Maternal health is defined as the health of women during pregnancy, childbirth, and post-pregnancy. Although some progress has been made in recent decades, it remains a significant public health problem in India. Maternal mental health is obviously also part of maternal health, though it gets far less attention in my country. This article will examine maternal mental health in India and the many barriers to adequate mental healthcare for (expecting) mothers through the lens of the Three Delay Framework.
While maternal health remains a key public health issue in India, within the country there are major inter-state disparities. States like Uttar Pradesh, Assam and Jharkhand record high maternal mortality rates (MMR 197;215; 71 respectively) compared to southern states such as Kerala (43) and Tamil Nadu (60). Health service utilisation also remains extremely poor for many women, mainly due to lack of decision making abilities. In LMICs, the social status of the women impacts their health – usually measured by indicators such as weight during pregnancy, burden of anemia, and health status of the child. Sadly, India is no exception.
While the physical health of far too many Indian women remains neglected, a “new” challenge that arises is their mental health.
Worldwide, with 140 million births a year, about 10% of pregnant women and 13% of women suffer from some mental health disorder, primarily depression. Perinatal mental illness is a profound complication of pregnancy and the postpartum period but still goes unnoticed in many resource-scarce countries, including India. The most common disorders experienced by pregnant women include anxiety, depression, mood disorders, postpartum depression, and feelings of isolation along with Premenstrual Dysphoric Disorder that is also a rising concern.
In India, pregnant women often prioritize their families’ well-being over their own, paying little heed to their mental well-being. They are often subject to family related and/or marital stress while navigating through life-altering phases such as pregnancy, childbirth, lactation, and (first) menstruation with minimal institutional or emotional support. Also, psychological vulnerability is exacerbated by the persistent prevalence of child marriage and early pregnancy, especially in South Asia.
Thaddeus & Maine’s Three Delay Framework (1994) delineates the impediments to receiving healthcare from a women-centric lens. They are: (1) delay the decision to seek care; (2) delay arrival at a health facility; and (3) delay the provision of adequate care.
Below we apply the framework on maternal mental health in the Indian context.
Delay of Seeking Care: How many of our mothers, house helps, or even female relatives will accept that they have a mental health concern? Most women ignore their mental health from pregnancy through early motherhood, afraid to show anxiety, irritability, or a need to withdraw, even from their newborn. Other issues revolve around the cultural beliefs around seeking mental health support, being seen as an “unfit” mother, or the general lack of awareness after being told that it is all normal to feel such things.
Delay of Reaching a Service Provider: Then there’s the distance to the facilities, cost of taking a session and transportation. Moreover, in rural India, women still ask for permission from their in-laws and husband before seeking medical care. Last but not least, the responsibility of taking care of the house falls upon the women – which also doesn’t help when one needs care.
Delay in Receiving Care: As per India’s National Mental Health Survey 2015-16, there is less than 1 psychologist per 100000 people. In such conditions, even if there is awareness, how will a person then access care? A brief visit to any of the rural area’s Health and Wellness centers in India would show us the “help” pregnant women receive during and post their pregnancy. Without training to cope with women’s emotional and mental well-being, physicians and nurses concentrate on mere checkups, and overworked Auxiliary Nurse Midwives (ANMs) and Medical Officers quite frequently work out their frustrations on patients—disregarding, trivializing, and neglecting their care, and in general not going beyond providing superficial level care.
Maternal and child health are considered vital building blocks for the rest of life. Inadequate care and support during these important first months (sometimes years), leads to further physical and mental health problems for new mothers, and cognitive impairment amongst children. In India there are no schemes or policies that provide mental healthcare to women. India’s 2014 National Mental Health Policy displays a very superficial understanding of mental health issues.
While there has been much progress on improving the maternal health of women through various schemes, frontline health workers, and a more targeted approach, maternal mental health still remains largely unspoken of. Though overburdened, ANMs and ASHAs are the most trusted supporters of women in their communities, but not as medical diagnosticians, rather as readily available confidants in times of urgent need.
To offer private emotional surveillance over time, maternal and child care policies need to extend beyond anemia and low birth weight. They need to extend mental health screening via ANMs and ASHAs by educating them to document distress indicators in their government apps. They can also help normalize the emotional challenges of pregnancy as well as bring out its beauty by sharing their own maternal experience. In addition to seamless referral procedures for more severe cases, policies should include unobtrusive counseling at ANC visits or ultrasounds—to make them feel that they are not alone!
Therefore, the beautiful and honoring phase of pregnancy and childbirth requires more than just routine checkups, it also requires emotional checkups of the mother, something that the developing countries fail to take into account.