Task-Shifting for Maternal Mental Health in LMICs: A Realist Review

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.