Psychosocial support for pregnant women and forfamilies with microcephaly and other neurologicalcomplications in the context of Zika virus
Interim guidance for health-care providers

WHO/ZIKV/MOC/16.6
Cover image: WHO/K. Reidy
Editorial and writing team: Mark van Ommeren, Edith van‘t Hof, Chiara Servili, Tarun Dua and Shekhar
Saxena (WHO Department of Mental Health and Substance Abuse, Geneva) and Devora Kestel (WHORegional Office of the Americas, Washington)
Peer reviewers: Marcio Gagliato (School of Public Health, University of São Paulo), Sarah Harrison (IASC
Reference Group on Mental Health and Psychosocial Support), Carmen Martínez (MSF Spain), Camila
Perera (IFRC), Atif Rahman (University of Liverpool & Human Development Research Foundation, Pakistan);
Panu Saaristo (IFRC health), Alison Schafer (World Vision International), Yutaro Setoya (WHO Division ofPacific Technical Support, Fiji), Saji Thomas (UNICEF), Lina Villa (IFRC), Louise Vinther-Larsen (IFRC), andNana Wiedermann (IFRC).
For feedback about this document, please contact the following WHO staff:
 Mental health and psychosocial support in emergencies: Mark van Ommeren (vanommerenm@who.int)
 Neurological conditions: Tarun Dua (duat@who.int)
 Developmental disorders: Chiara Servili (servilic@who.int)© World Health Organization 2016
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Contents
Introduction ..................................................................................................................................................... 4
1. Accurate Information ................................................................................................................................ 5
2. Conveying health information ................................................................................................................. 6
3. Supportive communication ...................................................................................................................... 7
4. Common reactions .................................................................................................................................... 9
5. Basic psychosocial support ..................................................................................................................... 10
6. Strengthening social support .................................................................................................................. 11
7. Stress reduction ......................................................................................................................................... 12
8. Advice on parenting................................................................................................................................ 15
References .................................................................................................................................................... 18│3

Introduction
On 1 February 2016 WHO announced that a cluster of microcephaly (1) and other neurologic disorders
reported in Brazil is a Public Health Emergency of International Concern. Several countries have reported anincrease in the incidence of cases of microcephaly and/or Guillain-Barré syndrome (GBS) (2) concurrent
with Zika virus outbreak (3). A causal relationship between Zika infection during pregnancy andmicrocephaly is strongly suspected, though not scientifically proven (4).
This document describes guidance for a supportive response by healthcare providers (e.g. physicians,
nurses), focusing primarily on women affected by Zika virus infection during pregnancy and their families, fortheir mental health and psychosocial needs.
Healthcare workers need to collaborate with colleagues in other sectors (e.g. social work, education) for acoordinated mental health and psychosocial response.
This guidance for healthcare providers suggests strategies that can be helpful when consulting with thefollowing groups of women and their families:Pregnant women with suspected or confirmed Zika virus infection
Pregnant women who know they carry a child with suspected microcephaly
Caregivers and families of an infant with microcephaly

When caring for pregnant women, it is important to involve trusted people who can support them. Thesemay be the woman’s partner, her friends or family members. Bear in mind that these people may need
psychosocial support as well.

Psychosocial support for other neurological conditions
Although this document is focused on microcephaly, many of the described supports (e.g.,
providing accurate information, supportive communication, providing basic psychosocial
support, strengthening social supports, managing concurrent mental disorders) also apply to otherneurological conditions - such as Guillain-Barré syndrome - that may be potentially associatedwith Zika virus.

4│1. Accurate Information
All healthcare providers need accurate information when providing support to womenwith Zika virus infection during pregnancy
Providing accurate information about a largely unknown communicable disease and its suspected effects
is important not only for public health reasons (5) but also because it can reduce anxiety in people andtheir communities. However, different agencies and different media channels often provide informationthat may be inconsistent or contradictory. Unverified but plausible-sounding rumours communicatedthrough social media can cause serious distress. New information about the Zika virus and its effects on
pregnant women, fetuses and infants, and GBS and other neurological complications will become
available over time. It is important you keep yourself updated on this information at all times.
You should also know about other services available to women and families affected by Zika virus infection
during pregnancy and/or microcephaly. These may include antenatal and postnatal home visits for womenwith special needs, health services for assessment of an infant with microcephaly and management ofneurodevelopmental disorders, hearing and visual impairment, psychological interventions, women’s
support groups, parent and community support groups, community-based rehabilitation services and socialand educational services for children with disabilities. You should also be aware of any services available for
persons with GBS and their families.



Be up to date with the latest scientific information on the Zika virus and its potential
consequences.



Be aware of the latest guidance on assessment and management of Zika virus and its
potential consequences.



Get acquainted with available services and support / referral systems for people and theirfamilies affected by Zika virus infection during pregnancy and/or microcephaly.

│52. Conveying health information
Health information should be conveyed in a manner that considers people’s well-being
The diagnosis and management of microcephaly and other neurological disorders are immediate concerns
for healthcare providers. The way a healthcare provider assesses and manages these health conditions
can have an impact on the psychosocial well-being of patients and their families. As stigma is a concern, it
is important to ensure confidentiality of any information and care provided. The steps below should beconsidered for protecting and promoting psychosocial well-being in the context of regular physical healthcare of Zika infection in women during pregnancy and/or microcephaly. Where possible, invite a trusted
partner or family member to attend the session. This will help them to learn about the relevant healthcondition and is an opportunity to encourage them to be supportive. It is important to allocate sufficient
time within healthcare sessions to properly implement the steps below.
Provide accurate and understandable information (see Section 1 on accurate information) on allassessments and investigations before they occur and on the results of those tests.



Ask the person about what they know about Zika and/or microcephaly or other neurologicalcomplications. Take the time to listen to the person’s and their partner’s/family members’ reactions(thoughts, feelings) to the results.



Educate the person on what you know about the prognosis of Zika and/or microcephaly or otherneurological complications.
-

It is important to emphasize that many babies with microcephaly do not develop developmental
disorders or other severe neurological complications.



Check with the person to see if they have understood test results and their implications. Ask them tosummarize their understanding of what you have conveyed. Correct gently if there is any
misunderstanding.



Throughout the care, encourage the person and their family members to take notes and to return tothe clinic if they have further questions.



Explain the need for regular follow-up care to monitor neurodevelopment and assess for possible
complications.



Share information about, and refer people to, relevant services to address social, psychological andphysical health needs, as appropriate.



Educate about appropriate measures to control spread of the virus (such as male and female
condoms, mosquito repellent safe for use during pregnancy, and insecticide treated bednets).



Before ending each session, restate and confirm what the next action step is for the person, such asattending another appointment or contacting a service.

6│

Encourage women to involve and invite a trusted person (partner, friend, family member, orfriend) to the session or to any follow-up sessions.



Ensure confidentiality of any care provided.

Emphasize that many babies with microcephaly do not develop developmental disorders orother severe neurological complications.

3. Supportive communication
The way you communicate with women and families affected by Zika virus and/or
microcephaly or other neurological complications is very important.
They may be confused or feel upset, anxious or angry (see section 4 on psychological reactions). You should
try to use simple language, and avoid technical terms to ensure that they understand the information you
give them.
Being calm and showing understanding can help people in distress feel more understood, respected, cared
for appropriately, and empowered to make informed decisions and plans. However, some healthcare
providers lose their good communication skills when they are with someone who is acutely distressed. Healthcare providers may not communicate well when under the pressure of time or overworked. This is especiallycommon during epidemics.
Listening to someone can be a great support. It is, however, important not to pressure anyone to share theirstory with you. Some people may not want to speak about their circumstances. However, they may value it
if you stay with them quietly; let them know that you are there when they want to talk. Don’t talk too much,allow for silence. Keeping silent for a while may give the person space and encourage them to share withyou if they wish. In Box 1 you can find suggestions for things to say and do, and what not to say and do.
Most importantly, be yourself, be genuine and be sincere in offering your help and care.

│7

Box 1. Do’s and don’ts of supportive communication (adapted from WHO et al, 10)
DO’S

DON’TS Try to find a quiet place to talk, and minimize
outside distractions.
 Provide actual information, if you have it. Be
honest about things you know and don`t know.
“I do not know, but I will try to find out aboutthat for you and will let you know as new
information on this becomes available.” Let them know you are listening; for example,
nod your head or say: “hmmmm…..”
 Be patient and calm.
 Give information in a way that people canunderstand- keep it simple.
 Respect people`s right to make their own
decisions.
 Be aware of and set aside your own biases andprejudices.
 Make it clear to people that even if they refuse
help now, they can still access help in the
future.
 Respect privacy and keep the person`s story
confidential, if appropriate.
 Acknowledge the person`s strengths and how
they have helped themselves.
 Allow for silence.
 Make sure you understand what people say by
repeating what you understood to them, andasking them if you understood them correctly.
 Behave appropriately by considering
person`s culture, age and gender.

the Be sensitive. Acknowledge how they are feelingabout things: “I am so sorry. I can imagine this isvery sad for you”.

8│ Don’t pressure someone to tell their story.
 Don`t take away the person`s strength andsense of being able to care for themselves.
 Do not blame the person for becoming
pregnant.
 Do not blame the person for not using insect
repellent.
 Don’t interrupt or rush someone’s story (likelooking at your watch or speaking too rapidly).
 Don`t make up things you do not know.
 Don`t feel, think and act as if you must solve all
the person`s problems for them.
 Don’t use overly technical terms.
 Don’t give false promises or false reassurances.
 Don’t feel you have to try to solve all the
person’s problems for them.
 Don’t tell them someone else’s story.
 Don’t judge what the person has done or has
not done, or how they are feeling. Don’tsay...”You shouldn't feel that way”.
 Don`t talk about your own troubles.

4. Common reactions
People may react in various ways to being affected by Zika virus and its potential consequences
In normal times, on average one in five women presents symptoms of distress during pregnancy or afterchildbirth. Women who have contracted Zika virus infection during pregnancy and/or who are told theirchild may have or has microcephaly may be even more likely to develop symptoms of distress. Some
examples of symptoms of distress are listed below:


Irritability, anger



Guilt, shameInsomnia, nightmares

Physical symptoms (shaking, headaches, feeling very tired, loss of appetite, aches and pains) without
an organic causeCrying, sadness, depressed mood, grief

Excessive worries, anxiety, fear

In addition, to minimize their stress, women may engage in unhealthy behaviours, such as tobacco andalcohol use.
Some of the above-mentioned psychological reactions are also common and normal during pregnancy,such as feeling very tired or having sleeping problems. In women experiencing psychological distress,
physical symptoms such as headaches may worsen.
The partner/father or close family may react in similar ways to the stress and uncertainties of the situationand the unknown future of the child and the effect it will have on the family.
There will be people with severe symptoms of psychological distress, who need more than the support you
can give them. Their symptoms are considered severe if they cannot function in their daily lives or if they area danger to themselves or their children. They may have difficulties caring for themselves or their children.
Depression and other mental disorders should be considered in women who are not functioning well in
daily activities because of their distress for a prolonged period of time (e.g. more than 2 weeks) (6, 7)
Healthcare workers should monitor for depression during antenatal and postnatal visits. Depression inpregnant women can be managed effectively with psychological treatments 1 (e.g., 8).
Antidepressant medicines should be avoided, especially during the first trimester.



Make sure that people in danger to themselves or others are not left alone. Stay with them until youorganize help from relevant services.

Unless you are trained to assess and manage severe symptoms of distress, you should refer people
with severe symptoms of distress to specialized care.

1 WHO recommends interpersonal therapy and cognitive behaviour therapy as treatments for depression.

│95. Basic psychosocial support
A key feature of basic psychosocial support to women who are afraid of microcephaly is asking
about their needs and concerns and trying to help to address these.2


Ask about people`s needs and concerns around- Pregnancy and having had Zika virus,- Carrying a child with microcephaly, or- Having a child with microcephaly

Listen to them carefully. Try to understand what is most important to them at this moment, and help
them work out what their priorities are.



Help people address urgent needs and, where possible, their concernsGive accurate information (see Section 1 on accurate information)Help people with any decision-making, as necessaryHelp connect people with loved ones and social support (see Section 6 on strengthening social support)

If feasible, consider discussing with women affected by Zika how they can help one other.



If relevant, teach people basic stress management techniques (see Section 7 on stress reduction)

Provide basic psychosocial support, using the above principles, to people with GBS and other neurologicalcomplications.

Always ask about any other needs or concerns the person may have. Do not presume that Zika
and its possible consequences are people’s main worries. They may have other concerns such as
financial and family problems, including domestic violence, as well as other health problems,
including mental health problems. Link these people to the relevant services and supports toaddress these needs and concerns.

2 The approach described here is consistent with psychological first aid (10).

10 │6. Strengthening social support
People tend to cope better when they have friends, family members, or community groups that offer careand support. If the woman has a partner, it is usually helpful to include that person in the discussion to
encourage supporting each other.
A person does not necessarily need many social supports, but they do need someone who can be helpful
to them and provide support in their specific situation. Sometimes, emotional distress can affect a person’s
ability to get support when they need it.

Consider saying the following to the person:“I would like to help you strengthen your social support. For some people, social support
means sharing their difficulties and feelings with other people they trust. Or it might just be
helpful spending time with friends or family and not talking about problems. For others, it
might be using resources from trusted people such as knowledge that is needed to getsomething done. And for others, still, it might mean connecting with community
organizations or agencies to get support. These forms of social support can be very
powerful in reducing distress. Is there some way you think you might be able to strengthen
your social support?”

Help the person to decide in what way they want to strengthen their social support, for example, by talking
to someone, by getting more practical help, such as support with taking care of other children in the family,
run errands, or connecting with another agency or community organization. If the person is not sure aboutstrengthening their social support, even though you have reason to believe they need to, you may want todiscuss this further.
You may say:
“Many people feel unsure about talking with others about their problems or asking othersfor help. One reason is because they are worried they will burden the other person with
their problems. This is often not true though. People will often share problems when they
hear their friend also tell them about their own problems. Or they might ask for help in
return. This might be because that friend is also experiencing similar or other problems. In
general, there are many people who are happy to listen and try to help. It can also be
helpful hearing other people’s difficulties so you get a perspective about your own issues
especially if you think you are the only one experiencing a problem.”

Help the person to identify supportive and trusted family members, friends and community members and to
think through how each one can be involved in helping.
“Another reason people do not get support from others is because they have no one
they trust. If you think you don’t have anyone you can trust, shall we discuss more
together about finding someone in your family or community that you can trust?”│ 11

7. Stress reduction
The person’s concerns about their pregnancy and their baby might cause them a lot of stress. Concerns
about Zika in pregnant women and/or microcephaly may also cause social problems in families andcommunities (e.g. stigma, discrimination, abandonment). You can use the following strategies to help them
reduce stress.
Encourage coping through problem solving
Link the woman to social services and resources in the community to address any social problems
that can be addressed by the social sectorUse problem-solving techniques to help the person address major stressors, such as discrimination.
Work together with the client to brainstorm solutions and coping strategies for identified problems,prioritize them, and discuss how to implement these solutions and strategies.

When stressors cannot be solved or reduced, problem-solving techniques may be used to identify
ways to emotionally cope with the stressor. In general, do not give direct advice. Try to encourage
the person to develop their own solutions.

Discourage tobacco, alcohol and drug use as a way of copingTobacco, alcohol and drugs should be avoided during pregnancy and in breastfeeding mothers
because they are harmful for their babies

Tobacco, alcohol and drugs can cause a range of health problems. A commonly held myth is that
alcohol is helpful for mental health. Indeed, people often use alcohol and other substances as aform of self-medication. However, it does not help solve problems and its use often causes socialand health problems.



For tools on assessment and motivational interventions to reduce alcohol and other substance use,
see WHO ASSIST package (9).

Encourage positive copingEveryone has natural ways of coping. Encourage people to use their own positive coping strategies,
while avoiding negative strategies (see Box 2). This will help them to feel stronger and regain a senseof control.
Box 2. Examples of coping strategies (10)
Encourage positive coping strategies

Discourage negative coping strategies

 Get enough rest

 Don’t take drugs, smoke or drink alcohol Eat as regularly as possible and drink water Don’t sleep all day Talk and spend time with family and friends
 Discuss problems with someone you trust

 Don’t work all the time without any rest or
relaxation

 Do activities that help you relax (walk, sing,pray) Don’t isolate yourself from friends and loved
ones Do physical exercise

 Don’t neglect basic personal hygiene
 Don’t be violent

12 │Teach stress management


Identify and develop positive ways to relax (e.g. listening to music, playing sports). Ask: “What aresome of the things that give you comfort, strength and energy?”Teach the person a specific stress management technique; breathing exercises (See Box 3).
Encourage the person to regularly practise this strategy, and use it in response to feelings of anxiety
and stress.

Box 3. Relaxation exercise: instructions for slow breathing technique
I am going to teach you how to breathe in a way that will help relax your body and yourmind. It will take some practice before you feel the full benefits of this breathing
technique.
The reason this strategy focuses on breathing is because when we feel stressed ourbreathing becomes fast and shallow, making us feel tenser. To begin to relax, you needto start by changing your breathing.
Before we start, we will relax the body. Gently shake and loosen your arms and legs. Letthem go floppy and loose. Roll your shoulders back and gently move your head from side
to side.
Now place one hand on your belly and the other hand on your upper chest. I want you
to imagine you have a balloon in your stomach and when you breathe in you are goingto blow that balloon up, so your stomach will expand. And when you breathe out, the air
in the balloon will also go out. Watch me first. I am going to exhale first to get all the airout of my stomach.
[Demonstrate breathing from the stomach – try and exaggerate the pushing out and in ofyour stomach]
OK, now you try to breathe from your stomach with me. Remember, we start bybreathing out until all the air is out; then breathe in. If you can, try and breathe in throughyour nose and out through your mouth.
Great! Now the second step is to slow the rate of your breathing down. So we are goingto take three seconds to breathe in, then two seconds to hold your breath, and threeseconds to breathe out. I will count with you. You may close your eyes or keep them
open.
OK, so breathe in, 1, 2, 3. Hold, 1, 2. And breathe out, 1, 2, 3. Do you notice how slowly I
count?
[Repeat this breathing exercise for approximately one minute]That’s great. Now when you practise on your own, don’t be too concerned about trying
to keep exactly to three seconds. Just try your best to slow your breathing down when
you are stressed.
OK, now try on your own for one minute.

│ 13

When people excessively worry about Zika and/or its consequences, provide them with basic tips forminimizing excessive worrying (see Box 4).

Box 4: Basic tips to minimize excessive worrying about Zika and/or microcephaly

Ask worried people to select a half-hour worry period, allowing themselves to worry as muchas they like within that period but not during the rest of the day.



Ask people to use a “thinking stop” when worries pop up in their head that they cannot doanything about at that time. Ask them to write down those thoughts and postpone them tothe next worry period. People can thus choose to interrupt their negative thoughts and try tothink about something else.
Advise people that during their worry periods they can worry as much as they like but
they should also ask themselves what they can change and commit to taking someaction. (For example if they have worries due to a lack of information about Zika, thehealth status of their unborn baby, or what other services that are available, you should
help them make a plan about how to gain this information.)

14 │8. Advice on parenting
During pregnancy: for pregnant women with Zika virus infectionAssist the mother preparing for life with a baby. Support the creation of joyful and positive
expectations about the relationship with her baby and building confidence in her ability to providecare. Involve the father and family as much as possible; encouraging them to support the mother.



Remind the expectant mother that many babies born to mothers exposed to Zika virus infection
during pregnancy do not have microcephaly, and that many children with microcephaly may notdevelop developmental disorders or other severe neurological complications.

Provide basic psychosocial support, including stress reduction and strengthening of social supports.

After child birth: for mothers of children with microcephaly without evident neurological complications
Help the mother become aware of her baby’s positive characteristics and build her confidence incaring for the baby.

Remind the mother that many children with microcephaly do not develop developmental disorders
or other severe neurological complications.



Model a positive and caring attitude towards the child with microcephaly.

Counsel on breastfeeding.

Emphasize the importance of play and communication activities for promoting infants’ andchildren’s development throughout childhood (see Box 5 for age-appropriate activities) (12). Involve
fathers/other caregivers as much as possible.



If the mother or primary caregiver presents significant psychological distress, help identify a person
who can assist her with taking care of the baby.

Provide basic psychosocial support, including stress reduction and strengthening of social supports

Offer further assessment and follow up care for developmental monitoring to all children born withmicrocephaly.

│ 15

Box 5. Tips to promote child development (12)16 │After childbirth: for mothers of children with both microcephaly and neurological complications (e.g.
developmental disorders, epilepsy) (6)Help the mother become aware of her child’s positive characteristics and build her confidence incaring for the child.

Model a positive and caring attitude towards the child.



Inform caregivers about the health conditions and explain the problems.
-

Ask the caregivers’ about their explanation for and knowledge of the conditions. Explain that thechild’s health problems are not the mother’s fault and, if relevant, are not related to sins,
witchcraft, or other things (see Section 2 on conveying health information about Zika andmicrocephaly).
Promote child development.

-

All children, including those with developmental delays and neurological complications, can learn
and develop skills. Caregivers can help children develop by engaging with them in everyday
activities and play.
Provide or refer children for further assessment and management of health and neurologicalcomplications (feeding difficulties, epilepsy, visual and hearing impairment) as required.

Inform about other available services, such as community-based rehabilitation and social services.



If necessary, support the mother to overcome barriers that may prevent her from accessing the careand services she and/or her infant require.

Provide basic psychosocial support, including stress reduction and strengthening of social supports.

Offer parent skills training (13) and encourage informal parent support groups.



Offer or organize follow up care for developmental monitoring to all children born withmicrocephaly. Offer follow up care for epilepsy or other neurological conditions, as required.



Promote and protect the human rights of the child and family: be vigilant about human rights,
dignity and safety. Try to address any discrimination in collaboration with available social services,Box 6. Tips on parenting a child with microcephaly and neurodevelopmental complications


Being a parent, and having a child with microcephaly and neurodevelopmental
complications, will bring you many joys but can also be stressful and challenging at times.



Identifying what is important to you, in your role as a parent, can help guide your actions evenwhen times are difficult. What kind of parent do you want to be for this child? For example, tobe protective of my child, to be caring towards my child, to be responsive to his needs, to be
playful with my child, to be a good role model.

You can set small actions to do that are in line with your values. For example, spend some timeeach day playing with your child.



Taking care of yourself can be very important and also helps you care for your child andfamily.

│ 17

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Microcephaly. Geneva, World Health Organization (WHO), 2016. (http://www.who.int/emergencies/zika-virus/microcephaly/en, accessed 16 February 2016)

2.

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3.

Zika Virus. Geneva, WHO, 2016. (http://www.who.int/mediacentre/factsheets/zika/en/, accessed 16
February 2016)

4.

Women in the Context of Microcephaly and Zika Virus Disease: Online Q & A. Geneva, WHO, 2016.
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5.

Zika Virus Infection: Step by Step Guide on Risk Communications and Community Engagement.
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mhGAP Intervention Guide for Mental, Neurological and Substance Use Disorders in Non-specialized
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2016)

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Assessment and Management of Conditions Specifically Related to Stress: mhGAP Intervention Guide
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8.

Thinking Healthy: A Manual for Psychosocial Management of Perinatal Depression (WHO generic fieldtrial version 1.0). Geneva, WHO, 2015. (http://apps.who.int/iris/bitstream/10665/152936/1/WHO_MSD_MER_15.1_eng.pdf?ua=1&ua=1, accessed 16 February 2016)

9.

The WHO ASSIST Package. Geneva, WHO, 2011. (http://www.who.int/substance_abuse/publications/media_assist/en/, accessed 16 February 2016).

10. Psychological First Aid: Guide for Field Workers. Geneva, WHO, War Trauma Foundation, & World VisionInternational, 2011. (http://www.who.int/mental_health/publications/guide_field_workers/en/index.html,
accessed 16 February 2016)
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February 2016)12. Parent Skills Training for Caregivers of Children with Developmental Delays and Disorders (Version 1.0 for

pilot testing). Geneva, WHO (available upon request)

18 │