Conceptualising maternal mental health in rural Ghana: A realist qualitative analysis.

In low-and-middle income countries, maternal mental health needs remain neglected, and common mental disorders during pregnancy and after birth are routinely associated with hormonal changes. The psycho-social, and spiritual components of childbirth are often downplayed. A qualitative study was conducted as part of a wider realist evaluation on health systems responsiveness to examine the interrelationships between pregnant and postnatal women, their families, and their environment, and how these influence women's interactions with healthcare providers in Ghana. Data collection methods combined six qualitative interviews (n= 6) and 18 focus group discussions (n= 121) with pregnant and postnatal women, their relatives and health care providers (midwives, community mental health nurses) at the primary healthcare level. Data analysis was based on the Context-Mechanism-Outcome heuristic of realist evaluation methodology. A programme theory was developed and iteratively refined, drawing on Crowther's ecology of birth theory to unpack how context shapes women's interactions with public and alternative health care providers. We found that context interacts dynamically with embodiment, relationality, temporality, spatiality, and mystery of childbirth experiences, which in turn influence women's wellbeing in three primary areas. There is an intricate intersection of pregnancy with mental health impacting women's expectations of temporality, which does not always coincide with the timings provided by formal healthcare services. Societal deficiencies in social support structures for women facing economic challenges become particularly evident during the pregnancy and postnatal period, where women need heightened assistance. Socio-cultural beliefs associated with the mystery of childbirth, support the role of private providers in offering women a feeling of protection from uncertainty. Co-production of context specific interventions, including the integration of maternal and mental health policies, with relevant stakeholders can help formal healthcare providers accommodate women's perspectives on spirituality and mental health, which can subsequently help to make health system responsive to maternal mental health conditions.