The experience of pregnancy can be one of the most significant, yet perilous, in a person’s life. In India as in many other countries, health systems try to meet the physical challenges it poses for mothers with timely vaccinations, antenatal visits, proper nutrition, and various tests to detect high-risk pregnancies for proper precautionary care. Often, though, the mental challenges inherent in the emotional and overwhelming task of giving birth tend to be overlooked and needed psychiatric care for soon-to-be and new mothers is not delivered.
Perinatal depression during pregnancy or within the first year postpartum is one of the most common mental health disorders people experience. It is underdiagnosed in part because it can be masked by physiological changes associated with pregnancy, such as weight gain, fatigue, and sleep disturbances. Comprehensive data on its prevalence in India are not available, but a meta-analysis found that 22 percent of Indian women have postpartum depression.
22 percent of Indian women have postpartum depression
Women undergoing high-risk pregnancies due to comorbidities like hypertension and diabetes are at greater risk of postpartum depression. Social factors such as age, literacy level, family structure, occupation of the mother, and family income also influence risk. The child’s gender, help available in the postpartum period, problems with in-laws, type of house, and land ownership are also factors, according to one study conducted in rural areas in the state of Tamil Nadu.
Perinatal depression is also associated with self-harm during pregnancy and poor child development. The children of women with antenatal depression show significantly less motor and cognitive development in their first year of life.
For all these reasons, it’s crucial for primary care clinicians to screen for perinatal depression and offer options for treatment options.
A common screening tool in many high-income countries is the Edinburgh Postnatal Depression Scale, but given the diversity of languages spoken in India and the high prevalence of illiteracy, the scale needs to be adapted to work effectively. Nonetheless, a meta-analysis conducted in India found the scale to be a valid tool for screening for perinatal depression that should be used more widely.
One barrier to administering such screenings in India, and in other low- and middle-income countries, is the social stigma surrounding mental illnesses. This is compounded by unrealistic expectations about motherhood. Pregnant women and new mothers may be particularly averse to being labeled “bad mothers.” A recent study in Uganda found that the community’s negative attitudes toward mental illness and misbeliefs about its nature substantially hampered the help-seeking behavior of women and perpetuated a vicious cycle of untreated mental illness.
Lacking a supportive partner and poor access to mental health care can also be huge barriers. In low- and middle-income countries, primary health-care providers — who are pregnant women’s predominant point of contact — are often not trained to provide mental health services and tend to lack understanding of perinatal depression. For instance, In Ethiopia, only 12.9 percent of women with perinatal depression reached out for professional help, and only 4.2 percent had access to mental health services, pointing to a massive treatment gap.
To close the treatment gap in resource-limited settings, the World Health Organization recommends the stepped-care approach to maternal and child health services. The first step aims at providing nonstigmatizing care and fundamental support to women; the second is intended to enhance preventable interventions for vulnerable women who have symptoms but don’t meet the criteria for a mild mental condition; the third and fourth aim to gradually enhance the intensity of care provided to women suffering from mild and moderate mental illnesses through evidence-based methods. A first-line treatment for women experiencing depression is pharmacological therapy with certain antidepressants, but these women can also benefit from psychological therapy, which doesn’t risk drugs crossing the placenta and affecting the neonate.
India is resource constrained, with only 7.5 psychiatrists per million residents
India is resource constrained, with only 7.5 psychiatrists per million residents, so it’s essential to find innovative ways to extend care outside clinical settings. One possibility is a train-the-trainers approach, in which frontline workers are trained to screen and manage mental health conditions. In other settings, the success of these interventions depends on how culturally relevant they are and how local communities adapt to them — and India’s frontline health workers are well positioned for success given that they have frequent contact with pregnant women and new mothers and are viewed as approachable.
According to a systematic review of studies, nonspecialists such as lay counselors, nurses, and midwives have also been shown capable of providing effective care in high-income countries. India offers several examples, such as a lay worker–led, low-intensity group intervention shown to reduce depression in mothers by 30 percent. The train-the-trainers approach has been shown to be cost-effective and could help increase access to care.
Another method that can have great success is peer-led interventions in which someone who has experienced perinatal depression themselves can help provide support by sharing their personal stories and experiences, and can offer empathy, coping strategies, and insights, in a nonjudgmental environment. Peer-led interventions shift the focus from problem-solving to problem discussion, providing a rare opportunity for patients to receive validation for their feelings from trusted peers through an exchange of similar experiences. An evaluation of a mother-to-mother program in Pakistan and India found that it was successful and credited the success to shared experiences between mothers and the use of multimedia by peers to describe situations of distress. These programs are not new and have demonstrated success in addressing anxiety and depression by bridging the gap between mental health services and the community.
Perinatal depression occurs at the crux of maternal, mental, and child health. Addressing this illness at the grassroots level by destigmatizing mental health care, educating partners to be supportive, and promoting a nurturing community can improve the mental state of a pregnant woman significantly. Implementing evidence-based solutions on a local level, and integrating care provided by community members and frontline workers, would not only improve access to care but also be cost-effective and culturally adapted to different communities.
