Representative picture. AFP
Maternal mental health refers to the mental health of pregnant women or of people within a few weeks or months of giving birth. Although research suggests that the psychosocial well-being of people and their children is important, recognizing maternal mental health is not a priority on the health agenda in many low- and middle-income countries (LMICs). Although there is no reliable national data on maternal mental health, WHO estimates that one in three to one in five people in LMICs have a significant mental health problem during pregnancy or childbirth, compared to one in ten people in HMICs.
While discussion of postpartum mental health dominates maternal mental health discourse, there is evidence that India has a high rate of perinatal (during pregnancy and childbirth) mental health problems. Perinatal mental health problems tend to have severe maternal and fetal health implications, which can lead to low birth weight, anemia, and eventually infant feeding and growth retardation. However, there are gaps in knowledge about these mental health problems in India and screening for mental distress occurs, if at all, after birth.
According to the 2021 NCRB report, 18,588 women in the 18-30 age group died by suicide. Of these, ‘marital problems’ (particularly related to dowry) and ‘impotence/infertility’ were found to be the major causes of these suicide deaths. Despite this high rate of suicide among young women, and the causes of entrenched and repressive cultural factors and stigma surrounding marriage and infertility, there is limited conversation within government and civil society.
Maternal mental health in India is characterized by a higher number of young people giving birth (at least 7.9 percent of women aged 15-19 have started giving birth, Source: 2011 Census). India has a third of all child brides in the world, resulting in girls losing both education and future sources of income. Other important issues include limited access to contraception and family planning, unplanned pregnancies, intimate partner violence (IPV) (1 in 3 women in India experience IPV), lack of support from the birth family and economic dependence on the marital family. These stressors are compounded by the preference for a male child, poor nutrition during pregnancy, health issues such as anemia (NHFS 2020 found that one-third of all Indian women suffer from anemia), and lack of access to reliable prenatal care.
Maternal mental health has been further aggravated by the COVID pandemic in India. Already strained health systems were unable to provide the full range of reproductive and mental health services, limiting and hampering access to abortion, contraception and prenatal care.
According to the prevailing social norms in several parts of India, pregnant women normally go to their birth families for childbirth and in the immediate postpartum period, but the strict lockdown prevented them from doing so and therefore contributed to psychological distress. Gender norms, unpaid work, lack of partner support and the burden of child care play a significant role in the psychological distress of women of childbearing age in India. Data during the COVID-19 pandemic showed women were experiencing all of these stressors, in addition to job losses, wage cuts and uncertain job prospects.
Maternal mental health requires multiple intervention strategies, beginning with the revision of the medical curriculum to educate and raise awareness among gynecologists and obstetricians about maternal mental health on both perinatal and postpartum issues. Whilst NIMHANS recently launched a certificate course on prenatal mental health for health workers, this limits the acquisition of such knowledge to the initiative of the individual, while its inclusion in the mainstream MBBS curriculum will allow all future health workers to become aware of the topic and enable better recommendations.
Second, the health and wellness centers under the Ayushman Bharat program mention mental health services as one of the 12 services to be provided by them. Community Health Officers (CHOs) must be provided with tools to identify expectant and new mothers with mental health problems and provide them with basic counseling support.
Third, there is a need to create community-based programs that provide individuals with a safe space to talk about issues they experience during and after pregnancy, where they can learn and support one another. Such programs build on the existing knowledge of people in the community, are contextual and use local resources.
Ekjut, a community-based organization working in Jharkhand, demonstrated such an approach more than a decade ago, using participatory learning and action (PLA) tools, which are a collection of methods to empower and empower participants, Discuss issues and take action of common importance and concern. The intervention included regular meetings with facilitators from the community itself, where information about pregnancy, birth and care practices was shared through games and stories. Case studies from the local context were shared and community members discussed the issues and what strategies could be used to address them. A research study on this project showed that the formation and empowerment of women’s groups reduced neonatal mortality and a reduction in moderate depression by the age of three. The Ekjut study contains comprehensive lessons from which we can learn that it makes sense to link maternal mental health services to physical health. This will help women to access mental health services more easily without stigma.
At the macro-policy and implementation levels, the way to universalize maternal mental health coverage and improve access to reliable, affordable services is to integrate the mental health component into programs and programs to reduce maternal and child mortality. There is also a need to include maternal mental health data in the National Family Health Surveys and other data on women’s health in India. Better data collection and high-quality primary research on specific maternal mental health issues, both its causes and the models of service that work, can be important for advocacy and intervention design.
Finally, maternal mental health in India needs to be viewed from a perspective that also includes reproductive rights in the maternal mental health conversation. A lens of reproductive justice moves the conversation beyond just rights to accessible services. For example, what are the factors that prevent certain groups of women from claiming their rights or services? This is due to structural factors such as caste, religion, disability, which make it difficult to access quality health services. The lack of access to reliable health services during pregnancy, childbirth and postpartum contributes to psychological stress.
The author is CEO of the Mariwala Health Initiative. Views are personal.
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