Postpartum depression amidst COVID-19 pandemic: What further could be done?

To the Editor

The Corona Virus Disease 2019 (COVID-19) pandemic has inflicted every aspect of an individual’s life. From the recent evidence, it is evident that the impact of a pandemic on mental health would be at large, enduring, and superlative in developing countries with an under-resourced mental health workforce (Jacob et al., 2021; Kola et al., 2021). The increasing incidence of postpartum depression (PPD) is of particular concern (Swain et al., 2021; Upadhyay et al., 2017). In a crisis where the mental health resource is scanty, families form the most important support system (Chadda and Deb, 2013). Asian culture is “collectivistic” in nature, wherein the family attains the cardinal position in promoting mutuality and cooperation as compared to western societies “individualism” culture. This is even more pronounced in events surrounding pregnancy, childbirth, and child-rearing. However, significant changes in the family system evolved with the dissolution of the joint family and the rise of the nuclear and extended family system.

In the South-Asian countries predilection for a male child, unhappy relationships, financial constraints, the instance of domestic violence, and deprived social or emotional support are significant predictors for postpartum depression (PPD) (Swain et al., 2021; Upadhyay et al., 2017). Of late the United Nations Population Fund (United Nations agency aimed at improving reproductive and maternal health globally) approximated that owing to lockdown 12 million women could miss access to contraception resulting in 1.4 million unintended pregnancies (“One year into the pandemic, UNFPA estimates 12 million women have seen contraceptive interruptions, leading to 1.4 million unintended pregnancies | UNFPA - United Nations Population Fund, ” n.d.). Attributed to the financial constraints caused by the pandemic, unintended pregnancies would put a greater strain on financially strained families.

Postpartum is a much demanding period for the mother requiring significant personal and interpersonal adaption, and mental health issues during this period can have far-reaching consequences for the mother and child (Verkuijl et al., 2014). Among the commonest postpartum psychiatric disorders, PPD has a global prevalence rate of 100–150 per 1000 births (Swain et al., 2021). The pattern and cluster of psychiatric disorders and psychological distress among women are different from men owing to their social circumstances, cultural, and socio-economic determinants (Malhotra and Shah, 2015). Women or mother’s affected with depression cannot function properly, which would significantly deteriorate the growth and development of their children. In severe cases of depression, there could be intentional self-harm or baby directed violence (“Kasaragod woman held for strangling baby with earphone cable | Kerala News | Manorama English, ” n.d., “Kollam woman in depression strangles baby girl to death- The New Indian Express, ” n.d.). There is an alarming need to pay more focus on maternal mental health as an integral part of maternal and child care in low and middle-income countries like India, where the pooled prevalence of PPD among mothers were estimated as 22 % in a recent report (Swain et al., 2021).

Most primiparous mother experiences mild mood disturbances (postnatal blues) usually occurring within 3–4 days of delivery, which wades off in a week without any specific treatment other than emotional support from the family members. Among 10 % of primiparous mother’s these mood changes could turn into PPD disorder manifested as uncontrollable crying, insomnia, anhedonia, anorexia, intense bouts of sadness, doubts over raising the child, and thoughts of intentional self-harm (The ICD-10 Classification of Mental and Behavioural Disorders Clinical descriptions and diagnostic guidelines World Health Organization, n.d.). PPD requires professional help either through medication or psychotherapy. Intractable PPD might end up with postpartum psychosis; a delusional disorder manifested by unrealistic thoughts and hallucinations (The ICD-10 Classification of Mental and Behavioural Disorders Clinical descriptions and diagnostic guidelines World Health Organization, n.d.).

Though there have been visible changes towards better acceptance, the prevailing stigma associated with mental illness may prevent people from swiftly seeking help. Given the quandary and the maxim that prevention is better than cure, we need to look at proactive mechanisms to identify mothers at risk of PPD. Familial support in the ante and post-natal period can be improved by social education disseminated through media, community engagement, and by incorporating a culture of women-friendly home. These aspects demand a change in the attitude of the society towards women and women-centric issues and necessitates a long term, sustainable approach. Due medical attention on perinatal mental health should begin with the initial antenatal visit, wherein public health nurse could play a vital role. During antenatal registration and subsequent visits, the pregnant women should be assessed and screened by a public health nurse for any risks or symptoms of depression. Identification of any risk or symptom receives a prompt referral and active intervention from a specialist. Post-delivery the assessments are to be timed along with the immunization of the baby. Referral and counselling services can be enhanced through telehealth facilities, particularly in remote areas where specialist services are scanty. Rapidly growing technology-based social networking can be used to proliferate a continued follow up, and integrate all the stakeholders in the loop to track and give effective time-bound intervention at minimum added cost. Sharing experiences amonng members of the networking group could lead to early identification and resolution of health issues. On the corollary, loopholes in the primary or district-level health systems or tracking systems may pose challenges in its implementation.

To sum up, programs aimed at delivering maternal mental health need to be tailored in accordance to the socio-cultural differences of a country and incorporate family, societal support systems, public health nurse, gynaecologist, psychologist, and paediatrician to provide seamless care to the needy.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of Competing Interest

None.