The Knowledge SUCCESS team recently spoke with Linos Muhvu, Secretary and Chief Talent Team Leader at the Society for Pre and Post Natal Services (SPANS) in the Goromonzi District of Zimbabwe, about the links between mental health and family planning and reproductive health. The devastation that COVID-19 has caused around the world—deaths, economic collapse, and long-term isolation—has exacerbated the mental health struggles people faced even before the pandemic struck. Women’s mental well-being in particular has been affected by rising rates of gender-based violence and reduced access to family planning services during lockdowns. In turn, increased anxiety and depression brought on by pandemic-induced stressors can negatively impact contraceptive continuation and self-care more generally.
Linos speaks about SPANS’ approach of integrating mental health and family planning through family therapy. “If you talk about family planning,” Linos says, “it’s a family issue.” We also discuss contraceptive choice, self-care and traditional mental health care, stigma related to mental health, and the upcoming conference hosted by SPANS called the International Conference on Maternal Mental Health in Africa (ICMMHA).
Linos reminds us that mental health services should be a component of a holistic package of family planning care and how crucial these services are for better reproductive health outcomes.
Reana Thomas: Hi everybody! We are so excited to be speaking with Linos Muhvu from the Society for Pre and Post Natal Services, or SPANS. He is going to be speaking to us about mental health and family planning. I am Reana Thomas, a technical officer at FHI 360, currently in Durham, North Carolina in the US.
Linos Muhvu: I am Linos Muhvu, in Zimbabwe. We are based at Ruwa Clinic in Goromonzi District, 21 kilometers along Mutare Road. I work with an organization called Society for Pre and Post Natal services as the Secretary and the Chief Talent Team Leader.
Linos: Looking at just the definition of what is mental health, it’s so inspiring to know that mental health is very key to the extent that an individual can then be able to contribute to herself or himself. An individual can be able to contribute to this society, to the family around him. Any individual can contribute to the world just because of having sound mental health.
“So that, alone from that the whole definition, it will put more promoted as to say we need to increase our voices to advocate for sound mental health for everyone—not only in Zimbabwe, but around the world.”
Linos: Let me start by making this very clear: I know people they miss, or they use these words interchangeably. Some, they take “methods in contraceptives” as a way of family planning. But from my personal understanding, if you talk of family planning, it’s a family issue, whereby a wife and a husband—possibly including other significant family members, they sit down as a family. And they agree in terms of how many children they want to do.
So considering family disputes and the need for mental health, and also based on science now that is telling us, “from the womb to the world”—meaning to say children can also suffer from mental health disorders—that a mother or a family they are exposed to and they can also suffer mental health disorders outside in the environment when the child is now born, and is interacting with the entire environment. So looking at that, if this is family planning, we are talking of people that agreeing on, on one of the number of children they want to do and looking at disputes, violence—all those issues which are happening within the family:
“We say we need to promote sound mental health for the mother, the father, and the child.”
So to me, that’s how now family planning comes in to make sure that we need a sound mental health child, a sound mental health mother, a sound mental health father: The entire family.
Linos: Yeah, looking at our context, starting from myself: I want to agree that I need sound mental health, but due to our challenges within the families, my own family and the entire clan of Muhvu’s family—a lot of issues, social issues, social problems that affect us as a family emotionally, psychologically. And it happened not by negligence or not by knowing, but it’s the virtue of our current situation where, you […] find space, wherever you can, you can share these social problems that affect individuals that also affect somebody’s sound mental health. So looking at that, looking at mental health disorders, starting from the distress, which you know, we see there’s not much attention. Post traumatic disorders, mild and moderate depression and anxiety—they’re very common, to each individual, and all these, they affect somebody’s sound mental health.
So you found out this way, like they are for years, except for severe mental health issues where we can get the psychiatric centers where government is investing much in that, and other rehabilitation centers where people who went through psychiatric evaluation—and maybe taken at that stage, they can go for the rehabilitation centers. But this bigger chunk of people that are suffering distress, mild and moderate, for sure, such issues that are very common prior to COVID-19, and this is more like an extension.
Linos: Let me say—let me respond to this question this way: Now women that come [to the clinic] for contraceptive method—being it the natural, the loop [IUD], we name it—you find out the challenges. There are women who just come because they just want to enjoy themselves sexually. There’s nothing to do with … like they don’t want to plan for any family, but they want to plan so that they don’t get pregnant. But now also the housewives come for these contraceptive methods. So the challenge is, within the family, there are conflicts that people should face. We agree to say, if we are to talk of family planning, it’s a family matter. They should sit down and agree in terms of how many children, how best they can space their children. So that at the end of the day, they help them to decide “Which contraceptive method are we going to take so that we don’t have unwanted pregnancy?”
So looking at the type of the women that we are talking about, for those that they want to enjoy themselves, you find out they don’t have much issues, but if they will, then they come [to the clinic] when something unfortunate—maybe they’re using condoms, or they’re using a loop—any other side effects that they may come across, they are most likely to be honest, because it’s their own business. But for those that are married and the unfortunate, if a wife decides on her own just to come and say, “Now, I want to be, like, on this method of con–being it a loop or whatever, without maybe telling a partner—a lot of it causes family disputes. And that disadvantages a very good service, especially in terms of care and utilization.
And those families—definitely they affect individuals’ mental health, in the ways of if somebody experienced some side effects and you imagine it, does not tell her husband, there will be a lot of problems like domestic violence, extramarital affairs. If you may imagine if women is a continuously bleeding [because she is using contraception discreetly without her husband knowing] and possibly the husband might need, if you know some sexual activities on a daily basis and a woman is bleeding on a daily basis—let’s take that scenario that causes a lot of infidelity within families. And as a result now, in terms of service, instead of the service now that has been provided, which is very good, it has to be, no, it becomes a problem.
So let’s take now those that are married under the age of 18 years, adolescents in fact. You see they need multiple services, which most of them, they are not receiving. They need social support; they need to go back to school. There are a lot of issues. They need to take care of their children. It definitely, they need to prevent themselves from unwanted pregnancy. And having that big pile of problems, definitely that will then affect them mentally. And they need care more than anyone else, particularly to make sure that they’re emotionally sound, they’re psychologically sound, so that they are able then to fulfill, to achieve their full potential.
Linos: Being an organization which is focusing on promoting sound mental health: We use our family therapy approach where we see them as a family, and explore now using that contraceptive method, chat, and also to accept whatever solution—whether being taken by a wife with a husband, or particularly if the wife maybe decided to just get into this contraceptive method without telling [her partner. So we try to sit down them, provide family therapy.
Linos: Okay, the family approach: I’m saying we are not going to look at an individual in isolation. That’s number one. And also we believe that when a family dispute happened, or whatever issue or whatever challenge that affect the family—it won’t affect the individual alone. It goes to the children and many other extended families—being families by choice, being families by extended, nuclear, whatever child-added family—whatever the way you want to define the family in this conversation. But what we believe is, the family approach, it also looks at the broader. Individuals who have been affected by the problem at hand. So that’s why we say family therapy fits very well because one, it does not look at an individual as the person who suffers and we don’t want to listen on a single story. It’s good to also hear this side of the story.
Plus, imagine, everyone wants to be, not to be, like, wrong, but want to be good. So the wife may come and start to complain about the husband, and not even notice some unique outcomes or some good part of being in a relationship. And the communication is not one way, it’s two-way. If there’s a family, what’s your contribution? What do you—what are your contributors for that conflict to happen? So that’s why we say family approach fits very well in addressing family issues or family dispute, being it domestic-violent, being it conflicts. That’s why we adopted the family thinking, or the family lens.
Reana: You made such an important point that nothing ever happens alone. There’s always somebody else, or some societal factors–some other influence or effect happening around us all the time.
Linos: Yeah, to be honest, we still have a lot to do because this stigma—does not come, like, just because people, they just want to. But the problem is, there is a lack of that understanding. People—what they know is mental illnesses. They don’t know what is mental health. So, we started the program to educate the women during their routine antenatal and postnatal care. So, most women, now they started now to appreciate the need for mental health care. Was most women, they thought if you are saying “mental health,” even if you ask them to define right now, They will tell you, “It’s more to do with those that are ‘Medi’ [i.e., have mental illnesses],” but if in actual terms—if you know very well, in that first definition, getting it from the whole “What is mentally ill?” We are saying you’re able to make informed choices. It means you put the sound mental health.
We are able to productively contribute to the society, to yourself, and to the world. So the challenge is the stigma is brought by the lack of information and education. So therefore we are saying the first voice that came before us, or it is maybe just because of negligence. People, they don’t want to learn more, or people are much concerned about the physical aspect, considering the, all the, what has been put in place with the system to say people, they just come for the physical issues, but not for mental health issues. Primarily not the severity was what people they know are psychiatric units and halfway homes, but not just to say no, I’m not, I’m strained—I need somebody to talk to, to promote my sound mental health … to maintain my sound mental health. Such infrastructure is not in place, but since we started to integrate now mental health into primary health care, and focusing on putting infrastructure. Now most people are celebrating in some, they are very, they’re open up now to say no, as much as we are using this language with this in certain language, which women they use to define that they’re in depression, they’re in anxiety. And I found out, 80% of women that we meet, they need our services.
Linos: Okay. One thing good about these contraceptive methods: I think we can now try to expand our clientele. Then for those possibly with mild and moderate mental health issues that affect everyone, definitely those, they are able to make their own choices—and look at the adolescents that are also benefiting a lot from these contraceptive methods.
So yes, as an organization, I think, as I mentioned, this is our area of focus and we definitely want to make sure that whichever client that I’m talking about, they are mentally sound and they recognize the importance of these contraceptive methods at a given stage.
Of course we have now the “Sisters With a Voice”—some they call, some call them “sex commercial workers”, but because of changes, they are now called “Sisters with a Voice”—and possibly we can extend, the good part of these contraceptive methods, but some, of course, like a condom. It’s very good to prevent the transmission of HIV, sexually transmitted diseases.
And what about for those that are practicing homosexuality? Transgender? Even this clientele becomes broader now, with a lot of benefit. So I think we need then to broaden our thinking as we are looking at our clientele and considering for each client, they will, the benefits associated with that. Let’s look at those that are transgender—they definitely need that. And what we can do is we can then try them to understand. So that, of course they may affect it somehow, but they can understand the benefits associated with that. Whereas they have good sound mental health, and also run away from issues of stigma and discrimination. For the Sisters with a Voice, the same thing—they are in business, they should take the condom as well, so that they prevent unwanted pregnancy, transmission of HIV, and other sexually transmitted infections.
So it becomes more like a holistic package of contraceptive methods.
Linos: Yeah, of course. We are saying it’s challenging, yes—but pushed by passion, everything becomes very easy. You’re more like “I want to go and do more,” because it is because of passion. And of course, yes … definitely, we need funding, to make sure that our day-to-day activities they call is pay our plan [that is, that SPANS’ plans are covered financially].
So our biggest challenge is now to get networking now with organizations or individuals to where the resources are. I think this is some of such great opportunity that will help us to get networked and get linked to where the resources are. So I think the big challenge of course becomes funding.
Linos: The nature of the activities that we are doing and also the relationship, it helps us a lot. I think the big advantage that we have is a signed memorandum of understanding with our Ministry of Health in childcare, so that we complement them within their national strategy.
To work with them using their already existing system to save more from the province, from the national province to the district. So within that system, you find that also other interested partner, like the local authorities, they also complement the government through their own clinics. So we being a partner, we also partner with them so that we access, like the, the land that we access to put this infrastructure that we are currently using. And many the organizations that are also into international family planning programs, since we are also dealing with the clientele who are within the reproductive age.
Linos: What we do is during them … we meet with those that are within the reproductive [services], or possibly they come for their antenatal or their routine [exam]. So during the mental health education that we do, that’s the way we talk about these family planning advantages. Then definitely, we then network with the service providers who are providing such services. We want to make sure that it’s done properly so that the contraceptive family planning methods, they benefited a lot from them. So the idea is we want to increase the care utilization, other than having these conflicts. So we want to bridge that gap to make sure that there’s proper care utilization.
Linos: Yeah. Thank you so much, Reana, for mentioning a very key word. Let’s look at the traditional, I believe like in the Zimbabwe context, we believe in a collective care or community care—all those issues that we receive as an organization, we are sure that they’ve been once discussed within the family. It was this way they got a lot of social support. So, looking at our context, you found out most people, they believe in the community or the collective care way. They say, they need somebody to help them, move out of a situation which is troubling them. Yes of course, some now they also adopted the self care where they can listen to the TV, walking, honey, there are quite a number of individual activities, which they take, to make sure that they promote their sound mental health. But most of them wellness, they know, like look for the support system. Some they go to church to say, guys, look, this is the problem that I have. Some of them go to brothers and sisters. This is exactly how things, they are in my context.
Linos: Let’s talk of globally—and particularly for the developed world. Being in a developing world or country, like Zimbabwe—that [digital tools] would be very good, but we are limited to these tele-health being either WhatsApp or SMS. Most people, they have smartphones. So if you had to talk of the digital aspect, we need them to zero down to WhatsApp messages and definitely SMS. Was, I know the data bundles, yeah, most people, they find it very challenging and also the issue of confidentiality. They also find it, it challenges as well. And with people to say when to go online. Yeah. It’s still a big challenge, particularly for Africa.
I facilitated on a webinar on this topic and I picked a lot of issues. Where, some, they tried to implement to go online, but they find it very difficult. Like in Malawi there’s no reliable internet connections—they were saying for them, definitely is out if we want to do online, but if you have to use SMS, you just go to the service providers, you agree to say how many you are going to post per day, and also if they’re approved, the type of illnesses that we are going to use. So yes, it’s a process, but when we are in need and we are behind it, we want to embrace it.
Linos: From, even if you look at, from our discussion, the integration of mental health services is very, very, very key. Even if, look at the clientele that I mentioned, you see, I think that will be something that I think it’s really linking to those that are providing family planning care services to say, of course they are, they are giving the service, but they forget that the clientele has got some issues that they’re also facing that affect them mentally, and and as a result that can also affect the service utilization.
Linos: We’re privileged to be the host of the International Conference on Maternal and Mental Health in Africa. It’s going to be a virtual one, is online, is going to be held from 25 to 27 in May, 2021. So we want to increase the awareness, want also to consolidate the gains, want also to increase the collaboration, the network around promoting paternal, maternal, and child mental health in Africa. So this is the biggest African central conference ever—of course we hosted the first one in 2016, so this one’s going to be the second. So, this is such a great opportunity, particularly for Africans to put together all the indigenous knowledge system that I was talking about to promote maternal, paternal, and child mental health issues. So this is actually a great opportunity not to miss, to come and learn what is happening.
Linos: Yeah. Let me say, this is such a very good opportunity for, starting to think about integrating mental health in family planning care services—its importance. Okay. Just looking at our discussion for sure, personally, and what we experience on a daily basis. I think this is such a missing link that we definitely want to make sure that we embrace and we also, like, accept. To integrate mental health. And that is going to bring good outcomes at the end of the day, particularly for the services that we provide, and taking clients from that different angles to see if we are to provide a contraceptive method, particularly for those that are in business—what are their issues? There’s a lot of conflicts that have been in their business, and they will be affected mentally. Imagine they’re also a lot of, some, some gaps there, depending on which one can they also be encouraged to take them both. Possibly being with the loop, whatever which contraceptive, and also a condom, so that they also limited the transmission of HIV among other sexual transmitted diseases.
And for those that are in families, what can we do for them? So definitely by looking at them in concert and the factor in the mental health aspect, that surely is going to help for service uptake. Especially for those that are in promotion of family planning,