuse is when a child is being hurt, on purpose, in any way, physically or emotionally. This includes emotional, physical and sexual abuse, and emotional and physical neglect.
While working, health workers may come across mothers who are engaging in or witnessing abuse of their own children.
It is common for abusive parents to report being physically, sexually or emotionally abused themselves as children. However, there are parents who have not been abused as children who become abusive. There are also parents who have been abused as children who do not abuse their own children.
Some of the reasons parents or caregivers can become abusive are:
None of these factors mean that abuse will definitely happen. It is important to explore carefully all the details before making a claim of child abuse.
The child’s age and physical, mental, emotional and social development can increase the chance of abuse. Younger children, due to their physical size and developmental status, are more vulnerable to certain forms of abuse, such as the ‘battered child syndrome’, the ‘shaken infant syndrome’ and the ‘failure to thrive syndrome’.
The child’s behaviour (e.g. crying, being unresponsive, irritable or aggressive) can increase the likelihood of abuse, particularly if a parent is not able to relate to the child, or has difficulty controlling his or her own emotions.
In general, children who are thought to be ‘different’, such as disabled children, are at greater risk of abuse. Children who are socially isolated can also be at high risk. For example, a child who does not have close relationships with his family and has few or no friends can be more vulnerable.
The situation of some families can increase the likelihood of abuse, such as:
Abusive families are often isolated from their neighbours and the community. As a result, abusive families tend to participate less in community activities and make less use of available economic, health and social resources. A health worker may notice over-reactions to the child’s negative behaviour, and very little reaction to positive behaviour. In addition, abusive parents often use inconsistent and inappropriate forms of punishment and discipline.
It is important to remember that cultural or religious differences can make it difficult to identify or act on child abuse. What one culture defines as child abuse can be a socially acceptable act in another culture.
For example, values concerning the role of the child in the family, and attitudes about the use of physical punishment, differ between cultures. It is important to be sensitive and careful in these cases.
Health and social workers have a duty and legal obligation to take action if child abuse is taking place. You may notice that a mother is not coping. She might say something that causes the health worker to be concerned, such as:
It is important to take these comments seriously.
Child abuse may be a mild, single event, or more serious or ongoing. The health worker’s responses should adapt to the level of abuse.
You can help the mother who has hurt her child, or is afraid that she may hurt her child, to think about some short-term solutions. A health worker can say:
Help the mother understand the baby’s needs and behaviour. For example, explain that the baby is not trying to frustrate her on purpose. If you think that she should be referred to a counsellor, you can introduce the idea by saying: ‘It sounds as though you are extremely stressed and that you need help immediately. I need to refer you to someone who will be able to give you the help and support you need. They might want to speak to you, your partner or your family about the situation.’
You can offer her some longer-term suggestions, like:
You may have to call Social Services or Child Welfare. The mother may have said things like:
The mother may feel unsure or even scared about Child Welfare getting involved in her life. Many mothers fear that their child/children will be taken away from them.
Urgent action must be taken if a mother has hurt her child more than once.
A pregnant teenager is waiting in the clinic for her antenatal check-up. She seems sulky and is not engaging with other women who are waiting. She has booked late for antenatal care and has missed some of her appointments. When you call her to come for her check-up, she sighs loudly and takes her time in coming through. You think she is being disrespectful and rude. When you talk with her she says there is no point in looking after herself in the pregnancy. She explains how she is not interested in spending time with her friends and no one in her family ‘gets’ her.
Pregnant teenagers are at greater risk of developing mental illness. Adolescence is a time when a number of physical and emotional changes take place. Teenagers are vulnerable, and may have difficulties dealing with crises or recovering from trauma. They also may experience pressure to engage in sex or use alcohol and drugs.
She has been late in booking and missed appointments; these could indicate withdrawal or avoidance behaviour. These may be linked to her feelings of hopelessness and social withdrawal.
She might be depressed or really scared about what is happening to her. Her fear may affect her functioning to a degree that she has an anxiety disorder.
When you talk to her in private, you ask her why she got pregnant when she is so young. You tell her that she is ruining her future. She says she is leaving now; she does not need your advice.
No, you judged her and gave her unwanted advice. This has meant that she does not want to interact with you and wants to avoid the self-hating feelings your discussion created in her. She wants to leave the clinic and may not come back for any further care.
Do not judge her. Explore her feelings and reflect these back to her. Explain to her that her fear is natural. Show empathy. Kindness and acceptance from you may help with the difficult behaviours that this teenager has shown.
A pregnant mother has another child by a different father who is not providing any financial support. The father of this pregnancy is unknown. She was in a relationship with someone who has left the country, and also had unprotected sex with a stranger at a party. This pregnancy was unplanned and is unwanted. She does not know what to do. She is distressed and worries that she will not be able to support another child by herself. She feels guilty that she got herself into this crisis.
About 60% of all pregnancies in South Africa are unintended (unplanned). Of these, one out of three is unwanted.
Any women experiencing distress needs non-judgemental support and kindness to help them to make the best decision for themselves. She should not be persuaded to make a decision according to your own assessment of the situation. This could be damaging for her mental health. Rather, you could provide her information about her options and explore with her the implications of these, without leading her down any particular path. You could speak about how the decision is difficult to make but that she is best able to make it for herself.
She can choose to have a termination or give the baby up for adoption.
Yes, no matter what your beliefs are, you are legally obliged to provide information on Termination of Pregnancy (TOP) services for those who want this information. You are obligated by law to inform the woman of her rights and refer her to another health worker or facility where she can get a termination.
Certain state hospitals or clinics perform free terminations of pregnancy, although sometimes only if the woman is referred by a health worker. It also depends on how far her pregnancy has advanced. Termination on request is only available if the woman is less than twelve weeks pregnant.
If she chooses to terminate the pregnancy without safe medical care, she may have a backstreet abortion – which could lead to infections, damage to internal organs or a continued pregnancy. She may feel that this is her only option due to the stigma and fear she confronts. She could prosecute you for withholding information.
A poor, pregnant mother is waiting outside the clinic. She is from a neighbouring country and does not speak the local language. She came to South Africa because of fighting in her home country. Her husband has no regular employment and is trying to get day work as a labourer. They live in a backyard dwelling with no flush toilet and only an outside tap for water. She does not understand how the system at the clinic works, and even though she has been outside for two hours, other people are being seen before her. They ignore her and walk past her into the clinic. She is now sitting on the pavement crying. She appears malnourished.
She could be overwhelmed and confused by her situation. If she is depressed, then she is also less able to make decisions to help herself. Malnourishment could also make her unable to think clearly or make decisions about her situation. She may not feel strong enough to get help. She may not feel that she is worthy of assistance.
You bring this mother into the clinic and want to do her antenatal check-up. She has turned away from you and won’t let you examine her. She keeps crying.
Be gentle and understanding. She is unable to speak the local language so try to get someone that she trusts to act as an interpreter. Try to explain what is happening and how the clinic works in simple language. Check that she understands before you examine her.
A young mother at your facility has come in with her new baby. It is a hot day and she is wearing a long-sleeved jersey over her dress. You remember her from when she gave birth as her partner seemed charming and was extremely attentive. You are surprised that she has not been back sooner for her postnatal check-up. The child looks well-cared for but wakes up and starts crying hungrily. The mother carefully covers herself up when feeding the baby. While she is waiting to see you, she takes a call on her cellphone. She seems agitated by the conversation and tells the person on the line that she is at home. She reassures the person she is speaking to that she would never leave without telling him and that, of course, she still loves him.
You ask the mother about her relationship with her partner. She starts crying and tells you that it is very difficult. She says that at times everything is fine, and then he starts finding fault in the things that she does. He comes home and says the house has not been cleaned properly and that his work shirts are not ironed. She tries hard to get everything done, but never seems to be good enough for him. He shouts at her, tells her she is useless and sometimes hits her. Then he is sorry, says he won’t do it again and everything is fine for a while. She keeps hoping that this time he will change and be the loving person that she once knew. She worries that she has nowhere else to go and that she is stupid and unable to earn money to support herself and the baby. He won’t let her see her cousins who live nearby.
The mother has been describing domestic abuse.
The ‘cycle of violence’.
A pregnant mother at your facility has brought her two children with her, and they look dirty and uncared for. The oldest child is not at school even though she is old enough. The mother is irritable and shouts at the children and warns them that she is going to beat them if they don’t behave. The children are playing quietly in the corner of the room. Your cousin is a neighbour of this woman, and she has told you that the husband is unemployed. He shouts and swears at his wife and the neighbours won’t talk to them.
You talk to the mother and she tells you that she does sometimes get out of control and hit her children.
You can say:
While you are talking, the older child comes over and you notice that she has bruises on her arms. Some of them look old and some are new. You realise that this may be a case of ongoing child abuse.
You are obliged to contact Social Services and report child abuse. The mother may feel unsure or even scared about Social Services getting involved in her life. She may fear that the children will be taken away. She may get aggressive or break down in tears – both are signs of fear.