by Dr. Urvashi Priyadarshini, Dr. Arathi P Rao and Dr. K. Rajasekharan Nayar
The concept of being “healthy” is commonly associated with physical health, and mental health normally occupies a secondary role although it is contained in the WHO definition of health. It was and is considered a taboo and, people with mental health problems feel uncomfortable discussing their issues due to fear of stigma and discrimination. However, in recent years, the importance of Mental Health is being globally acknowledged and it has even been included as a target in the Sustainable Development Goals (SDG 3.4).
According to the World Health Organization, globally, approximately 10% of pregnant women and 13% of women who have given birth, experience mental health problems. In developing countries such as India, these numbers are even higher, 15.6% and 19.8%, during and post-pregnancy respectively.  These mental health problems most commonly include antenatal and postpartum depression, psychosis, anxiety, stress, etc.
Several factors may be contributing to the high prevalence of maternal mental health (MMH) problems. These can be poverty and lack of financial resources, unsupportive spouse or family, pressure for a male child, unintended or adolescent pregnancy, domestic violence, large family size, general stress and/ or anxiety regarding the pregnancy or pre-existing psychiatric problems. . The recent COVID-19 pandemic has led to additional stress factors in the general population and especially among pregnant and new mothers. The fear of infection, for oneself and their infants, may be a stress-causing factor in mothers. Pregnant mothers also may have socially isolated themselves to avoid infection and this may lead to the feeling of loneliness, hence taking a toll on their mental health. Due to hospitals and healthcare facilities being hotspots for COVID-19 infection, home deliveries with or without the assistance of trained health workers are being preferred. This may again heighten the levels of stress and anxiety in expecting mothers.
The failure to address MMH issues may affect maternal morbidity and mortality with its impact on her children. Mental illnesses sometimes go undiagnosed because some of the key signs and symptoms, such as fatigue and poor sleep patterns, align with symptoms of pregnancy itself. Pregnant women and mothers who have mental health problems may develop high-risk behaviors such as alcoholism or substance abuse. This is not only harmful to the fetus but may also lead the mother to neglect the child. Antenatal depression and anxiety have been associated with pregnancy-related complications, negative childbirth experiences, and even pre-term labor. It is also associated with more frequent hospital visits, hospitalizations due to exaggeration of “pregnancy symptoms.”  Several studies show that postpartum depression is strongly linked to cognitive, emotional, and behavioral problems in children because the mother is unable to bond with the infant. Due to depression, the ability of the mother to take care of her newborn is jeopardized and as a result, the survival and development of the infant are hampered. In low- and middle-income countries (LMICs), maternal depression is seen to be linked with low infant birth weight, malnourished and growth-stunted children, incomplete schedules of immunization (in children), multiple episodes of hospitalizations due to neglect, and in certain instances, infant -deaths. Women plagued with mental health problems are also seen to be non-compliant with antenatal or postnatal care regimen. MMH issues can also lead to maternal mortality either directly through suicide or indirectly through compromised physical health needs.
The well-being of women has been made a priority by the Government through the Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) Programmes. This programme follows the “continuum of care” approach that provides integrated health service from adolescence, pre-pregnancy to delivery and immediate postnatal period to early childhood. The “Adolescent” domain focuses on both the physical and mental wellbeing, but, in the “Maternal” domain of the programme, the focus remains largely on the various interventions for physical health with special attention to reducing maternal deaths. Although, India has recognized the importance of mental health with the introduction National Mental Health Policy in 2014, Maternal Mental Health remains unfocused. This component remains to be integrated into the RMNCH+A programme to ensure a comprehensive approach towards maternal healthcare.
The immediate concern is to make policymakers and healthcare workers aware of the “missed opportunity” of integrating maternal mental health into existing policies. An inter-sectoral collaboration between maternal health programs and mental health programs is the way to go for addressing this problem. This could include:
- screening for mental health issues during pregnancy,
- establishing proper referral channels for counseling,
- development of treatment protocols for MMH problems as some pharmaceutical drugs cannot be prescribed during pregnancy,
- sensitization training for non-specialists and staff,
- mental health literacy campaigns for the community to avoid stigmatization
- establishing telehealth or digital health services for ease of consultation (helpful during the time of pandemic or pandemic-like situations)
- health education or counseling sessions for young couples at high risk for mental health issues
An improvement in the maternal mental health status is the need of the hour for achieving other health targets in the country concerning women and children because of its direct impact on maternal morbidity and mortality and the intergenerational impact on the health of the children. With the uncertainty of the pandemic, it is imperative to acknowledge and address this problem. As many developed countries, such as the United Kingdom, have successfully implemented maternal mental health policies, a mental health dimension for pregnant and postnatal women will add to the holistic approach of the national programme.
Dr. Urvashi Priyadarshini is a dental surgeon and currently a postgraduate student, pursuing Master of Public Health (Health Policy) at Prasanna School of Public Health, Manipal Academy of Higher Education (MAHE), Manipal, India.
Dr. Arathi P Rao is the Coordinator of MPH Programme and the Head of Manipal Health Literacy Unit at the Prasanna School of Public Health, Manipal Academy of Higher Education (MAHE), Manipal, India.
Dr. K. Rajasekharan Nayar is the Principal of Global Institute of Public Health and the Chief Fellow at Santhigiri Research Foundation, Thiruvananthapuram, Kerala.
- World Health Organization. WHO | Maternal mental health [Internet]. who.int. 2020 [cited 24 September 2020]. Available from: https://www.who.int/mental_health/maternal-child/maternal_mental_health/en/
- World Health Organization. Maternal Mental Health and Child Health and Development in Low and Middle Income Countries [Internet]. Who.int. 2008 [cited 24 September 2020]. Available from: https://www.who.int/mental_health/prevention/suicide/mmh_jan08_meeting_report.pdf?ua=1
- World Health Organization. Improving Maternal Mental Health [Internet]. Who.int. [cited 24 September 2020]. Available from: https://www.who.int/mental_health/prevention/suicide/Perinatal_depression_mmh_final.pdf?ua=1
- Rahman A, Surkan PJ, Cayetano CE, Rwagatare P, Dickson KE (2013) Grand Challenges: Integrating Maternal Mental Health into Maternal and Child Health Programmes. PLoS Med 10(5): e1001442. https://doi.org/10.1371/journal.pmed.1001442