Abstract
BACKGROUND:
Pregnancy and early motherhood represent periods of significant psychological vulnerability. An estimated 10–15% of mothers experience postpartum depression (PPD) annually in India. Maternal mental health (MMH) represents a critical public health concern, impacting both maternal and child well-being. This study constitutes the first qualitative exploration in India to examine perspectives of both mothers and healthcare professionals regarding PPD for the development of culturally appropriate educational intervention.
MATERIALS AND METHODS:
This qualitative exploratory study, conducted from April to August 2023, employed three focus group discussions among a total of 25 participants: 14 mothers attending immunization clinics at urban and rural primary health centres, and 11 healthcare professionals with expertise in MMH. Semi-structured discussion guides facilitated exploration of PPD awareness, cultural beliefs, barriers, and intervention preferences. Audio recordings were transcribed verbatim and analyzed using thematic analysis.
RESULTS:
Five distinct themes emerged across two participant categories: PPD awareness, barriers to help-seeking, impact of PPD, management strategies, and video intervention preferences. Findings revealed a lack of PPD awareness among mothers. Public health experts perceived an increasing trend in the occurrence of PPD in rural settings. Both groups endorsed video interventions as effective tools, emphasizing it to be concise, available in regional language, and a multi-platform dissemination strategy.
CONCLUSION:
This qualitative study reveals substantial knowledge gaps regarding PPD and suggests video interventions as effective tools towards awareness promotion. Culturally relevant educational interventions hold strong potential to enhance PPD literacy. Integrating these insights would enable health policy frameworks to strengthen early identification systems and improve care pathways.
Keywords: Health education, maternal health, mental health literacy, postpartum depression, video intervention
Introduction
The well-being of the mothers, particularly during the perinatal period, represents a global public health challenge transcending cultural and socioeconomic boundaries.[1] While motherhood is characterized by joy and fulfillment, it also represents a period of profound physical, psychological, and social transformation that may precipitate emotional distress among vulnerable women.[2,3]
Depression and anxiety constitute the most prevalent forms of maternal mental health (MMH) disorders, with postpartum depression (PPD) affecting an estimated 10–15% of mothers annually in India, with 25–50% experiencing persistent symptoms extending beyond 6 months postpartum.[4,5] Given the higher prevalence of PPD in low- and middle-income countries like India, a comprehensive understanding and systematic identification of PPD remains crucial for providing evidence-based maternity care.[6,7]
PPD manifests through diverse symptomatology, including persistent sadness, anxiety, irritability, sleep and appetite disturbances, concentration difficulties, and feelings of guilt or inadequacy.[8] Mothers diagnosed with PPD demonstrate a threefold increased risk of suicidal behaviors compared to unaffected mothers.[9] The symptoms frequently become conflated with “baby blues,” while community stereotypes perpetuate misconceptions that PPD represents normal postpartum experiences.[10] Societal stigmatization and misunderstanding of PPD create significant barriers to treatment access, contributing to widespread underdiagnosis of mood disorders.[11] The stigma becomes exacerbated through cultural idealization of motherhood, leading affected mothers to experience self-blame and perceived weakness. Epidemiological studies indicate that approximately 50% of mothers with PPD remain undiagnosed by healthcare professionals, although 80% achieve full recovery with appropriate treatment.[12]
There are established models to examine health behavior. This qualitative exploration is based on the Health Belief Model, which emphasizes the role of knowledge, attitudes, and environmental factors in health behavior adoption.[13] These theoretical frameworks guide understanding of how maternal awareness, cultural beliefs, and social support systems influence help-seeking behaviors for PPD as depicted in Figure 1.
Figure 1.
Conceptual framework illustrating factors influencing postpartum depression (PPD) recognition and help-seeking behavior
Creating awareness represents the most effective strategy for reducing underdiagnosis rates and facilitating appropriate help-seeking behaviors. Public awareness campaigns utilizing media platforms prove effective for depression education, while training workshops enhance knowledge among professionals and community health workers supporting individuals with psychiatric conditions.[14] Recent randomized controlled trials indicate that online depression literacy interventions significantly reduce stigma, particularly among individuals with elevated depression scores.[15] This study constitutes the first phase of a comprehensive video intervention development project titled “Study on Awareness and Management Based Health Action Using Video intervention (SAMBHAV) for PPD” aimed at raising awareness and improving PPD literacy.[16] Through a qualitative approach, this study captures comprehensive perspectives on PPD from both mothers and healthcare professionals, informing culturally relevant video intervention content.
Materials and Methods
Study design and setting
A descriptive qualitative study design utilizing phenomenological approaches was employed to explore comprehensive perceptions of PPD among mothers and healthcare professionals. Three focus group discussions (FGDs) were conducted between April 2023 and August 2023, with separate sessions for mothers and healthcare professionals to capture context-specific insights and minimize social desirability bias.
FGDs with mothers were conducted at immunization clinics in Mathikere, Urban Primary Health Centre (UPHC), and Harohalli, Rural Primary Health Centre (RPHC), both affiliated with Ramaiah Medical College Hospital, Bengaluru. The healthcare professionals’ FGD was conducted online via the Zoom platform to accommodate professional scheduling constraints and geographical diversity.
Study participants and sampling
A total of 25 participants were enrolled, comprising 14 mothers and 11 healthcare professionals. Convenience sampling was utilized to recruit participants meeting specific inclusion criteria.
Mothers included individuals with children aged ≤1.5 years, fluent in the Kannada language, and attending immunization clinics at designated health centers. Exclusion criteria encompassed mothers with diagnosed psychiatric conditions or those unable to provide informed consent. Healthcare professionals were recruited based on expertise in MMH disciplines from both government and private healthcare sectors. The multidisciplinary team included: Pediatrician, gynecologist, clinical psychologist, psychiatric social worker, yoga expert, speech pathologist, clinical nursing specialist (one each), public health specialists (n = 2), and perinatal mental health specialist (n = 2).
Data collection tools and techniques
Study team members recruited mothers during routine immunization clinic visits. Detailed explanations were provided individually, with interested participants invited to participate following written informed consent.
Healthcare professionals received email invitations requesting participation. Due to logistical constraints and professional schedule accommodations, these FGDs were conducted online using the Zoom platform to ensure maximum participation.
Semi-structured FGD guides were developed through a comprehensive literature review, addressing MMH, PPD awareness, and intervention preferences. Separate guides were prepared for mothers and healthcare experts to ensure relevance and exploration depth for each participant group.
Each FGD was facilitated by two investigators proficient in both Kannada and English languages. The FGD with mothers was conducted in Kannada while healthcare professional discussions occurred in English, ensuring optimal communication and participant comfort. All sessions were audio-recorded with participant consent, supplemented by detailed field notes to enhance data richness and contextual understanding.
Ethical considerations
Ethical committee clearance was obtained from the Institute Ethics Committee of National Institute of Mental Health and Neurosciences (NIMHANS) (Ref No. NIMHANS/37th IEC (BEH.SC.DIV)/2022 and Ramaiah Medical College Hospital, Bangalore (Ref No: MSRMC/EC/AP-04/06-2022). The trial was registered under the Clinical Trial Registry-India (CTRI/2023/03/050836). All procedures adhered to the Declaration of Helsinki principles for research involving human participants.
Statistical analysis method
Audio recordings from Kannada FGDs were transcribed and translated into English by bilingual research team members. English FGDs were transcribed verbatim. Thematic analysis was performed manually following Braun and Clarke’s framework. The data familiarization, initial code generation, theme searching, review and refinement, theme definition and naming, and report production were done by two independent researchers with a background in a master’s in public health and psychology; however, the inter-coder reliability could not be checked. Multiple transcript reviews enhanced data familiarity, followed by code generation and organization.
Results
Three FGDs focused primarily on components relevant to educational video on PPD awareness. Total participant involvement included 14 mothers (mean age 27.6 ± 2.78 years) and 11 healthcare professionals. Regarding educational qualification, 50% of the mothers held graduate or higher degrees, with 85.7% being homemakers, and more than half (64.3%) were within 6 months postpartum. Among the healthcare professionals, 72.7% possessed over 10 years of professional experience across diverse health domains.
FGD durations ranged from 45 to 98 minutes (average 65 minutes). Results were organized under two primary categories: Mothers and healthcare professionals, with specific themes and subthemes identified and detailed in Tables 1 and 2, respectively.
Table 1.
Themes and subthemes from FGDs among mothers
| Themes | Sub themes | |
|---|---|---|
| PPD Awareness: Prevalence, risk factors, and symptoms | Lack of Knowledge and Awareness | |
| Mental Health Matters | ||
| Navigating Change: Marriage, Motherhood, and Mental Health | ||
| Stressors: The Path to Mental Illness | ||
| Barriers to seeking help | Traditions Shape Perceptions | |
| Underestimated and Overlooked | ||
| Silent Struggles: Impact of Stigma | ||
| Management and available services for tackling PPD | Self-Care and Family Support Matters | |
| Routine Screening for Maternal Mental Health | ||
| Strategies for improving awareness and dissemination | Seeing is Believing: To Raise Awareness | |
| Short and Engaging Content |
FGD: focus group discussion, PPD: postpartum depression
Table 2.
Themes and subthemes FGDs among healthcare professionals
| Themes | Sub themes | |
|---|---|---|
| PPD Awareness: Prevalence, Risk Factors, and Symptoms | PPD Prevalence | |
| Triad of Risk Factors | ||
| Spectrum of PPD Symptoms | ||
| Barriers to Seeking Help | Stigma and Discrimination | |
| Barriers to Access and Implementation | ||
| Management and Available Services for Tackling PPD | Importance of Early Screening | |
| Holistic Approaches towards PPD | ||
| Impact of PPD | Stepped-Care for improving Access | |
| Impact on Mother | ||
| Impact on children and family | ||
| Strategies for Improving Awareness and Dissemination | Engage Families to Promote Well-Being | |
| Leveraging Media and Technology for Maternal Well-Being |
FGD: focus group discussion, PPD: postpartum depression
Theme 1: Understanding PPD prevalence, risk factors, and symptoms
Mothers: Most mothers indicated unfamiliarity with MMH, particularly PPD. Understanding varied significantly, with some recognizing related issues without awareness of potential mental health connections. Many emphasized mental well-being importance for maternal and child health, though RPHC mothers showed limited responses regarding MMH awareness. Participants identified contributing factors, including post-marriage environmental adaptation challenges, and conception immediately following marriage, potentially amplifying stress and mental health risks. Physical and mental changes during pregnancy could be additional distress contributors. Several mothers highlighted a crucial lack of support from husbands, in-laws, and parents throughout postpartum periods. Mothers lacked adequate knowledge about symptoms.
Healthcare professionals: PPD prevalence responses varied between government and private practitioners. Private practitioners mentioned that fewer numbers get reported, and contrary to that, there was an increase in numbers found in rural community settings as reported by public health experts, with improvement in maternal health and screening services. Overall, MMH issues have increased over recent years, with risk factors including physical and psychological changes, high-risk pregnancies, domestic violence, societal pressures, and work-life balance challenges. Emotional and family support were identified as critical factors, along with a previous history of mental illness, potentially impacting mothers during the pregnancy and postpartum period. Experts categorize PPD symptoms as psychological or cognitive, varying by severity.
Symptoms included sadness, irritability, restlessness, anxiety, self-harm or suicidal ideation, and bonding/feeding difficulties. Initial symptoms may be present as postpartum blues (crying, mood swings), but persistence beyond 10 days may indicate PPD. PPD can disrupt daily activities, with mothers experiencing feelings of inadequacy, preferring isolation, losing interest, and suffering from insomnia.
Theme 2: Barriers to seeking help
Mothers: Participants frequently reference cultural contexts and PPD-associated stigma. Mental health issues during pregnancy are often dismissed as bad omens or attributed to superstitions. Older generation influences emerged as significant factors, with mothers feeling compelled to follow elders’ guidance in the family. Reluctance to seek help exists as MMH challenges often lack recognition as legitimate health conditions. Mental health stigma exacerbates these issues, deterring mothers from seeking support or discussing their experiences.
Healthcare professionals: Experts have identified significant barriers at individual, family, and healthcare system levels. Individual-level stigma and limited awareness regarding PPD impede help-seeking behaviors, with prevalent misconceptions discouraging mothers from sharing experiences. Family dynamics create barriers when relatives downplay symptoms as typical postpartum changes, deterring professional support seeking. Healthcare access limitations, including inadequate counselling services, mental health professional shortages, and privacy concerns at primary care centres, further restrict effective PPD support.
Theme 3: Available services for tackling PPD and its management
Mothers: Most participants lacked awareness of available MMH treatment services. Discussions introduced management strategies including self-care, family support, and healthcare worker/community assistance. One mother suggested consulting a “Manasika Doctor” (psychiatrist) could be beneficial. Emphasizing self-care, mothers expressed that well-being prioritization can build resilience to stress. Family support was widely recognized as essential for mental health. Participants suggested implementing guidelines to help healthcare workers identify and support at-risk pregnant and postpartum women during routine care visits.
Healthcare professionals: Experts indicated PPD management involves pharmacological and psychological approaches, with family involvement as needed. Psychological management, including psychoeducation for mothers, partners, and families, is often preferred, with cognitive-behavioral therapy being effective. Medication is reserved for severe cases. Peer support from mothers who have recovered can be beneficial. Currently, dedicated mental health services are scarce at the Primary Health Center (PHC) levels, though some areas are beginning to integrate MMH support. Antenatal and postnatal screenings remain limited, but referral pathways could enable trained frontline health workers to manage mild-to-moderate cases and refer severe cases to specialists.
Theme 4: Impact of PPD
Healthcare professionals: Experts reported that PPD impacts maternal health, family dynamics, and child development. Increased risks include maternal morbidity, mortality, and suicidal tendencies, alongside strained mother − child − family relationships. For infants, maternal PPD commonly leads to feeding difficulties, delayed vaccinations, and missed health check-ups, affecting physical and emotional development. Untreated PPD can influence a child’s behavior, potentially causing motor, temperament, and language delays.
Theme 5: Strategies for improving awareness and dissemination among mothers
Mothers: Detailed discussions addressed creating engaging, concise awareness videos, covering content, duration, and dissemination strategies. Mothers emphasized video conciseness and engagement requirements. They expressed video-based education as a viable approach, given widespread mobile phone access, supported by additional materials like flyers, brochures, and posters for public spaces and health centres. Additionally, they suggested sharing videos on online platforms, including YouTube and WhatsApp, to maximize reach and impact.
Healthcare professionals: Discussions highlighted critical perinatal mental health awareness gaps, particularly regarding PPD, underscoring needs to improve mental health literacy from antenatal through postnatal periods. This awareness gap extends to healthcare providers and mothers. Experts suggested leveraging existing health workforces with targeted grassroots training. Video-based interventions, developed with stakeholder input, were recommended as effective tools given accessibility and comprehension ease. Dissemination could occur through government channels and social media platforms to broaden community reach.
Discussion
The present investigation explores PPD perceptions among mothers and healthcare professionals, examining mental health understanding, cultural beliefs, stigma, prevalence, risk factors, help-seeking barriers, and overall impact. The research explores prevention and management strategies while highlighting participant suggestions for developing and disseminating educational videos.
Based on the FGDs of this study, this qualitative exploration yielded two broad categories encompassing five distinct themes, each with relevant subthemes reflecting the insights of both mothers and healthcare experts. Study findings reveal substantial PPD awareness deficits among mothers, with many reporting complete unfamiliarity with PPD and MMH terminology. This aligns with previous studies indicating that over 90% of women were unaware of PPD.[2,17]
The public health experts, as part of FGD, suggested an increase in the number of mothers with PPD in rural community settings with recent improvement in maternal health and screening services, contradicting a meta-analysis conducted in India.[18] This discrepancy may be attributed to limited mental health access, cultural differences, treatment-seeking patterns from rural settings, and a lack of mental health resources, resulting in underreporting or misdiagnosis. Additionally, experts were mainly from tertiary settings providing severe condition treatment. Further research is needed to explore these factors and clarify the true prevalence of PPD among both rural and urban settings.
The study highlights significant barriers to help-seeking PPD among mothers. Key barriers preventing mothers from seeking help for PPD include a lack of awareness deficits, compounded by stigma and cultural beliefs. In India, PPD is often viewed as a “bad omen,” reinforced by older generations. Traditional maternal care, influenced by cultural norms, often emphasizes elder guidance, who may downplay mental health concerns. Healthcare professionals identified barriers at the individual, family, and healthcare system levels.
Cultural norms, particularly at the individual and family level, significantly shape mental health attitudes, discouraging treatment-seeking due to perceived stigma.[19,20] Furthermore, many mothers are uncertain about appropriate support sources due to awareness deficits. At the healthcare system levels, an acute shortage of trained mental health professionals exists, with only 0.3 psychiatrists per 100,000 people in India.[21] Addressing these cultural beliefs and enhancing mental health literacy within families and communities is essential.
The study underscores the profound impact of PPD on maternal health, family dynamics, and child development. Experts indicate PPD can lead to increased maternal morbidity, mortality, and suicidal ideation, consistent with prior studies.[22] Women with PPD face increased suicidal behavior risks, especially within the first year.[23,24] Additionally, mothers reported partner and family support as crucial during postpartum periods, aligning with previous research.[25,26,27,28] Lack of partner support represents one of the major PPD risk factors.[18,29,30]
Maternal PPD can impact infants, leading to feeding difficulties, delayed vaccinations, and missed health check-ups, affecting physical and emotional development, consistent with previous studies.[31,32] PPD prevention begins with raising awareness through health education from antenatal periods, continuing through the first postpartum year.
Experts emphasize that effective PPD management involves both pharmacological and psychological approaches, with critical involvement from families. Psychological management, including psychoeducation, is often preferred, with cognitive-behavioral therapy proving effective, along with peer support from recovered mothers considered beneficial, consistent with previous studies.[33,34]
Based on existing health policy benchmarks, comprehensive strategies including health education, routine screening, and health worker training are essential to support mothers with PPD. Integration with general health services alongside obstetric and pediatric services may further enhance perinatal mental health care within the healthcare system level for early identification and appropriate PPD treatment.[35] Also, family-centered education has shown a positive effect on reducing the severity of posttraumatic stress among mothers.[36]
All participants expressed a positive attitude towards using educational videos as effective in improving PPD literacy. They suggested that the video should be short, relevant, and presented in the local language, addressing PPD complexities. Video interventions tend to appeal to emotional components in the listener, creating empathy and identification, which aids in the reduction of stigma and promotes help-seeking. Video interventions can also be easily disseminated.[33,37] This aligns with previous research showing that educational videos can reduce stigma and increase PPD knowledge.
Strengths and limitations
The study’s strength lies in being the first qualitative exploration in India to examine the perceptions of both mothers’ and healthcare professionals’ perceptions on PPD, addressing knowledge gaps for video development.
However, the study’s limitations include limited generalizability, although external validity is not the primary aim of qualitative research. The study was also only conducted among 14 mothers, who were mainly homemakers and/or graduates. This sample is not representative of diverse populations, suggesting limited generalizability. Additionally, interpersonal dynamics in FGDs may have hindered some participants from sharing openly, though efforts were made to include all voices in the discussion. The study was conducted in specific geographical regions, potentially limiting broader applicability across India’s diverse cultural contexts. The findings are preliminary, highlighting the need for further research on PPD among diverse Indian populations.
Conclusion
This was the first qualitative exploration of both the mothers’ and professionals’ perceptions on development of video on PPD, providing culturally grounded insights for video-based interventions. This study reveals substantial knowledge gaps regarding PPD and suggests video interventions as effective tools towards awareness promotion. Culturally relevant educational interventions hold strong potential to enhance PPD literacy. Integrating these insights would enable health policy frameworks to strengthen early identification systems and improve care pathways. Future research should focus on developing and testing culturally appropriate interventions, evaluating long-term outcomes of video-based education programs, and exploring the implementation of stepped-care models in diverse healthcare settings.
AI policy
Artificial intelligence (AI) tools were used exclusively to generate the conceptual framework figure (illustration/diagram) included in this manuscript. No AI tools were used in the collection, analysis, or interpretation of data for this study. All data analysis and manuscript writing were conducted entirely by human researchers. The authors remain fully responsible for the scientific integrity of all manuscript content.
Abbreviations
FGD: Focus group discussion; MMH: Maternal mental health; PPD: Postpartum depression; PHC: Primary Health Centre; RPHC: Rural Primary Health Centre; UPHC: Urban Primary Health Centre.
Ethical consideration
Ethical committee clearance is obtained from the Institute Ethics Committee of NIMHANS and Ramaiah Medical College and Hospital, Bangalore.
Author’s contributions
LK: Conceptualization, Project administration, Methodology, Supervision, and Writing – review and editing; SG: Resources and Supervision; DR: Resources and Supervision; SG: Methodology and Writing – review and editing; SA: Methodology, and Data Curation; DRS: Writing – original draft; MKS: Writing – review and editing; VHS: Writing – review and editing; MP: Methodology, analysis, Writing – review and editing; KV: Writing – review and editing.
Availability of data and materials
The Audio recordings with full transcription and translation, and the datasets utilized and analyzed in this study, are available from the corresponding author upon reasonable request.
Conflicts of interest
The authors declare that no competing financial interests or personal relationships could have influenced the work presented in this paper.
Acknowledgment
We extend our gratitude to all mothers and healthcare professionals who participated in this study. We acknowledge the support of immunization clinic staff at Urban and Rural Primary Health Centres affiliated with Ramaiah Medical College Hospital. The authors would like to express their sincere gratitude to all the mothers and healthcare professionals who participated in the FGDs, as well as to the medical officers of the PHCs for their valuable contributions to this study. Special thanks to Ms. Manasapriya, Intern and Ms. Shreya Shankar, Fellow, Department of Mental Health Education towards contribution to the transcription and translation of the FGD among mothers and health experts.
Funding Statement
This study is part of a research project titled “Study on Awareness and Management Based Health Action Using Video intervention (SAMBHAV) for PPD among mothers attending immunization clinic in a tertiary medical college hospital” funded by the Indian Council for Medical Research (ICMR), New Delhi as an Ad-hoc project under the extramural research program for the year 2021 (Reference No 202113266).
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The Audio recordings with full transcription and translation, and the datasets utilized and analyzed in this study, are available from the corresponding author upon reasonable request.