Why Is India Ignoring Mental Health Of Its Moms?

32 year old, Pranjla a primigravida (first-time-mom) who resides in North Delhi’s Model Town says her whole world changes once the sunsets, as the approaching night time gets her anxiety to uncontrollably high levels which she has been dealing with for the past nine months after her pregnancy. Although she says there is no set clock for the anxiety to set in at night the effect on her is more prominent. 

”I started having it 2-3 months after giving birth. To define it I would say it's like having excessive fear and worry, to an extent that you cannot eat or sleep. It will not necessarily last the whole day but at any point in time any sad or negative thought can trigger it,” Pranjla stated while sharing her experience with BW Healthcare World. 

She said that once the baby comes the mother becomes secondary adding that the mother is on her own as everyone’s attention is on the baby and along with others mothers also start neglecting themselves. 

Adding further Pranjla stated, “You are no longer a beautiful woman, the constant pains, the constant crying babies, staying up most of the night with the baby, staying indoors for so long.  A lot of support is needed to get through this stage, some lucky ones get support for a couple of months, which always seems less.”

Over 23 per cent of women in India suffer from anxiety during the course of their pregnancy according to a 2020 research published in an American journal Sage Journals. Anxiety is known to be a prominent cause for depression, experts say that chances of falling into depression become much higher when an anxiety disorder already exists. 

Perinatal depression is the most common comorbidity of pregnancy and remains a major public health challenge around the globe. As per England’s National Health Service (NHS) perinatal period begins from conception and lasts till a year post the pregnancy.

Global studies indicate that 13 to 30 per cent of women suffer from perinatal depression with most of the burden in low and middle-income countries. Several Indian studies published in the US journal PubMed Central have revealed that the prevalence of perinatal depression is anywhere around 22 to 23 per cent in Indian women. 

The studies further showed that factors such as financial difficulties, past history of psychiatric illness in mothers, marital conflict, domestic violence or ill-treatment by in-laws, lack of support from husband and birth of a female baby were few of the multitude of risk factors related with perinatal depression.

A devastating outcome of perinatal depression is suicide, Dr Kersi Chavda, Consultant, Psychiatry, P. D. Hinduja Hospital & Medical Research Centre at Mahim stated that in a study on an Indian cohort of pregnant women, suicidality was noted in 7.6 per cent of mothers.

Dr Chavda further said that perinatal depression is also associated with negative effects on a child’s behavioural, cognitive and emotional development, birth outcomes, and physical growth.

Signs & Symptoms Of Perinatal Depression

Depression is the outcome of neurotransmitter imbalances, says Dr Kamna Chhibber, Department of Mental Health and Behavioral Sciences, Fortis Healthcare adding that it can be triggered on account of psychological or social factors that increase vulnerability to the precipitation of the illness.

According to Dr Supriya Malik, Developmental Psychologist and Founder at eMbrace, common signs of perinatal depression include frequent crying, trouble sleeping, (even when the baby is sleeping), fatigue or low energy, changes in appetite, increased anxiety, trouble feeling connected to your developing baby (poor foetal attachment), feelings of excessive guilt or low self-worth, and hopelessness about the future. 

Other signs include difficulty in concentrating, remembering or making decisions, persistent doubts about the ability to care for the new baby, thoughts about death, suicide or harming oneself or the baby.

Multitude Of Transitions 

Pregnancy is the single most life-altering and dramatic experience for women, experts say the drastic changes in their biological, physical and mental health make them vulnerable to depression. 

“Changes in hormone levels, notably the postpartum decline in oestrogen and progesterone are a contributing factor. Genetic predisposition can become a concern for those with a history of depression,” said Dr Swati Sinha, Senior Consultant, Obstetrics & Gynecology -Senior Consultant Rosewalk Healthcare By Rainbow Children’s Hospital, Delhi. 

Psychologists believe that for many women pregnancy and having a child means losing their self-identity and they are not encouraged to speak about this. 

“It is important that women speak out about having such feelings because it is OK for one to want a baby and yet be sad because your entire life is changing,” Dr Malik delineated. 

Dr Malik further said that the idea of having a child has been romanticised for women adding that it is often associated with notions such as “a baby completes a woman”, “having a child is the most important thing for a woman” etc. “These are dangerous notions because pregnancy and post-natal period may not be such a great period for everyone,” Dr Malik added. 

Experts also say due to the intense stigma around mental health women may fear being labelled as ‘crazy’ or ‘weak’ which can deter them from seeking help and openly discussing their feelings. 

“Understanding and support from the family play pivotal roles in identifying and facilitating recovery from perinatal depression. Families must provide the young mother with the time and space she needs to care for herself. It's crucial to remember that perinatal depression is a phase that, with strong family support, can be navigated,” stated Dr Harini Atturu, Consultant - Psychiatry, CARE Hospitals, Hi-Tec City, Hyderabad.

Clinical experts advise women to openly share their thoughts and feelings with healthcare providers and not hesitate due to shame or guilt in seeking help. Preplanning for postpartum depression, and navigating with the help of healthy habits like exercise and mindfulness coupled with therapy and counselling are some of the ways that might make the road easier. 

 Medications - Not A First-line Treatment

55-year-old Nazmeen living in New Delhi's Paschim Vihar has been taking antidepressants for the last 21 years without a miss. She first started taking the medications regularly after the birth of her third daughter who was six months old when she fell into depression the second time. 

She says a few years earlier the loss of her father put her into depression. She then resorted to antidepressants which made her better following which she stopped taking the drugs. But a few years later after her third daughter was born. A feeling of loneliness at home struck her suddenly with the other two kids visiting school and her husband busy at work. 

“This led me to being disinterested in household chores and my condition then slowly went from bad to worse as I did not realise what was happening to me. My husband then realised that there was a problem and we went to see the doctor and my meds started again,” said Nazmeen while speaking to BW Healthcare World. 

Since then she says the medications have been a regular part of her life as her doctor advised her not to go off from the drugs. 

“When I got better I asked the doctor to take me off the meds or to reduce my dosage, he always insisted saying that it might make my condition bad again. I tried going off the antidepressants myself. Everything was normal but it created a difficulty for me in falling asleep so I had to continue.”

On August 04 the United States Food and Drug Administration gave its nod to the first oral drug indicated for the treatment of postpartum depression - Zuranalone. Experts say that although this is a welcome step cautious enthusiasm is warranted as drugs are only one aspect of addressing perinatal depression. 

Dr Sinha stated that drug interventions are not typically the primary approach for addressing a range of issues. “Some medications have the potential to lead to substance abuse due to their propensity for dependence and tolerance. Extended usage can result in alterations to brain chemistry, compelling individuals to seek higher doses to achieve identical effects. This pattern heightens the risk of addiction, adversely impacting both their physical and mental wellness,” Dr Sinha said. 

According to experts medications are not recommended as a first-line solution for most patients, and best practice is to consider plans that target psychosocial factors linked with the development of perinatal depression. However, in specific cases, the judicious use of medication under strict medical supervision can be effective.

Awareness - The Biggest Impediment

Awareness stands as the biggest obstacle to availing effective treatment options or counselling. According to a 2019 study published in PubMed, over 91 per cent of pregnant women in India were not aware of perinatal depression while only 8 per cent (23 out of 270 women) had knowledge about it.  

Another challenge experts say is the awareness of medical practitioners and the healthcare workers themselves. The study states that close to 60 per cent of nursing professionals surveyed believe that postnatal depression is a non-serious condition. While 25 per cent (5 doctors) of medical practitioners believed that women get postpartum depression as they have unrealistic expectations. 

While explaining the lack of awareness among obstetricians and healthcare workers, Dr Malik said that most do not ask questions about how the patient is feeling and are unaware of symptoms of perinatal depression. 

“Finally, they don't know where to refer or how to handle this patient. They will ask the patient to cheer up, go out with family etc. but not encourage them to seek mental health support,” Dr Malik enumerated. 

The medical talent in mental health is also scarce in India while for some patients the expensive fees for availing a counselling session is itself a barrier.

Maternal Mental Health Missing In Govt Schemes

The government’s flagship maternal health scheme in effect since 2013, the reproductive, maternal, newborn, child and adolescent health (RMNCH + A) programme fails to cater to the mental health challenges that arise out of pregnancy while only focusing on the physical well-being aspect of mothers.

The National Mental Health Program (NMHP) in effect since 1982 also fails to include maternal mental health in its purview even after many revisions of the program over the years. 

“Mental health is often not fully integrated into maternal and child healthcare programs. This results in perinatal depression being overlooked during prenatal and postpartum care,” Dr Malik explained.

Dr Malik also highlighted that the health management information systems are also not properly documented. 

Further, Dr Sinha said that the government can play a pivotal role by allocating funds for mental health programs, training healthcare providers, and creating policies that prioritise maternal mental well-being. “Government-initiated helplines and accessible treatment centres can ensure timely assistance, reducing the prevalence and impact of perinatal depression,” Dr Sinha added.