https://orcid.org/0000-0001-7016-8771
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Abstract
Climate change exerts wide-ranging and significant effects on global mental health via multifactorial pathways, including food insecurity. Indigenous Peoples and pregnant women inequitably experience the harms associated with climate change and food insecurity. This study explores food security and maternal mental health during pregnancy among rural Ugandan Bakiga and Indigenous Batwa women in the context of climate change. Using a community-based research approach, we conducted a series of focus group discussions about climate, food security, and health during pregnancy in four Indigenous Batwa communities and four Bakiga communities in rural Kanungu District, Uganda, as well as longitudinal follow up interviews later in the year. Data were evaluated using a qualitative thematic analysis. Women consistently identified mental health as an important factor affecting maternal-fetal wellbeing during pregnancy. Many women identified that weather and climate extremes, such as prolonged droughts and unpredictable weather events, have made it more difficult for them to obtain sufficient food for themselves and their families during pregnancy, resulting in significant mental distress. More extreme weather conditions have made physical labour difficult or impossible during pregnancy, and resultant hunger further decreased ability to obtain food—a vicious cycle. Women described how anxiety was compounded by worry about future famine, as they anticipated further decreases in crop yields and rising food prices in a changing climate. Indigenous Batwa women experienced additional distress around their lack of access to Indigenous lands and its nutritious food sources. Overall, mothers in rural Uganda described food insecurity and climate extremes as major sources of stress during pregnancy, and they anticipate challenges will worsen. Interventions to enhance adaptive capacity to climate change are needed and should have a focus on the intricate connections with food insecurity and mental health as drivers of overall maternal health.
Citation: Bryson JM, Patterson K, Cunsolo A, Berrang-Ford L, Lwasa S, Namanya DB, et al. (2024) “When you have stress because you don’t have food”: Climate, food security, and mental health during pregnancy among Bakiga and Indigenous Batwa women in rural Uganda. PLOS Clim 3(10): e0000399. https://doi.org/10.1371/journal.pclm.0000399
Editor: Noureddine Benkeblia, University of the West Indies, JAMAICA
Received: January 30, 2024; Accepted: August 11, 2024; Published: October 31, 2024
Copyright: © 2024 Bryson et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: As established by the University of Guelph Research Ethics Board and as per the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans, due to the in-depth and unique opinions and experiences expressed in qualitative interviews, and the small population sizes of the Batwa communities, it is not possible to de-identify our qualitative transcripts. Consequently, and at the request of Batwa communities, we are unable to provide de-identified data and researchers are unable to request access to the data for secondary use. Please contact the University of Guelph Research Ethics Board (reb@uoguelph.ca) for further details.
Funding: Financial support was provided by a University of Guelph (www.uoguelph.ca) Summerlee travel scholarship awarded to JMB; a Frederick Banting Doctoral Graduate Scholarship (Canadian Institutes of Health Research, cihr-irsc.gc.ca), an International Development Research Centre (www.idrc.ca) doctoral research award, and a University of Guelph (www.uoguelph.ca) Summerlee research grant awarded to KP; and a Canadian Institutes of Health Research (cihr-irsc.gc.ca) grant awarded to SLH, LBF, SL, DBN, JDF and the IHACC Research Team. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
The effects of climate change on mental health are an important global public health challenge [1–4]. For example, increased weather and climate extremes, such as floods, hurricanes, droughts, and wildfires, are linked with depression, anxiety, and post-traumatic stress disorder [2,4–10]. For millions of people, forced displacement and migration due to climate-related environmental destruction or resource depletion is emotionally traumatic and can increase sensitivity to other stressors [2,11]. Further, ecological grief from climate change is a growing issue, and encompasses the distress people feel in relation to physical ecological losses, disruption of place-based knowledge and sense of self, and anticipation of future environmental loss as a result of climate change [3,12]. Yet despite the gravity of mental health issues associated with climate change, these issues are often underrepresented in the literature compared to physical health challenges [13–15].
Notably, climate change can impact mental health via direct and indirect impacts on food security [4,16]. Food availability, accessibility, nutrient value, and stability are projected to decline globally due to climate change [16–19]. The health consequences are likely to be most severe in regions where climate change exacerbates already high levels of undernutrition [1,19,20], such as sub-Saharan Africa, where the prevalence of undernutrition is 22.8%—the highest in the world and climbing [21]. The association between food security and mental wellbeing has been described for many populations, including in sub-Saharan Africa [22–28]. People facing food insecurity consistently express feelings of stress, anxiety, despair, hopelessness, and shame about their challenges getting enough food [29–31]. Quantitatively, multiple analyses have found dose-response relationships between food insecurity and lower scores on mental health indices [23,25]. Pregnant women have particularly high sensitivity to food insecurity [32]. Hunger has been described as “the most potent physical and psychological stressor for women across the globe” [33]. Indeed, increased antenatal nutritional needs [34], combined with increased difficulty of obtaining food when pregnant [35,36], poses a significant challenge which is highly influenced by seasonality and climate [37–39]. Food insecurity during pregnancy has been strongly associated with increased maternal stress, depression, and mental illness across multiple populations [2,40–45]. Considering climate change is linked to increasing severity of food security challenges [18,19,21,32], it is reasonable to anticipate an associated increase in mental health morbidity [23,25], which may be further exacerbated during pregnancy. However, there is minimal research addressing the interactions between climate, seasonality, food insecurity, and mental health [24,46], and even less focused on the experience of women during pregnancy.
Indigenous Peoples have documented several climate change impacts on their food systems [47–50]. Factors such as land dispossession, colonialism, and discrimination are at the root of these challenges, increase climate change risks, and make it more difficult for Indigenous Peoples to adapt [10,48,51–54]. There is a small but growing body of research exploring the impacts of climate change on mental health in Indigenous Peoples which has documented increased stress, anxiety, sadness, and grief associated with changes in the land, restricted abilities to participate in Indigenous practices, and isolation and loss of sense of place [7,55–62]. Several studies have identified connections between climate and food insecurity or climate and mental health among Indigenous Peoples [8,57,59,60,63–71], but exploring this intersection was the main objective of only one study [72]. Furthermore, there is a large research gap on climate change and mental health for Indigenous Peoples in Africa [8], despite the strong impacts of climate change and food insecurity in this region [20].
Herein, we examine food security and maternal mental health during pregnancy among rural Ugandan Bakiga and Indigenous Batwa women in the context of climate change. Specific objectives were to document and characterize: 1) pathways by which food security affects mental wellbeing during pregnancy; 2) influences of seasonality and climate change on maternal mental health directly and via food insecurity; and 3) unique experiences of Indigenous mothers navigating the intersection of pregnancy, climate, food, and mental health.
Methods
Partner communities
Kanungu District, in southwest Uganda, is home to approximately 252,000 people [73]. Nearly 700 Batwa people live in the area, with the Bakiga ethnic group composing most of the remaining population. The Batwa are an Indigenous Peoples who hunted and gathered in the forest until the creation of Bwindi Impenetrable National Park led to their forced eviction from traditional lands without compensation in the 1990s [51,74]. They have since been denied virtually all access to the forest, barring them from access to traditional foods and medicines, and disrupting their spiritual connection to the land [74,75]. The forced transition to an agrarian lifestyle has been difficult for the Batwa, contributing to inequities in several areas. Regarding physical health, Batwa experience higher rates of under-five mortality [51], acute gastrointestinal illness [76], malaria [77,78], and pregnancy loss [79] compared to local or national averages. Food security is a major challenge, with 97% of Batwa households identified as food insecure, one of the highest rates in the published literature [47]. As a consequence, undernutrition is significantly higher among Batwa compared to the neighbouring Bakiga communities [80]. The Bakiga participate mostly in farming, both subsistence and cash crops, in addition to limited work opportunities in the tourism industry [47]. Some Bakiga landowners employ Batwa labourers [47]. The Bakiga experience similar health and food security challenges as the Batwa, but with lower magnitude, extent, and frequency [79–81]. There is a lack of research about mental health in these communities; however, experiences of land displacement and resulting stressors are likely to have impacted mental wellbeing for the Batwa [47,51,82], like many other Indigenous Peoples.
The local food systems in Batwa and Bakiga communities mainly consist of subsistence agriculture (crops and small livestock such as goats) with some cash cropping [47,81]. Farming is physically demanding, almost entirely accomplished by manual labour. Bananas, maize, beans, and potatoes are the main crops in the area. Cash crops also include tea and coffee. There is limited access to large markets and most food is consumed or traded locally [81]. In the dry season when agriculture yields are low, household food needs are supported by trading with other farms and engaging in manual labour in exchange for food or cash to purchase food at local markets [47]. Manual labour available in the area is generally low-paying, including cleaning, cooking, digging in the fields, collecting tea, making bricks, and selling handicrafts [47].
Approach to research
A community-based adaptation research approach was used for this work [83], and partner community members were involved in all stages of the research process. This approach aimed to ensure that research was mutually beneficial, collaborative, and rooted in long-term relationships [83]. Batwa community members engaged in this study to identify priority research questions in the context of climate change and health [51,81]. In addition, two local community organizational partners were engaged: the Batwa Development Program, a local non-governmental organization which focuses on Batwa community wellbeing; and Bwindi Community Hospital, which serves over 100,000 people in Kanungu District. Maternal health was identified as a research priority, which served as the impetus for this study and others [79]. These community and organizational partners were involved in defining research questions, data collection, preliminary data interpretation, validation of results, and results dissemination and sharing.
Ethics statement
This study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving research study participants were approved by the University of Guelph Research Ethics Board (REF #16MY016), Makerere University School of Social Sciences Research Ethics (REF #MAKSS REC 04 17 044), and the Uganda National Council for Science and Technology (REF #SS 4334). Written or verbal informed consent was obtained from all participants. Verbal consent was witnessed and formally recorded.
Conceptual framework
The conceptualization of mental health for the purposes of this work was based on the framework developed by Kirmayer and Valasskakis [84] and adapted by Cunsolo Willox et al. in the context of Inuit mental health [56]. For the purposes of this work, mental health was understood as “a broad territory that includes well-being, everyday problems in living associated with bodily symptoms of stress and anxiety, mild depression, and seasonal fluctuations in mood and energy, as well as more severe psychiatric disorders, such as major depression, bipolar disorder, schizophrenia, and other psychotic disorders,” [56,84]. Further, mental health was acknowledged as a dynamic individual experience that fluctuates continuously along a spectrum of wellbeing; it is affected by complex, intersecting factors including socioeconomic status, social support networks, culture, mental illness, physical health, food security, environment, and adaptability and resilience, among others [56]. Sense of place and connection to the land and land-based ways of life also contribute to mental health, as described elsewhere, for instance, in Northern Canada and the Australian Wheatbelt [3]. The risks posed to mental health as a consequence of climate change were conceptualized as a function of climate-related hazards and the exposure and vulnerability of affected people [10].
Data-gathering methods
Ten partner communities in Kanungu District shared their experiences on maternal health and climate (Fig 1). A series of eight focus group discussions (FGDs) were conducted in May and June 2017: four in Indigenous Batwa communities and four in geographically matched neighbouring Bakiga communities, involving a total of 24 Batwa and 22 Bakiga women ranging in age from 18 to elderly. These communities are variable distances from both Bwindi Impenetrable National Park (which can impact land fertility and microclimates) and Bwindi Community Hospital (which can impact access to healthcare) and thus represent varying experiences living in the region. All FGDs were conducted with the support and invitations of local chairpersons, who co-led contacting and inviting women to participate in research and coordinating data collection. FGDs were conducted within each community, where women felt comfortable, to lessen some of the power imbalances that existed between the researchers and participants. Batwa communities of varying population size and geographical distance from Bwindi Impenetrable Forest and Bwindi Community Hospital interested in participating were invited to represent a wide range of life experiences in Kanungu District. Within communities, women of diverse ages from 18 to elderly engaged in each FGD to ensure that experiences with pregnancy over several decades were represented. All women having at least one current or previous pregnancy were eligible to participate in the FGDs. FGDs were conducted in English with simultaneous translation to the local language (Rukiga) by an experienced local research associate, who obtained informed consent. All FGDs were audio-recorded with informed consent.
Not to scale. Base map and data from OpenStreetMap and OpenStreetMap Foundation. Available from https://www.arcgis.com/home/item.html?id=d1255ac5efac4508b34579bf8979708c.
A semi-structured, conversational style was used for FGDs, whereby a guide of several pre-determined questions (available upon request of authors) was used to elicit conversation and women were able to further direct the conversation in whichever directions they felt to be most important. Major FGD topics included impacts of food security on health during pregnancy, influences of climate on food security and health, and changes in maternal-infant health over time. As women brought up new topics, the discussion guide was updated in an iterative process so that these participant-identified areas of interest could be discussed in other communities [85]. Of note, the theme of climate-related mental health challenges was entirely emergent from early FGDs, as the discussion guide initially did not explicitly prompt participants to consider mental wellbeing but rather health generally. As mental health was quickly highlighted by women as an important part of their pregnancies to discuss, it was incorporated into FGDs. Additional information on antenatal maternal mental health was gathered in FGDs in two Batwa communities from April to December 2017 to learn more about their experiences with pregnancy in a longitudinal manner.
Data analysis
The data generated in the FGDs were analyzed via a qualitative thematic analysis (Fig 2) [86,87]. NVivo 10 was used to facilitate manual coding of the data, quotation retrieval, and overall data organization including comparison of the Batwa and Bakiga experiences. Direct quotes that informed the themes are drawn upon in the paper.
FGD = Focus group discussion.
Peer debriefing [88] was conducted frequently during data collection and analysis with local experts (e.g. Bwindi Community Hospital physicians, Batwa community members), research colleagues who have worked alongside the partner communities, and the team of local researchers to gain insight into preliminary findings and later to confirm the themes. These consultations involved both informal discussions and formal sessions. Gathering of information from a diverse group of knowledge-holders allowed for triangulation of information, which improved authenticity and validity in qualitative analysis [88]. In addition, prolonged engagement and partnership with community members also contributed greatly to the validity of the research [88].
Results
The information shared by mothers on their experiences with mental health, climate change, and food security during pregnancy can be integrated under three main themes: 1) Pregnancy-specific stressors challenged maternal mental health and were compounded by food insecurity; 2) Inequities exacerbated food security stressors for Indigenous mothers; and 3) Seasonality and environmental exposures can influence mental health during pregnancy.
Pregnancy-specific stressors challenged maternal mental health and were compounded by food insecurity
In every community where mental health was discussed, stress, anxiety, or sadness during pregnancy was an important concern with connections to food security and climate (Fig 3). The experience of pregnancy itself was associated with a baseline level of increased stress for many women, in addition to climate and food security related stressors. Some communicated that the state of being pregnant often causes mental distress in this context, saying sadness comes “because of being pregnant.” Many women associated maternal stress with the health risks of being pregnant, and outcomes such as miscarriages and still births were distressing in these communities. As a Batwa woman explained, “You feel sad because of all that time carrying a pregnancy and it is lost.” The challenge of poor food security was a significant source of stress during pregnancy, as women often bore the majority or totality of the responsibilities of providing food for the family. The issues of food availability and accessibility caused significant struggle in Indigenous Batwa communities for almost all women. Women explained that nutrient-dense foods like rice and meat, which they often crave during pregnancy, were especially hard to obtain due to cost.
Adjacent icons have direct connections.
Manual digging and harvesting in the fields were often required of women to obtain food. This work is strenuous, especially in challenging environmental conditions like heavy rain and extreme heat. Women described the difficulty of the work increasing when pregnant and the ability to cope with harsh weather waning, yet the need to provide food persisting. Consequently, decreased ability to perform physical labour while pregnant was associated with poor food security and mental wellbeing. As one woman explained,
We are depressed and we are stressed, because when we are pregnant we find we don’t have energy to go and work and get what we want. We find we depend on begging.
Thoughts about the future consequences of not having the energy to work and get food for the family while pregnant were also distressing:
You see other people going to prepare food for the future, and you are weak… You start thinking in the future you won’t have food and others will have food.
Since more children meant greater demand for food and money for essentials like school fees, the workload and stress of the mother’s provider role increased with family size. As one Batwa woman said, “I’m producing many children [and] every responsibility is on me.” For some women, social support was available when they were unwell and unable to support their family while pregnant, explaining, “When we are sick the men have to take over.” But for others, “We don’t get help at all.” The mental distress associated with the provider role was described to affect physical health as well: “I find I become sick—like having a headache—because of the stress of looking for food to cook for the children, and I can’t find any.”
Women from Bakiga communities also faced challenges with food insecurity during pregnancy. Like Batwa women, Bakiga women were typically the main provider of food for the family, which was a source of stress. For example, a woman discussed the possibility of children taking risks because of their mother’s inability to provide for them during pregnancy, saying women can be “scared” thinking that “your kids are going to go and steal somewhere because you’re not working, you’re not finding [food] for them…or you are going to fail to get school fees.” Some women worried about the impacts of their stress on their fetus, saying “when you have stress because you don’t have food…you can produce a small baby, or you produce the baby before term.”
However, although Bakiga women described facing similar challenges to Batwa women, they were reported on a different level of severity. Whereas Batwa women reported struggling to obtain any food at all or eating only one staple starch for weeks on end, women from a Bakiga community described being stressed about not being able to access specific foods they desired during the pregnancy, explaining,
We have food, but sometimes maybe if you feel that you want a certain type of food and you can’t afford to get it at the moment, you can be stressed.
Hence, relatively food-secure women still experienced stress during pregnancy related to food, even if their experience was different than those with severe food insecurity. Regardless of the differences between Bakiga and Indigenous Batwa, when asked if mothers worry about not getting enough food while pregnant, a Bakiga woman emphatically replied “Yes. So much.”
Inequities exacerbated food security stressors for Indigenous mothers
While both Batwa and Bakiga women experienced stress related to food and climate, the Indigenous Batwa women described additional sensitivity attributable to expulsion from their traditional lands in the forest. Women explained that when the Batwa lived as hunter-gatherers they had a bountiful supply of food from the forest, including “honey,” “wild yams,” “pig,” and “Uganda kobs [antelope].” Older women who had once lived in the forest described the relative ease of getting these nutritious foods in the past, saying, “Before when we were in the forest we would think of eating meat, and we would be craving meat, and we would get it. But now when we are pregnant, we pray for good foods…but we can’t get them.” Outside of the forest, farming has been difficult. Foods like meat and fish were too expensive for most Batwa to purchase, which meant for some women “You find even throughout the pregnancy you can get meat like once.” These descriptions of food inaccessibility were in stark contrast to the food availability of the past, and the injustice can be heightened during pregnancy and the antenatal period when nutrient-dense food was said to be craved but unattainable. In one Batwa community, a woman expressed how pregnant women are physically weaker now because their access to the forest is cut off, saying women in the past “had strong immunity because the type of food they used to eat from the forest.” This elderly woman also lamented the loss of access to traditional medicines, saying “These young mothers, they never took the local herbs from the forest…so even their babies are born weak because the mothers are not strong.”
Seasonality and environmental exposures can influence mental health during pregnancy
Dealing with environmental health exposures during pregnancy was described as stressful by both Bakiga and Indigenous Batwa mothers. A Bakiga woman shared that she had a lot of sad thoughts in the dry season because “I’m always not feeling well, as if I’m going to have a miscarriage.” She explained that the sunshine in the dry season made her feel very hot all the time, which she worried could harm her baby. These feelings of malaise related to weather in pregnancy, including both cold rainy conditions and hot dry conditions, negatively impacted ability to work for food. For example, a Batwa woman explained “In the dry season because there is a lot of sunshine, no food, all the time you feel hot… You find you are stressed because of that.” A Bakiga woman added that, when you are pregnant,
Your mood usually changes because in the dry season you find you don’t even have enough food. If the dry season is prolonged, so there is no food, you are worried because your children don’t have enough food to eat.
Droughts were particularly arduous, and women reported them to be increasing in length and frequency. The rainy season also presented barriers to food availability when extreme weather such as strong wind, rain, or hailstorms damaged crops. Furthermore, the seasons were described as changing and unpredictable, which heightened challenges faced in agriculture and consequent stress related to food security. In one Batwa community where the cultural tourism industry was an important source of income, the rainy season was associated with more stress related to food accessibility as tourism decreased and women felt they had less energy to work when pregnant during the rains. And while some women did not feel season significantly impacted their mental wellbeing, most agreed that being pregnant reduced their ability to manage environmental exposures which impacted their mental health. Many also felt that food security was a major determinant of their ability to adapt to harsher environmental conditions; if they had more food, they would feel healthier while pregnant and be better able to keep up with their normal activities, even in challenging weather.
Although the Bakiga women reported better ability to cope with food insecurity, when asked how the difficulty of obtaining food while pregnant has changed over time, they were concerned about the future:
We are thinking even in the future that the famine is going to be high because we are experiencing a lot of insects which are destroying our crops. At least every type of crop now has a disease… We don’t have an income, yet things are going high [becoming expensive]. Buying posho [a staple cornmeal] from the shop, it’s very hard—it’s expensive yet we don’t have any income… and our crops are not growing well. So, we are thinking in the future it will be very hard to get food.
Overall, the women’s projections for the future consistently lacked hope for better food security.
Discussion
This study described how challenges with food insecurity and climate are common experiences during pregnancy that are associated with stress, sadness, and worry for Bakiga and Indigenous Batwa mothers in rural Uganda. Indeed, the negative impacts of food insecurity on mental health have been well-established in the general literature [89], and there is growing evidence of the negative impacts of climate change on mental health [8,10,90,91]. Our work advanced this understanding by providing qualitative research that aimed to understand the pathways through which food insecurity, climate, and mental health intersect for pregnant mothers, given their heightened sensitivity to these challenges. Especially considering physical health has been emphasized to a greater degree than mental health in the climate change-health literature [13–15], our work addresses both an underrepresented topic and emphasizes women and Indigenous voices, whose perspectives have historically been neglected.
Batwa and Bakiga mothers identified strong connections between their experiences of food insecurity and mental health struggles during pregnancy. This is consistent with quantitative research for both pregnant women [45,92] and mothers more broadly [40,46,93], which has demonstrated positive associations between food insecurity scores and indices of depression, anxiety, and other mental illness. Food insecurity is a universally taxing experience, but women in the communities described several other gendered sources of stress, including providing for children and fear of poor pregnancy outcomes, that contributed to a greater baseline stress level during pregnancy. Further, weather and climate extremes, such as heavy rains, extreme heat, and droughts, were described as sources of stress for mothers via their impacts on physical wellness and food security. Each additional stressor draws from a mother’s overall mental health resiliency and decreases her available reserves to mediate further negative emotional effects of challenges such as climate change; this is the concept of allostatic load, whereby cumulative acute and chronic pressures leave a physiological and psychological stamp on the body that limits future adaptive capacity to stressors [94,95]. Higher allostatic loads have been linked to socioeconomic health disparities [94,95], indicating that the same socioeconomic factors which contribute to mental health stressors can also entrench it. Thus, weather and climate exposures that affect food security can exert even stronger influences on mental health during a time of increased cumulative stress like pregnancy.
The stressor of food insecurity often falls disproportionately on women, who, like Batwa and Bakiga mothers, are responsible for the majority of household food acquisition in many communities [96,97]. During pregnancy, the challenges of strenuous physical labour in subsistence agriculture were magnified for Batwa and Bakiga women, yet they lacked alternative means of procuring food; this reported struggle to provide for themselves and their family led to increased mental distress, meanwhile the associated undernutrition made it even harder to work to obtain food, resulting in an unforgiving cycle of maternal health challenges and food insecurity well-described by mothers [38]. Challenging weather conditions like drought and extreme heat compounded this stress. Indeed, the relationship between food insecurity and mental illness was bidirectional among low-income pregnant South African women, in that food insecurity increased the odds of having a mental illness and having a mental illness increased the odds of food insecurity [45]. For Batwa and Bakiga mothers, the stress of food insecurity was not solely focused on their own health but that of their children as well, born and unborn. Women were concerned their mental stress during pregnancy could cause low birth weight or preterm delivery of their infants, both of which have been linked to antenatal depression and anxiety with greater magnitude of association in lower income nations [98]. Considering the odds of neonatal death are 3.8 times greater among babies with low birth weight in Uganda [99], improving maternal mental health during pregnancy could have important impacts on reducing neonatal deaths.
Mothers also described stress around keeping their children fed while they were pregnant. This is common source of distress for mothers in their role as household provider; in South Africa, women described high levels of depression, anxiety, shame, guilt, and anger associated with the inability to consistently provide food for their children, saying “{crying} ‘Everybody asks me for a piece of bread and then I don’t have for them,’” and, “‘It makes me feel uneasy. How am I going to get it, where am I going to get it? I think about the day of tomorrow as well…[what] am I going to do if the children don’t have milk?’” [97]. Lacking social support in times of food insecurity was an issue for some Batwa and Bakiga mothers–a lost opportunity for adaptive capacity that others utilized to persevere through difficult periods in pregnancy. In northern Uganda, the association between food insecurity and depression was stronger for those with lower social support [92]. Interventions which work to build new and strengthen existing support networks for pregnant women facing food insecurity may help to improve maternal mental health and could warrant prioritization for both research and public health programming.
Women from all communities described weather, seasonality, and climate factors which directly and indirectly contributed to psychological distress during pregnancy. Although the impacts of climate change on mental wellbeing have been well documented for the overall global population [8,10,90,91], there is an absence of research focused on these effects during pregnancy. Direct climate impacts identified by Batwa and Bakiga mothers included weather exposures such as heat which made them feel physically unwell and consequently worry about the health of their fetus. Importantly, these women have noted that challenging weather exposures are becoming more frequent and longer in duration over time [38], which indicates that while the weather events described in this work are generally short-lived and isolated experiences, their evolving nature is defining of climate change.
Indirectly, weather exposures made working for food in the fields difficult during pregnancy, contributing to food insecurity and the accompanying stress. Women described changes in climate over time, particularly longer and more frequent droughts and greater seasonal unpredictability, that have limited their agricultural yields and cause fear and anxiety that the burden of hunger will be even greater in the future. Indeed, dry periods and extreme precipitation events are projected to increase in the region [100–104]. It is therefore crucial that interventions that aim to improve food security are climate-informed to see long-term sustainable benefits. Alternative income-generating activities are one such intervention that could strengthen adaptive capacity for mothers via decreasing dependence on the land for food. Some Batwa women were already involved in the tourism industry; this may improve their ability to adapt to conditions such as longer dry seasons, which are tourist high seasons and therefore times of higher food security [38]. Overall, our results indicate that increasing climate change resiliency is likely to have beneficial impacts for both food security and maternal mental wellbeing; research that identifies strategies for climate change adaptive capacity and public health interventions that implement identified strategies could have robust benefits for mental health in these communities, in addition to the physical maternal-child health benefits.
The Indigenous Batwa mothers described more severe challenges with the stress of food insecurity, much of which was related to their forced expulsion from their ancestral lands and traditional forest way of life. This reported disparity is consistent with findings of significantly higher undernutrition among Batwa women (45.86% vs. 0.42% and 3.00% vs. 0% prevalence of moderate acute malnutrition and severe acute malnutrition, respectively, among Batwa vs. Bakiga adult women) [80]. Less agricultural experience, land ownership, land access and agricultural inputs have been identified as barriers to food security by the Batwa [38]; these sensitivities to food insecurity are direct consequences of land dispossession, a common experience of Indigenous Peoples globally which limits health and climate change adaptive capacity [47,105,106]. Batwa Elders who participated in FGDs lamented new mothers prevented from eating nutritious traditional foods and medicines once abundant in the forest from which they have been barred for decades [74]. One Elder left a FGD early in frustration after describing her observations that young mothers and their babies are weaker than in the past because they cannot access these forest foods and medicines. There is a strong sense of loss here, especially for mothers, despite the emotional vocabulary being difficult to translate, or being culturally inappropriate.
Sense of place is intimately related to health and wellbeing for Indigenous Peoples, and when connection or attachment to place is eroded, emotional responses of sadness, anxiety, anger, and grief are common [55]. The injustice of unfair compensation for their land dispossession, continuing lack of representation at decision-making tables, and discrimination [107] are additional burdens that can mentally and spiritually tax Batwa mothers, adding to the stresses of pregnancy and negatively impacting their mental health overall. Our results suggest that interventions, including policy change, which focus on secure and just land access for the Batwa are important not only for food security, as acknowledged by the United Nations 2030 Agenda for Sustainable Development [108], but also for the direct and indirect impacts on maternal mental health.
Although on a population level the Batwa struggled more significantly with food insecurity, there remained individual Bakiga women who had severe challenges. As well, for women who worried about lack of access to specific foods during pregnancy (meat, for example), the subjective experience of food insecurity was nonetheless stressful, despite their ability to access food in general. Thus, maternal nutrition interventions would be useful in all communities, while acknowledging higher levels of support are warranted in Indigenous Batwa communities where the needs are broader and more acute. Furthermore, when food security and climate change adaptation interventions are implemented, the impact on mental health should be considered in all stages from program development to impact evaluation, given its importance to overall wellbeing as identified by mothers broadly. While this work highlights the need to better support mothers, it also highlights that they have developed expertise in adaptation that should be sought out, valued, and integrated into interventions for maternal mental health and wellbeing.
Conclusions
This study provided evidence that the interactions between climate, food insecurity, and maternal mental health are numerous, nuanced, and interconnected. For Bakiga and Indigenous Batwa mothers in rural Uganda, food insecurity was a significant source of stress, sadness, and worry during pregnancy. Forced displacement from traditional forest lands has resulted in additional barriers to both food security and mental wellbeing for Indigenous Batwa mothers. Women identified climate hazards, including drought and heat as mental health stressors, both directly and via their impacts on food insecurity during pregnancy. Furthermore, mothers were concerned that food insecurity will continue to worsen as regional climatic changes have threatened their agricultural livelihoods; the impacts on antenatal depression and anxiety could be significant. Interventions to improve climate change adaptive capacity should thus be implemented considering the heightened sensitivity of pregnant mothers and their children to the impacts of food insecurity and mental health challenges, with special attention for Indigenous mothers who have additional sensitivities for negative outcomes. The 2015 Uganda National Climate Change Policy includes considerations for the impacts of climate change on food security and health generally, but makes no mention of mental health [109]. In 2023, Uganda began developing a National Adaptation Plan for climate change with the support of the UN Environment Programme [110]; it is imperative given the findings of our work and others’ that the impact of climate change on mental health and its intersections with food security and pregnancy be integrated in this plan. Further, the consultation of Indigenous women and mothers in development of these policies would add a valuable depth of knowledge from lived experience and expertise. Despite the threats to maternal-child health posed by climate change and food insecurity, mothers have continued to demonstrate strength and leadership, and with additional supports they can better overcome the challenges they face in a changing climate.
Supporting information
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https://doi.org/10.1371/journal.pclm.0000399.s001
(DOCX)
Acknowledgments
We are deeply grateful to our partner communities for their contributions to this research. We especially thank the mothers who took the time to share their experiences with us. We value the opportunity to listen to women and Indigenous voices. We also sincerely thank our partner organizations in Uganda: Bwindi Community Hospital, the Batwa Development Program, the District of Kanungu Government, and the Ugandan Ministry of Health.
The Indigenous Health Adaptation to Climate Change Research Team includes Lea Berrang-Ford, Cesar Carcamo, Victoria Edge, James Ford, Patricia Garcia, Sherilee Harper, Alejandro Llanos, Shuaib Lwasa, and Didacus Namanya.
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