The silent mental health burden of motherhood

For Mary (not her real name), becoming a mother was accompanied by a darkness she could neither explain nor escape.

The 26-year-old gave birth to her first child prematurely at 25 weeks.

She had not even known she was pregnant during the first few months of the pregnancy.

When her son was born, motherhood became overwhelming. Mary developed postpartum depression, struggled to bond with her baby, and began hurting herself.

Four months after the child was born, she left home, leaving her son with her mother.

She says she was in denial and feared that remaining close to the child could put him at risk.

“I kept my distance from my son because I was in denial and afraid of what I might do. I thought leaving him with my mother was the best way to protect him. I did not understand what was happening to me or feel capable of coping with motherhood,” she recalls.

Her decision to leave home plunged her into another crisis.

She became homeless as she struggled with the trauma of having been raped.

At her lowest point in Nairobi, she contemplated ending her life by running into an oncoming train.

An elderly woman intervened and saved her, later tracing her family and helping her return home.

A friend eventually encouraged  Mary to seek counselling. She later registered for mental health support through the Maisha Mothers SMS platform, opening a door to professional help.

She had been separated from her son for about two years when she finally saw him again.

“I talked and slowly began understanding what I had gone through. After two years, I was able to see my child again. It was not easy after staying away for so long, but I knew I had to rebuild our relationship,” Mary says.

The recovery was gradual. Mary continued to experience trauma and persistent headaches and sometimes pinched her skin when overwhelmed.

After about two months of support through Maisha Mothers, however, she says she began to notice a change.

“After two months, I started seeing changes in myself. I was still dealing with the trauma and headaches, but I was beginning to understand my feelings and what had happened to me. Slowly, I started healing,” she says, with a measure of relief.

Today, Mary says she is a proud mother who loves her son.

For Carina Nthenya, another 26-year-old mother, the road to motherhood was also shaped by trauma.

An actress and nursing student, Carina is raising her four-year-old son.

She says she became involved with a boyfriend of her friend. Three weeks later, she discovered that she was pregnant.

The man, a boda boda rider, acknowledged the pregnancy, and the two eventually married.

But the marriage became difficult.

Carina says her husband was unfaithful, and the relationship eventually collapsed, leaving her to raise their child.

“My life became very difficult after the marriage failed. I was left with the responsibility of taking care of my child, yet I did not have a job and his father was not supporting us,” she says.

Without employment and with little financial support from the child's father, she struggled to provide for her son. She eventually developed depression.

“I was trying to provide for my son while dealing with everything that had happened to me. There was the trauma, the failed marriage, and the responsibility of raising my child, and eventually I became depressed.”

Carina was eventually connected to Maisha Mothers, where she received support.

Her experience, alongside Mary's, points to a wider challenge in maternal healthcare: reaching a woman through a health service does not necessarily mean understanding the circumstances affecting her wellbeing.

A woman may attend antenatal care, deliver in a hospital and return for postnatal services while dealing with violence, loneliness, grief or depression outside the facility.

This is the gap that Pathways segmentation, an approach led by Sonder Collective, is seeking to expose.

Traditional health data largely measures whether women access services.

While such indicators are important, they provide limited information about the social and behavioural circumstances shaping a woman's health outside the health facility.

Sarah Hassanen of Sonder Collective says this can result in women with apparently good access to healthcare being classified as less vulnerable.

Hassanen notes that conventional health data usually shows clinic access and service use, such as ANC attendance and institutional delivery.

“There could be occasional depression scores at times. But if the woman has good or moderate health system access, then she is usually considered less vulnerable,” she says.

She continues: “It only captures vulnerability for the women who reach the clinics. Their home environment is often overlooked when assessing vulnerability.”

Pathways therefore examines a wider range of information, including household structure, employment status, mobility, social connectedness, decision-making power, intimate partner violence history and how women engage with health services.

“Pathways works differently by capturing demographic and behavioural data, including household structure, employment status, mobility patterns, social connectedness, IPV history, and contact and engagement behaviour,” Hassanen says.

“This covers every aspect of the woman's life, from her family and her relationship with her partner to her engagement with the community.”

The findings also challenge assumptions that education, employment and independence automatically correspond with lower vulnerability.

The data found that intimate partner violence can affect single women who are educated, employed and able to make decisions independently.

Hassanen says segmentation helped the team understand these differences.

“It helped us see urban and rural women as different segments with unique needs and barriers, including factors invisible to a health system focused on clinical indicators rather than women’s social networks and life experiences,” Hassanen notes.

One group emerged as particularly important for Maisha Mothers.

Known as U2.2, it consists largely of urban, unpartnered women who head their own households. Many are employed, mobile and able to make decisions independently.

On conventional health indicators, the group appears relatively well served. About 97 per cent deliver in health facilities, while about 90 per cent receive postnatal care.

However, more than 40 per cent have experienced emotional violence in previous relationships, while more than a third have experienced physical violence. About 90 per cent receive no formal social assistance.

The group became a priority for Maisha Mothers because women fitting the profile were already showing interest in mental health services.

Although they were enrolling in the programme, retention was lower than expected.

The team therefore began examining whether the intervention fitted the realities of the women's lives.

Pathways also cautions against transferring an urban intervention directly to rural communities.

Another segment identified highly vulnerable rural mothers.

Only about 26 per cent have any formal education, barely one in five makes her own health decisions, while about half may require a partner's permission before seeking healthcare.

For such women, a phone-based intervention can be difficult to access if they do not control the phone, their movements or decisions about seeking treatment.

The World Health Organization estimates that one in four people will experience a mental health condition at some point in their lifetime.

For Shirley Liya, motherhood brought a weight she had not anticipated.

The woman in her early 20s, a single mother from Hamisi Constituency in Vihiga, says the pressures of raising her nine-month-old baby alone left her mentally and emotionally drained.

“Even small things, like not having enough diapers, can make life feel unbearable. When evening comes and you realise your baby has nothing, your stress levels rise. You feel like you have failed your child,” she says.

The constant financial and emotional strain eventually pushed Liya to seek help through a local maternal mental wellness programme, where she underwent a mental health assessment and counselling.

The assessment showed that she was experiencing high levels of stress. She was enrolled in therapy and also received essential household items, support she says helped ease some of the pressure.

“I went through a mental health assessment, and it showed I was under high stress. I started therapy and received some essential household items, which helped me cope,” she says.

For Liya, seeking help marked an important step in confronting the emotional toll of motherhood and finding ways to cope with the pressures of raising her child alone.

Martha Kagoya, a clinical psychologist, says the segmentation changed the questions the team was asking.

“We started asking different questions. Who does the mother live with? Who does she talk to when things are difficult? What has happened in her relationships? When is she actually free to receive support?” she says.

For an employed single mother, attending a conventional clinic appointment can be difficult even when she wants help.

Maisha Mothers responded by changing aspects of its intervention.

Instead of relying solely on the traditional therapist-client relationship, the programme introduced peer support, with community health promoters facilitating groups.

The CHPs were selected partly because of their own lived experiences, including single motherhood.

Kagoya says professional care remains essential, but peer support can help women remain connected to treatment.

“Clinical support remains essential, but another mother can sometimes create the trust that helps a woman open up, stay engaged and receive professional support,” she says.

The programme also adapted its delivery model for women with demanding schedules.

Peer sessions were offered through WhatsApp, with mothers able to participate through individual support, smaller groups or larger peer sessions.

Discussions focused on issues identified through Pathways, including relationship strain, isolation, grief, antenatal anxiety and postnatal depression.

One facilitator described the women as having “arrived already holding the same questions.”

“Mothers could choose individual, small-group or large-group peer sessions, giving them flexibility to fit support into their busy schedules while fostering a sense of community,” she says.

The high prevalence of intimate partner violence among women in U2.2 also meant that communication had to be handled carefully.

The programme introduced safe messaging procedures, careful timing of communication and agreed check words where necessary.

The objective was to ensure that seeking help did not expose a woman to additional danger.

The pilot recorded no privacy breaches across 12 care follow-ups, with no escalation required.

Early feedback was encouraging.

Fifty-seven mothers tested the model, all indicated that they wanted to return, while 89 per cent said the approach fitted their needs.

The findings are still early, but they provide an indication that adapting services to women's circumstances can improve engagement.

Mercy Mwende, Chief Operating Officer at Thalia Psychotherapy, says expanding services should not mean giving every woman the same intervention.

“The mistake would be thinking that scale means giving everybody the same thing,” she says.

For Thalia, the focus is now on whether the support offered is appropriate for the woman receiving it.

“The question we are now concentrating on is what makes the woman stay. Does the intervention fit her life? Does she trust it? Does she feel understood? Can we identify what she needs early enough to stop the problem becoming more serious?”

Mwende says mental health should be integrated into the healthcare services women already use rather than creating a completely separate system.

“If a woman is already coming to a health facility during pregnancy, that is an opportunity to recognise when she is struggling and connect her with support without asking her to search for another system,” she says.