In April 2021, Deepa Goel (name changed on request), a 33-year-old homemaker in Delhi and mother to a healthy baby boy came close to committing suicide barely three months after his birth. Two weeks after delivering the child, she began experiencing negative thoughts, insomnia and severe anxiety. She recalls trying to speak to her family about it but receiving no help or sympathy in return. “They said I am just emotional because of hormones. I was crying constantly for support but nobody understood me. It was only when I tried to end my life that my husband realised the gravity of my situation and took me to a therapist," she says. Goel was diagnosed with perinatal depression, a condition which can happen to a woman up to one year after the birth of a child.
"In India, more knowledge is there about postpartum depression which happens after one year of delivery. Perinatal depression isn't even included in psychologist textbooks. Often counsellors themselves cannot recognise the condition," says Priti Sridhar, CEO, Mariwala Health Initiative, the only grant making organisation for mental health in India. She adds that the "uniqueness of maternal mental health problems in India is the fact that many mothers are not financially independent, making it difficult for them to independently access support." According to the World Health Organization, one in three to one in five women in India suffer from mental health problems during pregnancy and after child birth. Yet, awareness on their plight is largely limited. "If you want to reduce maternal mortality, you must focus on the mental health of mothers," adds Sridhar. According to experts, addressing mental health in the period of pregnancy, delivery and up to 42 days after delivery provides a good opportunity for early intervention.
"Pregnant women or mothers with mental health problems are less likely to care adequately for their personal needs, to seek and receive antenatal or postnatal care, or adhere to prescribed health regimens. Suicide is now a leading cause of death in young women in the reproductive age group in the world's two most populous countries—India and China. Mental health problems in mothers can lead to increased maternal deaths, by adversely affecting physical health needs as well as more directly through suicide," says Sriram Haridass, India representative of the United Nations Population Fund which places safe motherhood as a priority for countries. The current maternal mortality ratio in India is 113/ 100,000 live births. However, the goal is to reach a ratio of less than 70 per 100,000 live births. "Looking back, the MMR in India was exceptionally high in 1990 with 556 women dying during childbirth per hundred thousand live births. Approximately 1.38 lakh women were dying every year on account of complications related to pregnancy and childbirth. The global MMR at the time was much lower at 385. There has been an accelerated decline in MMR in India—167 in 2011-13 against a global MMR of 216 (2015)," says Haridass. The direct causes or major complications that account for nearly two-thirds of all maternal deaths are obstetric complications—severe bleeding (primarily bleeding after childbirth), infections (usually after childbirth), high blood pressure during pregnancy (pre-eclampsia and eclampsia), complications from delivery and unsafe abortions. These are preventable and treatable as are many of the other poor health consequences of pregnancy.
"As maternal mortality has declined in India, disparities have become increasingly apparent. The risk of maternal death is disproportionately highest among the most vulnerable women belonging to the lowest wealth quintile, scheduled castes, scheduled tribes, minorities, and those who are poorly educated," adds Haridass. One of the lesser-known disparities faced by mothers is access to mental health solutions, a problem that has been amplified due to the ongoing Covid pandemic. In West Bengal's Purulia district, for example, Usha Mandal (name changed), a 28-year-old mother with no private income of her own, says the community mental health counsellor would not offer her therapy due to her caste. "I stopped going for my pregnancy health check-ups because I was so depressed. My husband didn't give me money to go to Kolkata for treatment. As a result, my child was stillborn as I wasn't even sane enough to be able to consume adequate food. The food given to me I hid under the bedcovers and then threw it away the next day when no one was around," she says.
In 2012, an intervention programme in Jharkhand to reduce infant mortality realised that giving mothers a safe space to talk about physical and mental health issues reduced risk of moderate depression by 65 per cent. "Child health depends upon the health of the mother. A key step in improving both mother and child health is to ensure the mother's mental wellbeing. Community-based interventions are beneficial for this. Due to the pandemic, most clinics have been focused on Covid care and maternal mental health has hardly been a priority," says Sridhar. Experts say that mental health must be addressed in the same manner that one would physical health. It is essential if one is to ensure the holistic wellbeing of mothers and children, and improve our health parameters in both areas.
