Perinatal mental health is having a moment – at the country level
Summary
Countries like Kenya and India are taking proactive steps to integrate perinatal mental health services into their existing healthcare systems. By prioritizing mental health alongside physical health, they are working to ensure that women receive the comprehensive care they need.
Perinatal mental health – a woman’s mental health during pregnancy and the first year postpartum – is gaining greater attention across the maternal and newborn health sector, and beyond. Given the substantial treatment gap for mental health issues, estimated to be up to 85% percent in low- and middle-income countries, far too many people lack access to any mental health support at all. And yet the long-term consequences of perinatal mental health disorders are significant, intergenerational, and well-established.
Women experiencing common perinatal mental disorders such as depression, anxiety, and somatic disorders are less likely to attend antenatal care/postnatal care, more likely to experience obstetric complications, and have a preterm birth. Alarming new data from high-income countries such as the Netherlands, the UK, and other European countries have found that suicide is the leading cause of death from women within one year postpartum. And the impacts on newborn and child outcomes are significant as well.
Newborns with mothers with unsupported perinatal mental health conditions are more likely to experience poor sleep, feeding difficulties, and poor weight gain and neurodevelopment. A mother’s mental state affects her ability to bond with the newborn and to be responsive to her baby’s needs to promote good cognitive, social, and emotional development The mental health of the mother and newborn are reinforcing – which makes the need to support the mother-baby dyad so crucial for survival and promoting maternal and newborn well-being.
Perinatal mental health is an issue that has largely been ignored on the global public health agenda despite the grave impact on millions of women and families globally. Nearly 20% of all perinatal women in low- and middle-income countries experience common perinatal mental disorders. And risk factors such as living in humanitarian settings, experiencing food insecurity, or gender-based violence only increases the prevalence. To truly meet women’s and newborn’s comprehensive health care needs as outlined in the Sustainable Development Goals, health care systems must address both physical and mental aspects of health and well-being. As a global MNH community, we need to continue to support the growing interest and enthusiasm in perinatal mental health with policy commitments, increased funding for mental health, and integrated program implementation that supports both the mother and the baby.
In the sections below, we describe several recent events that have contributed to the increase in attention in perinatal mental health at country level. These events showcase meaningful actions on the part of the Kenyan and Indian national governments to start to frame perinatal mental health as an urgent priority for their populations. They offer examples for how other countries can begin to address the mental health needs of their women, their newborns, and families.
A call to action for perinatal mental health
In 2022, a team of authors from local NGOs to UN agencies put forward a bold call to action: Silent burden no more: A global call to action to prioritize perinatal mental health. This call outlined seven discrete actions that need to be taken to ensure women have the fundamental human right to good mental health during the perinatal period. The actions are: 1) establishing global standards and targets for perinatal mental health; 2) including perinatal mental health in national policies linked to budgetary allocations; 3) integrating perinatal mental health into existing health systems; 4) strengthening and conducting implementation research in perinatal mental health programming; 5) leveraging community-level strengths through task-shifting; 6) addressing social determinants of perinatal mental health; and 7) addressing the stigma surrounding seeking and accessing perinatal mental health care.
This call to action helped to frame a satellite session at the International Maternal and Newborn Health Conference (IMNHC) in Cape Town, South Africa, in May 2023. At this satellite session, co-hosted by MOMENTUM Country and Global Leadership and SPANS, Zimbabwe, more than 150 global participants came together to discuss some of the ideas and challenges they face as academics, implementers, Ministry of Health representatives, researchers, and women with lived experience in working to meet the need for perinatal mental health promotion, support, and services. The discussions were an opportunity to learn from one another and advance the conversation – what is working, where, and why? What issues are still complex? What information is still needed? What untapped opportunities for progress exist, and what are some of the real health systems limitations and challenges to meeting women’s needs?
At the IMNHC satellite session, which kicked off the conference that hosted numerous panel presentations about perinatal mental health (see the full program here), attendees also debated universal mental health screening; discussed the societal expectations of how women should react following the birth of a child; shared the reality that communities are sources of support and strength, but also that community pressures, expectations, and stigma can overwhelm pregnant and postpartum people; and reiterated the need to move outside of the health “bubble” to address issues such as poverty, gendered policies, cultural norms, and financial dependence – challenges that exist largely outside of the health sector but have an outsized impact on the ability of women to experience good perinatal mental health and positive well-being. At the conclusion of the satellite session, there was discussion about how to best continue this momentum and energy – one of the ways was through a newly created Perinatal Mental Health Community of Practice.
Launching the Perinatal Mental Health Community of Practice
Following the enthusiasm from the IMNHC 2023 satellite session and the numerous discussions around perinatal mental health during the conference and beyond, experts with global representation quickly came together to form the first-ever global community of practice focused on perinatal mental health in low- and middle-income countries. The Perinatal Mental Health Community of Practice (CoP) launched in mid-2023 with 500 attendees joining this collaborative platform of experts and practitioners working in maternal and newborn health, mental health, and related fields.
The Perinatal Mental Health CoP strives to continue to bring people together to share evidence and best practices, amplifying individual efforts to address key issues. It is led by women and men in the regions of the world where the burden of perinatal mental health has gone significantly underrecognized and under-addressed. The CoP has four Technical Working Groups (TWGs) based on areas of interest of members: evidence and impact; information knowledge exchange and learning; advocacy; and adolescents. The TWGs are tackling issues through problem-solving webinars, information-gathering surveys, and co-authoring blogs with community-based organizations, among other creative mechanisms to share knowledge and learn from one another. The CoP also sends out monthly newsletters with recent literature and related events. We have also created a private LinkedIn account to further strengthen collaboration.
How are countries investing and prioritizing perinatal mental health?
While the global community is newly coalescing around this issue, countries are taking important steps at national and sub-national levels to actively address perinatal mental health through policy enactment and the development of action plans. Kenya and India serve as regional models; both are making strong statements in their commitments and actions at the national level.
Prioritizing perinatal mental health in Kenya
In the last four years, the Government of Kenya has continued to build on a commitment to prioritizing perinatal mental health. In 2020, the President of Kenya appointed a task force to investigate the mental health status in the country. The report recommended that national- and county-level health ministries and departments ensure integration of mental health services with antenatal and postnatal maternal health care. This recommendation gave mental health the same attention as physical well-being.
Just one year following this report, the Kenya Mental Health Action Plan 2021 was launched. This Action Plan outlines strategic objectives and priority actions – one of which is improving access to quality mental health services through mainstreaming mental health services in already existing health care programs (like HIV/AIDS, maternal and child health, or non-communicable diseases (NCDs), etc.), and mental health skills training for psychosocial staff and other health workers in those programs.
Additionally, the Kenya Mental Health Amendment Act of 2022 was enacted shortly after the Action Plan. With this law in place and with implementation, the mental health of every person is prioritized – reducing the incidences of mental illness while promoting access to mental health care, treatment and rehabilitation services. Also, in June 2023, key stakeholders came together at a consultative meeting convened by the Kenya Ministry of Health in collaboration with the World Health Organization to share evidence on maternal mental health, discuss challenges and opportunities for integration of maternal mental health in MNCH services at primary and community health care levels, and plan how to address the gaps in integrating maternal mental health in MNCH services. Kenya stands to be one of few countries with laws, action plans, and national commitments for addressing the perinatal mental health of their women.
Expanding access to perinatal mental health in India
Over the past decade, the Government of India made significant strides in improving maternal health with a marked reduction of MMR (maternal mortality ratio). This has been achieved largely due to an increase in the institutional birth rate (from 39% in 2005 to 88% in 2021) and flagship quality improvement programs. The focus of care in India is slowly shifting away from simply preventing mortality towards reducing maternal morbidity and improving women’s quality of life, including by addressing maternal mental health disorders and prioritizing respectful maternity care. India has taken proactive steps to address these challenges by increasingly recognizing that perinatal mental health has significant links to health outcomes for women and their newborns.
To address the unacceptable burden of perinatal mental health disorders, the Government of India identified an opportunity to integrate perinatal mental health services into existing maternal health services as a way to support, strengthen, and bring together previously siloed initiatives in maternal health, mental health, and comprehensive primary healthcare. For example, the National Mental Health Program has been in place since 1982 with the recent addition of the tele-mental health program. And the 2018 launch of the “Ayushman Bharat”, a Comprehensive Primary Health Care (CPHC) program, expanded the service coverage package to include mental health care as one of the main components.
In 2023, in an effort to further support the move from policy to delivery of services, MOMENTUM Country and Global Leadership began implementing a perinatal mental health model in Madhya Pradesh, India, that is integrated into the existing MNH health system. This is being done with the strategic technical engagement of the National Institute of Mental Health and Neurosciences (NIMHANS). The model uses a stepped care approach starting in the communities and supporting the health system to integrate information, screening, support, and treatment. The learning about how to integrate will inform other states in India that want to effectively integrate perinatal mental health into their overall primary health care and MNH platforms.
Sharing country experiences can help prioritize perinatal mental health
Addressing perinatal mental health presents an important opportunity to link with and strengthen health systems and overall mental health service provision. Commitments at the national policy level are imperative, but they must be supported with clear guidance that translates policy commitments to vital health services for women and newborns.
The direct impact of perinatal mental health on maternal and newborn outcomes and on the long-term well-being of women and their newborns makes this an important area to prioritize for immediate attention. The global health community increasingly acknowledges the interconnectedness of mental and physical health, and there is a growing discussion about how best to collaborate and to share country experiences that meaningfully address perinatal mental health in lower-resource settings through contextualized, effective, achievable ways across health care systems.
The perinatal mental health discussion is part of the agenda at the upcoming International Conference on Maternal Mental Health in Africa (ICAMMHA).
Shanon McNab is a Principal Technical Advisor, MOMENTUM Country and Global Leadership; Pasqueline Njau is a Senior Regional Advocacy and Policy Officer, PATH; and Dr. Parag Bhamare is the Country Lead, MNCH, Jhpiego India.
