Maternal Mental Health: Need to start conversations

Maternal mental health refers to the mental health of pregnant people or of people within a few weeks or months after childbirth. Despite research suggesting that the psychosocial well-being of people and their children is important, recognition of maternal mental health has not been a priority on health agendas for many low- and middle-income countries (LMICs). While there is no reliable national data on maternal mental health, the WHO estimates that one in three to one in five persons during pregnancy or childbirth in LMICs have a significant mental health issue, compared to one in ten persons in HMICs.

While discussion about postpartum mental health dominates the maternal mental health discourse, there is documentation that India has a high rate of perinatal (during pregnancy and labour) mental health issues. Perinatal mental health issues have a tendency to cause serious repercussions for maternal as well as foetal health- causing low birth weight, anaemia and eventually infant nutrition and stunting. However, there are knowledge gaps in India with respect to these mental health issues and any screening for mental health distress, if at all, happens after childbirth.

According to the NCRB report for 2021, 18,588 women in the age group 18-30 years died by suicide. Of these, ‘marriage-related issues’ (particularly in dowry-related issues) and ‘impotency/ infertility’ were found to be major causes of these deaths by suicides. Despite such numbers of death by suicide of young women and the causes being entrenched and repressive cultural factors and stigma around marriage and infertility, there is a limited conversation on this within the government and civil society.

Maternal mental health in India is characterised by a higher number of young persons who give birth (At least 7.9 per cent of women aged 15-19 years have started childbearing, Source: Census 2011). India has a third of the total number of child brides in the world, resulting in girls losing out on education as well as future income sources. 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 natal families and economic dependence on the marital family. These stressors are further compounded by the preference for a male child, lack of proper nutrition during pregnancy, health issues such as anaemia (NHFS 2020 revealed that a third of all Indian women suffer from anaemia),  and a lack of access to reliable antenatal care.

Maternal mental health has been further exacerbated by the COVID pandemic in India. Already burdened health systems were unable to provide the full range of reproductive and mental health services, limiting and punctuating access to abortions, contraception and antenatal care.

As per prevalent social norms in several parts of India, pregnant women normally go to their natal families for delivery and the immediate postpartum period, but the strict lockdown prevented them from doing so, therefore contributing to mental distress. Gendered norms, unpaid labour, lack of support from the partner and the burden of childcare play a significant role in mental distress among women of reproductive age in India. Data during the COVID-19 pandemic revealed that women experienced all these stressors, in addition to bearing job losses, pay cuts and uncertain employment prospects.

Maternal mental health requires multiple intervention strategies starting with overhauling the medical curriculum to train and sensitise gynaecologists and obstetricians on maternal mental health for both perinatal and postpartum issues. While NIMHANS has recently started a certificate course on prenatal mental health for health workers, this limits the acquisition of such knowledge to the initiative of the individual, whereas including it in the mainstream MBBS curriculum will enable all future healthcare workers to be aware of the issue and facilitate better referrals.

Secondly, the Health and Wellness centres under the Ayushman Bharat programme mention mental health services as one of the 12 services to be delivered by them. There is a need to have tools made available to the community health officers (CHOs) so that they can identify expectant and new mothers experiencing mental health issues and provide them with basic counselling support.

Thirdly, there is a need to create community-based programmes that facilitate a safe space for individuals to talk about issues they experience during and after pregnancy, where they are able to learn and support each other. Such programmes are built on the existing knowledge of people from the community, are contextual and use local resources.

Ekjut, a community-based organisation working in Jharkhand demonstrated one such approach more than a decade ago, using tools of Participatory Learning and Action (PLA), which are a collection of methods to enable and empower participants to discuss and take action on issues of common importance and concern. The intervention involved regular meetings with facilitators from the community itself, where information about pregnancy, delivery and care-seeking practices were shared through games and stories. Case studies from the local context were shared and community members discussed the problems and what strategies could be used to address them. A research study on this project showed that forming and facilitating women’s groups reduced neonatal mortality rates and a reduction in moderate depression by the third year. The Ekjut study has broad lessons for us to glean from- that there is merit in linking maternal mental health services with physical health. This will help women easily access mental health services without facing stigma.

At a macro policy and implementation level, the way forward for universalising maternal mental health care and enhancing access to reliable, affordable services is to integrate the mental health component with maternal and infant mortality reduction programs and schemes. There is also a need to include maternal mental health data in the National Family Health Surveys and in other data concerning women’s health in India. Better data collection and quality primary research on specific issues of maternal mental health issues in both on what causes it, and also what models of services have worked can be important for advocacy and intervention design.

Lastly, maternal mental health in India needs to be seen from a lens where reproductive rights are also built into the conversation on maternal mental health. A reproductive justice lens pushes the conversation beyond just rights, to accessible services. For instance, what are the factors that prevent certain groups of women from accessing their rights or services? This is due to structural factors like caste, religion, disability that impede access to quality health services. Inaccessibility to dependable health services during pregnancy, childbirth and postpartum contributes to mental distress.

The author is CEO at Mariwala Health Initiative. Views are personal.

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