Introduction
In September 2024, a meeting was held in Hyderabad to discuss integrated Perinatal Mental Health intervention in rural India. Representatives from six districts of Telangana partook in the meeting to identify key problems to maternal mental health in rural India and investigate potential solutions. Maternal Mental Health (MMH), also called Perinatal Mental Health (PMH), refers to the emotional well-being of a woman from the time of conception up until one year postpartum. MMH issues impact a mother’s ability to be responsive and sensitive to her baby. Such issues can be in the forms of antenatal depression, postpartum depression (PPD), postpartum anxiety (PPA), postnatal psychosis, or attachment disorders.
Mental health issues pose serious concerns. Per the National Mental Health Survey of India 2015-16, the lifetime prevalence and current prevalence of mental morbidity, mood disorders and depressive disorders based on gender as well as residence is elucidated in the table below.
| Category | Lifetime Prevalence | Current Prevalence |
| Any mental morbidity | 13.67% | 10.56% |
| Mood disorders | 5.6% | 2.8% |
| Depressive disorders | 5.3% | 2.7% |
Prevalence among adults
| Category | Rural | Urban Non-metro | Urban Metro |
| Any mental morbidity | Lifetime: 12.28%
Current: 9.57% |
Lifetime: 12.76%
Current: 9.73% |
Lifetime: 19.33%
Current: 14.71% |
| Mood disorders | Lifetime: 4.79%
Current: 2.24% |
Lifetime: 5.22%
Current: 2.05% |
Lifetime: 8.82%
Current: 5.57% |
| Depressive disorders | Lifetime: 4.48%
Current: 2.15% |
Lifetime: 4.93%
Current: 1.90% |
Lifetime: 8.23%
Current: 5.17% |
Prevalence based on residence
| Category | Females | Males |
| Any mental morbidity | Lifetime: 10.80%
Current: 7.47% |
Lifetime: 16.75%
Current: 13.86% |
| Mood disorders | Lifetime: 6.0%
Current: 3.09% |
Lifetime: 5.19%
Current: 2.57% |
| Depressive disorders | Lifetime: 5.7%
Current: 3.0% |
Lifetime: 4.8%
Current: 2.4% |
Prevalence based on gender
Additionally, the suicide incidence rate (per 100,000 population) in India is 10.6. The suicide incidence rate for females is 7.24, while for males is 14.30. However, females show a higher suicidal risk. It can be categorised into moderate and high risks.
| Characteristic | Moderate suicidal risk prevalence | High suicidal risk prevalence |
| Rural | 0.68 | 0.76 |
| Urban Non-metro | 0.60 | 0.54 |
| Urban Metro | 0.99 | 1.71 |
| Females | 0.83% | 1.14% |
| Males | 0.61% | 0.66% |
| Overall | 0.72% | 0.90% |
While urban metro areas depict a higher burden on mental health disease owing to the fast-paced and sedentary lifestyle, in rural areas and urban non-metro areas, mental health issues are often stigmatised and viewed through religious or cultural lenses, leading to delays in seeking professional care and reliance on traditional healing practices. Accessing mental health services can be challenging due to insufficient resources, poor-quality care, and socio-cultural beliefs that hinder treatment.
The economic costs of mental health issues cannot be overlooked. They can be organised as ‘direct costs’, such as the cost for diagnosis, treatment, and medication of the ailments, or as ‘invisible costs’, such as costs related to income reductions caused by death, disabilities, and the need for caregiving, including lost productivity from missed work or premature retirement. According to 2010 data, the worldwide economic burden of mental health disorders, both direct and indirect, was projected to be USD 2.5 trillion. Notably, the indirect costs amounted to USD 1.7 trillion, significantly exceeding the direct costs of USD 0.8 trillion. According to the World Health Organisation (WHO), the economic loss in India due to mental health issues, between 2012-2030, is estimated to be USD 1.03 trillion.
PMH, moreover, has not only high economic costs but a negative impact on the lives of mothers and children. Per a study, it was noted that PMI affects the fetus’ development and can cause challenges in the emotional development, cognitive development, and behaviour of a child. They may bring about attachment issues, hyperactivity disorders, and anxiety disorders in children. This requires robust institutional support, which is currently insufficient in India. A mother’s mental health significantly influences her ability to provide proper nutrition for her and the family. When a mother experiences a decline in mental health, her capacity to make healthy eating choices reduces leading to poor eating habits and nutritional deficiency.
The Issue of Perinatal Illnesses in India
A study conducted by AIIMS under Comprehensive Rural Health Services Project (CRHSP) Ballabgarh analysed the prevalence, psychosocial determinants, and risk factors associated with perinatal mental illness (PMI). It found that 5.6% of rural women suffer from some form of PMI, with PPD occurring in 2.2% of women, PPA in 0.74%, and both in 2.8%. The aim of the CRHSP Ballabgarh was to not only track demographic data and conduct community-based research in rural India, but also to provide preventive, health-promotion, and treatment services to the local population.
In another study on urban women, 26.3% of women were found to suffer from PPD. A meta-analysis on PPD found a pooled estimate of PPD in Indian mothers was 22%. Eight studies included women reporting depression within two weeks of giving birth. As maintained by a survey on suicidality in early pregnancy in urban India, 7.6% of pregnant women had suicidal thoughts, and 5.4% were moderate-highly suicidal. 2.4% of pregnant women had made a suicide plan during their pregnancy, and 1.7% had attempted suicide.
A systematic review of PPA and PPD reported possible causes for the occurrence of PMI. First, women with a history of anxiety, depression, or substance abuse disorders might be vulnerable to developing PMI. Without social support (information, advice, and emotional support) some women might find it difficult to cope with the stress of pregnancy. Another plausible cause could be socio-demographic factors such as age and income. Financial strain, unemployment, and low educational attainment could increase the likelihood of PMI. Stressful situations such as significant loss or personal trauma could exacerbate the risk of PMI. Unplanned pregnancies, previous pregnancy complications, and difficult birth experiences could aggravate the chances of PMI. Women with negative cognitive styles, such as high neuroticism or low self-esteem, are at elevated risks of experiencing PMI. Another plausible cause for declining MMH is nutritional deficiency, caused by food insecurity or poor eating habits. The stress associated with not having consistent access to nutritious food can lead to anxiety, depression, and other mental health issues. This situation creates a feedback loop, where mental health and nutritional challenges continue to reinforce one another.
The Paucity of Institutional Support
India has signed the UN Millennium Development Goals to reduce the maternal mortality rate (MMR) by 2030. As stated in a special bulletin, MMR has declined from 130 in 2014-16 to 97 in 2018-20. While there has been a steady decline in MMR, perinatal mental health has not been in focus.
An analysis of national policies for perinatal mental health in India found that of eleven relevant policy-related documents covering maternal health and mental health, not one included any provisions for perinatal mental health. While Pradhan Mantri Surakshit Matritva Abhiyan does advocate for counselling, it is oriented towards unintended, unwanted, or mistimed pregnancy, contraception, and family planning, with no attention to maternal mental health.
Additionally, institutional support for PMI is more accessible to educated, urban women due to better awareness of available mental health resources. In contrast, rural women face significant barriers, primarily due to limited knowledge and the lack of trained professionals in these areas. Even if rural women wish to seek help, they are constrained by the absence of mental health services (MHS). A study on rural women in Maharashtra discovered that the key barrier to MHS is stigma. The stigma in rural areas was observed to be a three-tiered concept consisting of insufficient understanding, unfavorable perceptions, and alienating behaviours. Another study conducted in rural Odisha elucidates this phenomenon, wherein majority of participants feared societal reactions and discrimination, and thus, refused to seek medical help. They also believe mental illness are spiritual problems that can be rectified by priests. This disparity highlights the need for increased awareness and improved access to mental health support in rural communities.
Learnings from Other Countries
A study on perinatal mental health care in Europe enables us to understand what worked in other countries and how it can be implemented to aid Indian women. For instance, Belgium published a protocol for screening, detecting, and treating PMI in the Flemish region. Under this, midwives conduct psychosocial assessments during hospital visits at 16 weeks gestation. Additional screenings are done at 20-21 weeks, 6-week postnatal gynecological visits, and at the baby’s 6-month check-up. In Finland, a similar protocol is followed, where initial screening is conducted at 13-18 weeks of gestation, with a follow-up at 35-36 gestational weeks, 1 week postpartum, and 5-6 weeks postpartum. Additionally, perinatal psychiatric outpatient clinics are being established in Finland to strengthen prenatal care.
Ireland developed a National Maternity Strategy outlining a model for integrating PMH services into maternity care. The care model uses a “hub and spoke” system. Smaller units (spokes) receive support from a liaison psychiatry team and mental health midwives, while larger maternity units (hubs) provide specialised perinatal mental health services led by a consultant psychiatrist. PMH midwives play a key role in Ireland. Similarly, in the Netherlands, primary care midwives provide care for both the physical and mental health of pregnant women. They are trained in recognizing severe mental health issues. Specialised medical-psychiatric departments, such as mother-baby units, are established to cater to women with severe psychiatric conditions.
India can learn from the experiences of these countries to create a similar policy and infrastructure for PMH while ensuring it reaches all beneficiaries even in rural areas.
Policy Suggestions
To develop an effective PMH policy, the government should refer to WHO’s guidelines for integrating PMH into a larger policy framework. Stepped care is a method recommended in the guidelines. Under this, the women ought to be screened during their antenatal visits and be treated based on the seriousness of the PMI issue. A successful incidence of such a method is seen in the case of South Africa, where 87.8% of women reported an improvement in their problem, 74.6% reported a positive mood at the time of the last assessment, and 91.7% of women rated the sessions as a positive experience.
Kangaroo mother care (KMC), a method where skin-to-skin contact with the baby is encouraged, is an effective way to build attachment between newborns and parents. It is recommended by the WHO and has been proven to reduce the risk of PMI in mothers and form a bond between the mother and the baby. Obstetrician-gynecologists and pediatricians could encourage KMC during postpartum check ups. It could be a recommended treatment option under stepped care method for minor cases of attachment disorders.
Establishing a mother-baby inpatient psychiatry unit is also a step in promoting PMH. These units can treat severe cases of PPA, PPD, and postnatal psychosis while providing a safe space for the mother and baby to bond. Research on a Perinatal Psychiatry Inpatient Unit (PPIU) in the US found a significant improvement in patients and high service satisfaction.
Women support groups can facilitate PMH intervention by providing knowledge and support to pregnant women in rural areas of India. As can be seen in the cases of Orissa and Jharkhand, women’s groups led by peer facilitators reduced MMR and PPD in tribal areas. A 57% reduction in PPD was noted in the intervention clusters.
Under the National Health Mission (NHM), Accredited Social Health Activists (ASHA) are tasked with being community healthcare facilitators. They play an integral role in maternal and newborn health by aiding in birth and advising on nutrition and care. However, even when identifying complications during pregnancy and delivery, they do not dedicate enough time, if any, to PMI. Adding MMH under the NHM and delegating ASHA workers to provide support to women suffering from PMI by screening for PMI during antenatal and postnatal visits could improve MMH.
Conclusion
PMH is an essential aspect of maternal health as well as child development. PMI impacts a woman’s psychological well-being and relationship with the child while having a high cost for the country. A focus on PMH can help India achieve MMR targets as well as improve the quality of life in the country. Therefore, it is crucial to raise awareness, provide accessible support, train healthcare professionals, invest in research, and advocate for policies that prioritize PMH.
