This study showed that mothers supported by pair-VHVs had a better mental health status than mothers supported by single-VHVs in a rural district of Lao PDR even after adjusting for potential confounding factors. This result supports the results of previous studies. For example, a study conducted in Japan reported that those who received continued support from nurses and midwives showed better mental health in the postpartum period [7]. Another study conducted in the USA demonstrated that social support such as that perceived from a partner, and family/friends was important to the physical and mental health of new mothers [8]. An Ethiopian study further showed that low social support including family support, support from a friendship network, and help from a spouse were independent predictors of postpartum depressive symptoms [9].
According to the results of this study, several types of support and information were significantly higher among mothers supported by pair-VHVs. In particular, it was very helpful for pregnant women when a VHV accompanied them to ANC visits in the area. Sato reported that one barrier for pregnant women to access health care facilities was “language difficulty,” since their ethnicity differed from that of the health workers in the area [16]. Most of the women in our study belonged to the Makong or Tree tribe and had not received formal education; therefore, conversation in Lao was difficult for them. The training of pair-VHVs to emphasize the importance of ANC and collaboration with health centers/hospital staff was a success. Especially in this study area, women in their mid-teens tend to marry men who live in villages far from their hometown, which means that they cannot easily ask for help from their own mother/family and often do not have friends in the neighborhood. They also tend not to have life and social skills because of their low level of education and young age. In addition, women find it difficult to ask for support from single-VHVs because most are male and engaged in various types of work in the area.
Furthermore, the results of this study showed that participants supported by pair-VHVs received a significantly higher level of support from their husbands and had a better relationship with their husbands than those supported by single-VHVs. A previous study showed that husband’s support was an important factor in improving the mental health status of mothers [8, 9]. As such, support from pair-VHVs influences not only the mental health status of mothers, but also improves the support received from their husbands and enhances their marital relationship.
Compared with other countries, the EPDS scores in this study were higher than those of research in Ethiopia (23.7% more than 7 total EPDS scores) and Nigeria (18.6% and 14.6% more than 8 total EPDS scores) [9, 23, 24]. In addition, the EPDS scores of mothers supported by single-VHVs were higher in Thailand (16.8% more than 9 total EPDS scores), Indonesia (22.4% more than 10 total EPDS scores), and India (11.9% more than 12 total EPDS scores) [25,26,27]. However, the results were lower than those of studies conducted in Pakistan (36% more than 11 total EPDS scores) [28].
This study was implemented in rural areas and used community-based data collection, similar to research in India and Pakistan [27, 28]. However, the studies in Ethiopia, Nigeria, Thailand, and Indonesia involved hospital or clinical based data collection [9, 23,24,25,26]. Thus, only mothers who had access to facility-based health services were targeted, which might have influenced their better EPDS scores compared to the participants in this study, especially the mothers supported by single-VHVs. These results may be influenced by the study setting and methodological differences, although the mental health status of participants, especially of mothers supported by single-VHVs, was relatively worse, even among other LMICs. Therefore, expanding the pair-VHV program is very important for ethnic minority women in remote rural areas in Lao PDR.
Limitations
This study highlights the need for a focus on ethnic minority mothers living in remote and rural villages in Lao PDR. However, this study has certain limitations. First, this was a cross-sectional posttest design study with nonequivalent groups. Absence of data before the introduction of pair-VHVs in the villages is a limitation. The difference between two groups in this study could therefore be attributed to selection differences at baseline. There is therefore the possibility that mothers supported by pair-VHVs possessed better mental health status before the project started.
Second, this study focused on the following factors: (1) biological characteristics, (2) economic status, and (3) social factors. However, other factors such as psychological, obstetric, and pediatric factors are also associated with postnatal depressive symptoms [29]. This information is difficult to collect in this study population. However, further clinical research will likely show improvements in postnatal depressive symptoms.
Finally, this study covers all villages where VHVs work as pairs. Comparative villages were selected where VHVs work alone in the same district. However, the participation rate was lower in villages where VHVs worked as pairs (64.2%) than in villages where they worked alone (91.3%). The number of targets for this analysis was only 34 in villages where VHVs work alone and 86 in villages where they work as pairs (29.6% and 45.3% of the total target population, respectively). This difference may have influenced the results of this study. Examining inter-interviewer differences is also necessary but was not possible in this study due to the limited numbers of participants. Despite these limitations, this study is valuable as it highlights the need for a focus on ethnic minority mothers living in remote and rural villages in Lao PDR where it is difficult to access essential and basic health services.