Task-Shifting for Maternal Mental Health in LMICs: A Realist Review
Abstract
Background: In low- and middle-income countries (LMICs), task-shared maternal mental health (MMH) interventions led by community health workers (CHWs) have shown promise in expanding psychosocial support access and care. Yet, less is known about how these interventions achieve their intended therapeutic outcomes. This review used realist synthesis to understand how task-shared MMH interventions work and for whom, and develop a programme theory to inform task-shared MMH intervention development and adaptation across diverse contexts.
Methods: A realist review was conducted following RAMESES guidelines to examine task-shared, psychosocial MMH interventions delivered to pregnant and postpartum women in LMICs. Searches were conducted across various databases and grey literature sources. Data extraction identified context-specific characteristics, implementation processes, and reported outcomes. Evidence was synthesised into context-mechanism-outcome configurations (CMOCs).
Results: 32 articles yielded 74 CMOCs, organised into 6 groupings spanning the intervention lifecycle. Institutional embedding and cultural resonance built legitimacy and acceptability. Training and incentive structures sustained delivery-agent quality, through engagement carried emotional costs. Household gatekeeping and stigma shaped whether legitimacy translated into participation, while social support mobilisation emerged as a core mechanism mediating symptoms improvement. And, structural adversity capped achievable benefit regardless of delivery quality.
Conclusions: CMOCs generated a programme theory in which legitimacy, workforce sustainability, household context, and engagement quality jointly determine whether interventions activate therapeutic mechanisms, bounded by structural adversity. This theory offers practical guidance for adapting task-shared MMH programmes across diverse contexts–supporting more sustainable, context-responsive integration of CHWs into global MMH systems.
Key messages: • Identifies how task-shared maternal mental health interventions work and for whom, with identified themes including culturally-resonant design, structured workforce preparation, and relational trust.
• Proposes a programme theory to inform task-shared, equity-driven maternal mental health intervention development and adaptation across diverse contexts worldwide.
Related
- Maternal mental health and its intergenerational transmission in-utero: a scoping review.
- Heat, maternal health, and community action: a realist study in Senegal
- Association between personal birth companion and maternal mental health in low- and middle-income countries: a systematic review
- Short courses on maternal mental health provided by healthcare providers in low- and middle-income countries: a scoping review.
- A realist synthesis of evidence on the effectiveness of interventions to prevent mental health problems in children and parents living in poverty
BibTeX
@article{elkhatib2026taskshifting,
title = {{Task-Shifting for Maternal Mental Health in LMICs: A Realist Review}},
author = {YN El-Khatib and S Nagraj and UA Ezeokoye and M Etuokwu},
journal = {The European Journal of Public Health},
year = {2026},
month = oct,
doi = {10.1093/eurpub/ckag169.1581},
url = {https://doi.org/10.1093/eurpub/ckag169.1581},
note = {CC BY-NC 4.0},
}
RIS
TY - JOUR
TI - Task-Shifting for Maternal Mental Health in LMICs: A Realist Review
AU - YN El-Khatib
AU - S Nagraj
AU - UA Ezeokoye
AU - M Etuokwu
PY - 2026
DA - 2026/10/01
JO - The European Journal of Public Health
DO - 10.1093/eurpub/ckag169.1581
UR - https://doi.org/10.1093/eurpub/ckag169.1581
AB - Background: In low- and middle-income countries (LMICs), task-shared maternal mental health (MMH) interventions led by community health workers (CHWs) have shown promise in expanding psychosocial support access and care. Yet, less is known about how these interventions achieve their intended therapeutic outcomes. This review used realist synthesis to understand how task-shared MMH interventions work and for whom, and develop a programme theory to inform task-shared MMH intervention development and adaptation across diverse contexts. Methods: A realist review was conducted following RAMESES guidelines to examine task-shared, psychosocial MMH interventions delivered to pregnant and postpartum women in LMICs. Searches were conducted across various databases and grey literature sources. Data extraction identified context-specific characteristics, implementation processes, and reported outcomes. Evidence was synthesised into context-mechanism-outcome configurations (CMOCs). Results: 32 articles yielded 74 CMOCs, organised into 6 groupings spanning the intervention lifecycle. Institutional embedding and cultural resonance built legitimacy and acceptability. Training and incentive structures sustained delivery-agent quality, through engagement carried emotional costs. Household gatekeeping and stigma shaped whether legitimacy translated into participation, while social support mobilisation emerged as a core mechanism mediating symptoms improvement. And, structural adversity capped achievable benefit regardless of delivery quality. Conclusions: CMOCs generated a programme theory in which legitimacy, workforce sustainability, household context, and engagement quality jointly determine whether interventions activate therapeutic mechanisms, bounded by structural adversity. This theory offers practical guidance for adapting task-shared MMH programmes across diverse contexts–supporting more sustainable, context-responsive integration of CHWs into global MMH systems. Key messages: • Identifies how task-shared maternal mental health interventions work and for whom, with identified themes including culturally-resonant design, structured workforce preparation, and relational trust. • Proposes a programme theory to inform task-shared, equity-driven maternal mental health intervention development and adaptation across diverse contexts worldwide.
SN - 1101-1262
SN - 1464-360X
ER -