Impact statement
In India, many women experience mental health conditions during the perinatal period, yet most of them do not receive treatment. The substantial negative impact of untreated perinatal mental health (PMH) conditions demands urgent, high-quality research into strategies to close this treatment gap. Interventions must be evidence-based, culturally tailored and consider the wider policy and health systems within which they sit. This situational analysis took a broad approach to understanding maternal health and socio-economic context as well as the systems and policies on a national, state and district level in two states, Haryana and Telangana. Using a mixed methods approach, we have mapped out the existing evidence on systems and policies, as well as delving into community-level barriers to PMH support. There are important socio-demographic differences between the two states, such as rates of adolescent pregnancy and intimate partner violence, as well as differences in maternal health outcomes and healthcare interactions. Understanding these factors will help shape future interventions as well as support policies for maternal mental health in India. Key barriers to seeking PMH support include stigma, isolation and transport difficulties. Calls are growing for the integration of mental health into routine maternal care. Delivering national and state-level plans and policies that are evidence-based and community-driven is essential. This situational analysis is part of the formative work of the Pregnancy and Mental Health project (PRAMH and provides an essential step for the co-development of a community-based intervention for women in the perinatal phase in Haryana and Telangana.
Introduction
The perinatal period, which encompasses pregnancy and the first year after giving birth, is associated with a high risk of mental disorders, particularly depression and anxiety (Biaggi et al., Reference Biaggi, Conroy, Pawlby and Pariante2016). Globally, up to 20% of women experience perinatal mental health conditions (PMHCs), with a higher prevalence in low- and middle-income countries (LMICs) (Fellmeth et al., Reference Fellmeth, Harrison, Opondo, Nair, Kurinczuk and Alderdice2021) where maternal mental illness is both under-recognised and under-treated (Gelaye et al., Reference Gelaye, Rondon, Araya and Williams2016), meaning the true disease burden is likely to be underestimated. Maternal mental health problems can have far-reaching consequences for both mothers and children. PMHCs are associated with difficulties in maternal self-care and infant bonding (Śliwerski et al., Reference Śliwerski, Kossakowska, Jarecka, Świtalska and Bielawska-Batorowicz2020), leading to intergenerational impacts. The total costs for a hypothetical cohort of women with perinatal depression and anxiety, as well as their children living in Pakistan, were estimated to be $16.5 billion (Bauer et al., Reference Bauer, Knapp, Alvi, Chaudhry, Gregoire, Malik, Sikander, Tayyaba, Waqas and Husain2024).
PMHCs can affect the infant before birth, after birth and long into a child’s development. Maternal depression is linked to stillbirth, premature birth and a reduction in birth weight (Räisänen et al., Reference Räisänen, Lehto, Nielsen, Gissler, Kramer and Heinonen2014). There are sequelae for the social and emotional development of the child: for instance, children of mothers with perinatal depression are more likely to show symptoms of attention deficit disorder and conduct disorder (Glover et al., Reference Glover2014). In addition, postnatal depression is the strongest predictor of parenting stress and difficulties in the mother–infant relationship (Leigh and Milgrom, Reference Leigh and Milgrom2008), and is associated with an increased risk of depression in adolescence (Murray et al., Reference Murray, Arteche, Fearon, Halligan, Goodyer and Cooper2011; Pearson et al., Reference Pearson, Evans, Kounali, Lewis, Heron, Ramchandani, O’Connor and Stein2013).
Although maternal mortality in India has reduced by over 50% since the early 2000s (Singh, Reference Singh2018) to 97 deaths per 100,000, maternal suicide constitutes an increasing proportion of maternal deaths. A recent report in Kerala estimated that maternal suicide accounted for nearly one in five maternal deaths in 2020 (Paily et al., Reference Paily, Ambujam, Thomas, Nair, Menon, Jayaprakash and Sidhik2020). Further progress towards the United Nations Sustainable Development Goal (UN SDG) for maternal mortality in India, therefore, depends on the urgent provision of better prevention and treatment for PMHCs in women.
Reducing the burden of PMHCs in India has been defined as a priority for research and clinical practice (Ganjekar et al., Reference Ganjekar, Thekkethayyil and Chandra2020; Desai and Chandra, Reference Desai and Chandra2023). India is the world’s most populous country with several languages as well as cultural, religious and socio-economic diversity, and a largely rural population distribution. Services for maternal and mental health vary greatly across and within the country’s 29 states (Ganjekar et al., Reference Ganjekar, Thekkethayyil and Chandra2020). In India, as in other LMICs, risk factors for mental disorders are more common (Varma et al., Reference Varma, Chandra, Thomas and Carey2007; Howard et al., Reference Howard, Oram, Galley, Trevillion and Feder2013; Choi et al., Reference Choi, Smit, Coleman, Mosery, Bangsberg, Safren and Psaros2019) than in high-income countries (HICs) and include: poverty, lack of employment, physical health problems, issues of safety and security and adolescent pregnancy (Agnafors et al., Reference Agnafors, Bladh, Svedin and Sydsjö2019). Importantly, intimate partner violence has been identified as one of the strongest predictors for PMHCs (Howard et al., Reference Howard, Oram, Galley, Trevillion and Feder2013; Halim et al., Reference Halim, Beard, Mesic, Patel, Henderson and Hibberd2018).
Widespread availability of perinatal mental health (PMH) services is critical for reducing maternal morbidity and mortality, yet maternal mental health has not been a policy priority in India in the past decades (Ganjekar et al., Reference Ganjekar, Thekkethayyil and Chandra2020). Increasingly, in parts of the country, efforts have been made to call attention to maternal mental health (The New Indian Express, 2019; Fuhr et al., Reference Fuhr, Weobong, Lazarus, Vanobberghen, Weiss, Singla, Tabana, Afonso, De, D’Souza, Joshi, Korgaonkar, Krishna, Price, Rahman and Patel2019; Ganjekar and Parthasarathy, Reference Ganjekar and Parthasarathy2023; UNICEF, 2023) such as the ‘Amma Manasu’ PMH programme in Kerala (Thiruvananthapuram, 2019) and the Thayi card in Karnataka (Ganjekar and Parthasarathy, Reference Ganjekar and Parthasarathy2023), which integrates mental health into routine antenatal care, a strategy recommended by World Health Organisation (WHO, 2022). Routine screening for PMHCs is associated with improved identification of women at risk, as well as increased referral and engagement with mental health services (Reilly et al., Reference Reilly, Kingston, Loxton, Talcevska and Austin2020) and is recommended in many countries including Australia (Highet and Purtell, Reference Highet and Purtell2012), the United States (O’Connor et al., Reference O’Connor, Rossom, Henninger, Groom and Burda2016) and the United Kingdom (National Collaborating Centre for Mental Health, 2007). However, screening and treatment require an understanding of the specific challenges and socio-cultural context of PMH and the local setting (Shrestha et al., Reference Shrestha, Pradhan, Tran, Gualano and Fisher2016). As India currently lacks a national maternal mental health programme, understanding existing efforts as well as challenges on a national, state and district level is important in shaping future policy.
This study presents the situational analysis for the formative phase of the SMARThealth PRegnancy And Mental Health (PRAMH) project (Votruba et al., Reference Votruba, Praveen, Mellers, Rajan, Thout, Arora, Malik, Kashyap, Majumdar, Hirst and Maulik2023). The situational analysis will investigate the nature and availability of maternal mental health policies, legislation, systems and services, as well as relevant context and community in India on a national, state and district level. Conducting a situational analysis is a critical first step when planning for research and implementation of a study in contexts where mental health services and systems are under-resourced or lacking (Murphy et al., Reference Murphy, Michalak, Colquhoun, Woo, Ng, Parikh, Culpepper, Dewa, Greenshaw, He, Kennedy, Li, Liu, Soares, Wang, Xu, Chen and Lam2019). This presents the first step in co-developing an intervention to support women’s PMH in Telangana and Haryana (Votruba et al., Reference Votruba, Praveen, Mellers, Rajan, Thout, Arora, Malik, Kashyap, Majumdar, Hirst and Maulik2023). These two states are located in South and North India (Supplementary Materials Figure 1). Both states differ socio-culturally and in terms of health services. Telangana has maintained an average of less than 70 maternal deaths per 100,000 live births since 2017, and the most recent data makes it the third best performing state in the country. In comparison, in Haryana, maternal mortality rates are not only higher but have increased from 98 to 110 (Sample Registration System, 2022).
Methods
This situational analysis focuses on the two sites of the PRAMH study: Siddipet District (Telangana state) and Faridabad District (Haryana state). We used a standardised tool (Hanlon et al., Reference Hanlon, Luitel, Kathree, Murhar, Shrivasta, Medhin, Ssebunnya, Fekadu, Shidhaye, Petersen, Jordans, Kigozi, Thornicroft, Patel, Tomlinson, Lund, Breuer, De Silva and Prince2014) developed by the PRIME consortium to collect data for the planning of integrated mental healthcare. This tool focuses on factors required for the implementation of WHO’s mhGAP (Dua et al., Reference Dua, Barbui, Clark, Fleischmann, Poznyak, van Ommeren, Yasamy, Ayuso-Mateos, Birbeck, Drummond, Freeman, Giannakopoulos, Levav, Obot, Omigbodun, Patel, Phillips, Prince, Rahimi-Movaghar, Rahman, Sander, Saunders, Servili, Rangaswamy, Unützer, Ventevogel, Vijayakumar, Thornicroft and Saxena2011) intervention guide. It was previously adapted for a maternal mental health context (Baron et al., Reference Baron, Hanlon, Mall, Honikman, Breuer, Kathree, Luitel, Nakku, Lund, Medhin, Patel, Petersen, Shrivastava and Tomlinson2016) and further modified for this study. The sections of the situational analysis were structured as follows:
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1. Socio-economic and maternal health context,
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2. Perinatal mental health policies and legislation,
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3. Perinatal mental health services – mental health treatment coverage, district level health services,
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4. Perinatal mental health and the community, and
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5. Monitoring and evaluation.
Data collection
Methods used to inform each section of the situational analysis are illustrated in Table 1. Secondary data was collected between February 2021 and April 2024 from publicly available sources. The scoping literature review was conducted between September 2022 and March 2025.
Table 1. Methods and data sources that have informed the situational analysis and interviews
Major socio-demographic determinants were explored, such as access to sanitation, clean water and power, as well as female literacy, adolescent pregnancy and intimate partner violence.
Maternal health was investigated using the National Family Health Surveys and Sample Registration System Bulletins to describe key indicators of care access and potentially identify opportunities for future perinatal mental health integration. We considered key indicators of maternal health access, such as the availability of institutional or otherwise assisted deliveries and receipt of antenatal care.
In addition, informal interviews were conducted between June 2022 and November 2023 with a number of experts (psychiatrists, psychologists, psychiatric nurses), to inform sections 3 (perinatal mental health services) and 4 (community) of the analysis. Informal interviews were employed as they allow ease of conversation and rapport building when dealing with a sensitive topic. These interviews provided an initial understanding of available services and community beliefs. The interviewees are illustrated in Table 1. Interviews were conducted by LM (medical doctor) and research assistants.
Scoping review
The question guiding the scoping review was: What is the evidence for perinatal mental health policies or policy recommendations in India? The search was limited to journal articles published in English between 1 January 2007 and 3 March 2025. Five databases were searched (Science Direct, Web of Science, PubMed, PsycInfo and Scopus). For a full search strategy, see Supplementary Materials. Inclusion criteria were as follows: (1) Focused on perinatal mental health, (2) Specific policy/health system/legislation recommendations, (3) Focused in India. Exclusion criteria are fully listed in the Supplementary Materials, but papers were excluded if there were no specific policy or system suggestions. For example, an article suggesting that maternal mental health is a priority without positing policy or health system suggestions would be excluded. This was found to be an important distinction in order to identify studies that actively engage in health system and policy planning. In addition, papers that made clinical practice recommendations for implementation by individual clinicians were excluded. However, if recommendations were made for implementation by a health system as a whole, these papers were included. The literature search yielded 541 articles, which were screened for eligibility, resulting in 82 included publications (Supplementary Materials Figure 2).
Results
Relevant context around perinatal mental health
Sociodemographic and economic indicators
Relevant data on the socio-demographic and economic situation at a national and state level is presented in Table 2. District-level data is also provided where available. Figures for population size, density and rural population are from the 2011 census (Office of the Registrar General & Census Commissioner, India 2011), as this is the most recent data. Both Haryana and Telangana have better-than-national-average sanitation, with a functioning latrine in 15% more homes in Haryana than the national average (NFHS-5, 2022). Telangana and Haryana have predominantly rural populations, with just under two-thirds of the population living in rural areas, slightly lower than the national average. However, Faridabad district is an exception with a majority urban population. Haryana has a higher population density, with better sanitation, water and electricity provision than seen nationally, along with higher-than-average figures for life-expectancy and female literacy and lower rates of adolescent pregnancy. Telangana has a lower population density than the national Indian average and better sanitation than the national average but below that found in Haryana. Life expectancy and adolescent pregnancy rates in Telangana are similar to the national average, but female literacy is considerably lower. Siddipet and Faridabad have similar levels of sanitation, water and electricity provision, but female literacy rates are higher in the Haryana district. Importantly, Haryana has the lowest proportion of female to male residents (Singh and Hans, Reference Singh and Hans2022), and the sex ratio at birth still remains below the national average. This has led to a shortage of brides in Haryana, and women are being sold into forced marriages or prostitution (Tong, Reference Tong2022).
Table 2. Key socio-demographic and economic indicators on a national, state and district levels for India, Haryana state and Faridabad district, Telangana state and Siddipet district
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• Population size, density and rural population are from the census 2011
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• Life expectancy is from the sample registration system (SRS)-abridged life tables 2016–2020 data
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• NFHS for literacy, sex ratios, home with data, fertility rate, total adolescent pregnancy and IPV data
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• In the National Family Health Survey-5 (NFHS-5), literacy rates were calculated based on those who have completed at least standard 9 (exam taken during Schooling) or passed a literacy test conducted as part of the survey.
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• Prevalence of intimate partner violence is measured in ever-married women aged 18–49.
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• Adolescent pregnancy: girls aged 15–19 who were pregnant or already mothers at the time of the survey
Adolescent pregnancy rates have dropped nationally from 7.9% (NFHS-4, 2017) to 6.8% (NFHS-5, 2022) between 2015/16 and 2019/21. Telangana has seen the biggest decrease in adolescent pregnancy from 10.8% (NFHS-4, 2017) to 5.8% (NFHS-5, 2022). Haryana’s adolescent pregnancy rate stands at 3.9%. Nationally, nearly a third of women have experienced spousal physical or sexual violence (NFHS-5, 2022). In Telangana, 36.9% of women reported experiencing intimate partner violence when surveyed and 4% during pregnancy. By contrast, the rate of intimate partner violence in Haryana, as measured by the NFHS-5, was 18.2%. Although another study found that 37% of currently married women in Haryana reported ever experiencing domestic violence (Nadda et al., Reference Nadda, Malik, Rohilla, Chahal, Chayal and Arora2018). According to the National Crime Bureau the rate of reported rape per lakh (100,000) population was 12.7 in Haryana (fourth highest rate in the country) and 4.3 in Telangana (National Crime Records Bureau, 2022). The total rate of crimes against women per one lakh of population in 2022 in both Haryana (118.7) and Telangana (117) were among the highest in the country (National Crime Records Bureau, 2022).
Maternal health
Key maternal health indicators for India, Telangana and Haryana are illustrated in Figure 1 (Health Management Information System 2020-2021, 2022; NFHS-5 2022; Office of the Registrar General & Census Commissioner, 2022). Telangana has a lower maternal mortality rate than the national average, with Telangana’s maternal mortality ratio (MMR) of 43 making it the third best performing state in the country (Office of the Registrar General & Census Commissioner, 2022). By contrast, Haryana’s MMR is higher than the national average and over double Telangana’s. The Ending Preventable Maternal Mortality (EPMM) initiative (WHO, 2015) has set a number of targets for 2025 for the SDGs to be met. One such target is that 90% of women attend at least four antenatal care visits during their pregnancy (WHO, 2015). As illustrated in Supplementary Table 1, 58.1% (NFHS-5, 2022) of women attended an antenatal clinic at least four times across the country in 2019–2020.
Figure 1. Key maternal health indicators for Telangana, Haryana and India.
Policies and legislation around perinatal mental health
At the time of conducting this review, there was no discrete national perinatal mental health policy or plan in place. In addition, a search for a specific perinatal mental health plan within national mental health and maternal health policy produced no results. We conclude that both mental and maternal/child health programmes currently fail to cover perinatal mental health. The search reviewed guidelines and strategies of maternal and mental health bodies. Results are displayed in the Supplementary Materials Table 4. National Health Mission maternal health programmes and the Federation of Obstetrics and Gynaecological Societies of India (FOGSI) guidelines were reviewed, but no guideline on maternal mental health was found. There is clear interest in maternal mental health from maternal health providers, but this has not yet translated into national guidelines or strategy.
The National Mental Health Programme (NMHP) was launched in 1982 (Wig and Murthy Reference Wig and Murthy2015) and has since been implemented in most states (National Health Mission 2018; National Health Mission 2019). The District Mental Health Programme (DMHP) was launched in four districts in 1996 as the main implementation arm of the NMHP, to provide community-based mental healthcare. The DMHP has evolved significantly over the years, and is now sanctioned for implementation in 738 districts (Kirpekar et al., Reference Kirpekar, Faye, Bhave, Gawande and Tadke2024). The National Mental Health Policy was released in 2014 (Ministry of Health & Family Welfare, 2014), increasing access to mental health services for vulnerable populations, including a multipart strategy for tackling suicide. The Mental Healthcare Act of 2017 (Government of India 2017) protects the rights of people with mental illnesses and decriminalises suicide. In addition, and of particular relevance to this review, this act mandates joint mother–infant care when a mother is admitted for a mental health crisis.
The scope of this article was to review perinatal mental health policies. However, importantly, other policies and acts will affect maternal mental health either directly or by influencing risk factors contributing to PMHCs. Major key points along the timeline of PMH are mapped below (see Figure 2), and include the launch of the National Mental Health Programme and Act in 1982 and the District Mental Health Programme in 1996, as well as subsequent schemes aiming at providing free, safe delivery in public facilities.
Figure 2. Relevant policies and major milestones affecting perinatal mental health in India.
It is important to note that despite legislation, this has not always translated into practice. The dowry remains embedded in religious and cultural traditions; 40–50% of female homicides in India were dowry-related between 1999 and 2016 (United Nations Office of Drugs and Crime, 2019). Sex selective abortions are still a significant problem across the country, as evidenced by the distorted sex ratio at birth, with an estimated 10 million gender biased sex selective abortions reportedly occurring between 1981 and 2005 (Kulkarni, Reference Kulkarni2007).
Perinatal mental health services
Specialist perinatal mental health inpatient and outpatient services exist at the National Institute for Mental Health and Neurosciences (NIMHANS) in Bangalore (Perinatal Psychiatry NIMHANS), which is home to India’s only mother and baby unit. This department provides patient care as well as driving academic work, including perinatal mental health research, as shown in Supplementary Materials Figure 3. It provides assessment and treatment tailored to the individual, including counselling for partners and family members, using multidisciplinary approaches. Perinatal mental health services also exist in other states. Kerala is the only state with a comprehensive perinatal mental health programme, which is implemented through the ‘Amma Manasu’(The New Indian Express, 2019) (‘mother’s mind’) programme. Karnataka has started to integrate mental health into its Reproductive and Child Health programme, with questions on risk factors and early signs of depression and anxiety added to the mother and child protection card (Thayi card) (Ganjekar and Parthasarathy, Reference Ganjekar and Parthasarathy2023).
In Haryana and Telangana, general services for mental healthcare exist at the state and district levels. Information from informal interviews with clinicians in Siddipet indicated that perinatal mental health training was delivered in Telangana in 2023. UNICEF and NIMHANS are running a project aiming to enhance maternal nutrition and improve the mental health of pregnant women (UNICEF, 2023). Working with the Government of Telangana, weight tracking, nutritional counselling, anaemia prevention and mental health screening will be integrated into routine antenatal check-ups (UNICEF, 2023). There is no mention of any perinatal mental health plan on the Haryana Health Department website (Health Department Haryana), and services are limited currently.
An overview of the availability of mental healthcare professionals, inpatient and outpatient facilities on a district level is displayed in Table 3.
Table 3. Available district-level healthcare in Faridabad district (Haryana) and Siddipet district (Telangana)
Note: Informal Interviews were conducted to complete this table.
Telangana’s largest centre for mental healthcare is the Institute of Mental Health in Hyderabad. A general mental healthcare centre exists in Siddipet, at the Government General Hospital, which has a 30-bed psychiatric ward and day clinic, and treats referrals from primary health care and walk-ins. Importantly, primary healthcare doctors do not treat mental health cases, but refer on to tertiary centres for treatment. Perinatal mental health orientation training was provided to Primary Health Care (PHC) doctors and Maternal and Child Health (MCH) supervisors (by NIMHANS in October 2023) for all districts in Telangana, including Siddipet. Auxiliary Nurse Midwives (ANMs) will be trained to complete mental health screening questionnaires with all pregnant women. Then, PHC doctors will review the score and refer to tertiary hospitals for treatment. Comments from informal interviews informed this section.
The State Mental Health Institute, Pandit Bhagwat Dayal Sharma University of Health Sciences in Rohtak, is the major mental health institute for the state of Haryana. In addition, the Department of Psychiatry Postgraduate Institute of Medical Education and Research, Chandigarh was one of the earliest general psychiatric units and runs satellite clinics in Haryana. There are no specific PMH services in Haryana, but cases can be seen in the District Hospital in Faridabad. Travel to district hospitals in both states can be challenging and expensive for women and their families. For instance, it can take around 2 hours from the furthest village in Faridabad to travel to the District Hospital by car, and there are no feasible public transport options. Private clinics and services exist. As part of the general mental health programme, awareness raising sessions are run for the ANMs, staff nurses, medical officers of the PHCs and Community Health Centres (CHCs). During these sessions information is given about general mental health, signs and symptoms of mental illness, prevention strategies and stigma. Accredited Social Health Activists (ASHAs) are also given a day of annual training on antenatal and postnatal mental health, to allow them to recognise symptoms, provide basic counselling and identify those who need further help. Basic psychiatric medicine (mostly antidepressants are available at the PHCs and CHCs). District counselling services exist in Haryana (‘14th Common Review Mission’ 2021). Again, data from informal interviews informed this section.
Perinatal mental health policies, systems and legislation: Literature review
The review of perinatal mental health policies, systems and legislation included 82 publications. An overview of these publications, their design, focus, location and policy/systems commentary is provided in Table 4. There were 26 prevalence studies, and 33 studies looked at risk factors or determinants of perinatal mental health conditions. Six studies focused on the Mental Health Care Act, and 12 studies were primarily focused on health systems or policies. Twenty-Two of the studies were performed at the national level, and 60 were performed at the state level, primarily in South India (Supplementary Materials Figure 3).
Table 4. List of included studies in this review
The evidence for specific policy/system recommendations varied: for some recommendations there was empirical evidence supporting feasibility and efficacy; other comments arose from the practical experience of a broad range of professionals in the field. Figure 3 illustrates some of the key recommendations. There is a broad consensus that mental healthcare for women during pregnancy and in the postnatal period should be integrated into routine maternal health services (Mariam and Srinivasan, Reference Mariam and Srinivasan2009; Prost et al., Reference Prost, Lakshminarayana, Nair, Tripathy, Copas, Mahapatra, Rath, Gope, Rath, Bajpai, Patel and Costello2012; Bagadia and Chandra, Reference Bagadia and Chandra2017; Shidhaye et al., Reference Shidhaye, Shidhaye and Phalke2017; Rathod et al., Reference Rathod, Honikman, Hanlon and Shidhaye2018; Sheeba et al., Reference Sheeba, Nath, Metgud, Krishna, Venkatesh, Vindhya and Murthy2019; Amipara et al., Reference Amipara, Baria and Nayak2020; Babu et al., Reference Babu, Murthy, Reddy, Deepa, Yamuna, Prafulla, Krishnan, Lobo, Rathnaiah and Kinra2020; Ransing et al., 2020; Ransing et al., Reference Ransing, Deshpande, Shete, Patil, Kukreti, Raghuveer, Mahadevaiah, Bhosale, Ramesh, Puri and Bantwal2020a; Behl, Reference Behl, George and Kuruvilla2021, Reference Behl2023; Ransing et al., Reference Ransing, Kukreti, Raghuveer, Mahadevaiah, Puri, Pemde, Karkal, Patil, Nirgude, Kataria, Sagvekar and Deshpande2021; Singla et al., Reference Singla, MacKinnon, Fuhr, Sikander, Rahman and Patel2021; Kalra et al., Reference Kalra, Tran, Romero, Chandra and Fisher2021, Reference Kalra, Tran, Romero, Chandra and Fisher2022; Kukreti et al., Reference Kukreti, Ransing, Raghuveer, Mahdevaiah, Deshpande, Kataria, Puri, Vallamkonda, Rana, Pemde, Yadav, Nain, Prasad and Garg2022; Nisarga et al., Reference Nisarga, Anupama and Madhu2022; Priyadarshini et al., Reference Priyadarshini, Rao and Dash2023; Thomas et al., Reference Thomas, Ekstrand, Thomas and Srinivasan2023; Behl et al., Reference Behl, Nemane and Sims2024, Reference Behl, Nemane and Gurpur2025; Handa et al., Reference Handa, Gaidhane and Choudhari2024; Kedare et al., Reference Kedare, Kadiani, Patkar and Gautam2024; Mhamane et al., Reference Mhamane, Karande and Ramanathan2024; Easwaran et al., Reference Easwaran, Orayj, Goruntla, Mekala, Bommireddy, Mopuri, Mantargi, Bhupalam, Thammisetty and Bandaru2025). Routine screening for mental health disorders in antenatal care is widely seen as critically important (Kukreja et al., Reference Kukreja, Datta, Bhakhri, Singh and Khan2012; Prost et al., Reference Prost, Lakshminarayana, Nair, Tripathy, Copas, Mahapatra, Rath, Gope, Rath, Bajpai, Patel and Costello2012; Shrivastava et al., Reference Shrivastava, Shrivastava and Ramasamy2015; Sheeba et al., Reference Sheeba, Nath, Metgud, Krishna, Venkatesh, Vindhya and Murthy2019; Amipara et al., Reference Amipara, Baria and Nayak2020; Joshi et al., Reference Joshi, Lyngdoh and Shidhaye2020; Doke et al., Reference Doke, Vaidya, Narula, Datar, Patil, Panchanadikar and Wagh2021; Fellmeth et al., Reference Fellmeth, Harrison, Opondo, Nair, Kurinczuk and Alderdice2021, Reference Fellmeth, Kanwar, Sharma, Chawla, DasGupta, Chhajed, Chandrakant, Thakur, Gupta, Bharti, Singh, Desai, Thippeswamy, Kurinczuk, Chandra, Nair, Verma, Kishore MT and Alderdice2023; Ransing et al., Reference Ransing, Kukreti, Raghuveer, Mahadevaiah, Puri, Pemde, Karkal, Patil, Nirgude, Kataria, Sagvekar and Deshpande2021; Shiva et al., Reference Shiva, Desai, Chand, Ganjekar, Vaiphei, Satyanarayana, Kishore, Thippeswamy and Chandra2021; Meerambika Mahapatro et al., Reference Mahapatro, Nayar, Roy, Jadhav and Panchkaran2022; Nisarga et al., Reference Nisarga, Anupama and Madhu2022; Kalra et al., Reference Kalra, Tran, Romero, Sagar and Fisher2024; Kumari and Basu, Reference Kumari and Basu2024; Priya et al., Reference Priya, Kaushal, Dogra and Dogra2024; Rajeev et al., Reference Rajeev, Nair, K and Maria2024) and should include screening for risk factors for suicide (Supraja et al., Reference Supraja, Thennarasu, Satyanarayana, Seena, Desai, Jangam and Chandra2016), so that at-risk individuals can be prioritised for early intervention (Mariam and Srinivasan, Reference Mariam and Srinivasan2009; Shrivastava et al., Reference Shrivastava, Shrivastava and Ramasamy2015; Rathod et al., Reference Rathod, Honikman, Hanlon and Shidhaye2018; Amipara et al., Reference Amipara, Baria and Nayak2020; Goyal et al., Reference Goyal, Gupta, Sharma, Dalal and Pradeep2020; Fellmeth et al., Reference Fellmeth, Harrison, Opondo, Nair, Kurinczuk and Alderdice2021; Jelly et al., Reference Jelly, Chadha, Kaur, Sharma, Sharma, Stephen and Rohilla2021; Mahale et al., Reference Mahale, Prabhu, Pai, Mahale and Nayak2021; Kumari and Basu, Reference Kumari and Basu2024; Rajeev et al., Reference Rajeev, Nair, K and Maria2024). Some valid screening instruments exist (Fellmeth et al., Reference Fellmeth, Harrison, Opondo, Nair, Kurinczuk and Alderdice2021), such as EPDS (Joshi et al., Reference Joshi, Lyngdoh and Shidhaye2020); however, these may have limitations when used in ‘Non-Western settings’(Shrestha et al., Reference Shrestha, Pradhan, Tran, Gualano and Fisher2016). A number of treatment interventions have been the subject of clinical trials, including the ‘Thinking Healthy Programme’(Fuhr et al., Reference Fuhr, Weobong, Lazarus, Vanobberghen, Weiss, Singla, Tabana, Afonso, De, D’Souza, Joshi, Korgaonkar, Krishna, Price, Rahman and Patel2019; Singla et al., Reference Singla, MacKinnon, Fuhr, Sikander, Rahman and Patel2021), participation in women’s groups (Tripathy et al., Reference Tripathy, Nair, Barnett, Mahapatra, Borghi, Rath, Rath, Gope, Mahto, Sinha, Lakshminarayana, Patel, Pagel, Prost and Costello2010) and individual (Prabhu et al., Reference Prabhu, George, Guruvare, Noronha, Jose, Nayak, George and Mayya2025) and group interventions (George et al., Reference George, Kumar and Girish2020) with preliminary evidence of efficacy.
Figure 3. Policy and system recommendations word cloud drawn from this review.
Perinatal mental health and the community
Through informal interviews with psychiatrists, psychologists and psychiatric nurses, we have gained an understanding of some community beliefs surrounding mental health. The following points were discussed with interviewees:
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1. In Telangana, and indeed throughout India, it is common practice that women go back to their family home around the seventh month of their pregnancy and stay until around 40 days after birth, particularly for the birth of the first child. Here, they are well supported, and the practice of isolating the mother during this time seems to be rare. However, when women move back to their husband’s family, they often receive less support and are expected to do the housework in addition to looking after the baby. Little is known about how this move may affect the risk of mental health conditions, and this could be explored further in focus groups.
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2. Stigma is a major barrier for women in need of mental health support. In families, some level of mental distress is frequently seen to be normal; family members often seem to reject the idea that PMHCs require treatment, help coming from outside is often not accepted and medical interventions can be seen as ‘unnecessary’. Consulting psychiatrists and psychotherapists, therapy and medication are widely considered as taboo. Counselling seems to be better accepted but is usually only available through the private system.
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3. Male child preference and dowry practices were also mentioned during interviews as factors that might influence a woman’s mental health following the birth of a girl child. If a woman delivers two or three baby girls, they may have more anxiety and depression symptoms in their subsequent deliveries.
Monitoring and evaluation
No monitoring and evaluation of perinatal mental health conditions has or is currently being conducted in the two districts. The 2015/2016 National Mental Health Survey (NMHS) found that states were at different stages of implementing their health management information systems. Only five states (including Chhattisgarh, Gujarat, Madhya Pradesh and Punjab) routinely recorded mental health in their information systems (National Institute of Mental Health and Neurosciences 2017). According to NMHS, 10% of the Indian population suffers from depression and anxiety, and 20% of these are pregnant women or new mothers (National Institute of Mental Health and Neurosciences 2017); however, this survey did not include Haryana or Telangana in its sampling. One study based in rural Haryana estimated the prevalence of common mental disorders in pregnancy to be 15.3% (Jha et al., Reference Jha, Salve, Goswami, Sagar and Kant2021) with 2.8% affected by major depression and 15.1% affected by anxiety. No comparable study looking at the prevalence of PMHCs in Telangana was found. However, prevalence rates for antenatal depression in South India range between 16.3% (George et al., Reference George, Lalitha, Antony, Kumar and Jacob2016) and 36.5% (Hegde et al., Reference Hegde, Sandeep and Keshav Pai2012). Estimates for postnatal depression prevalence in South India range from 19.8% (Chandran et al., Reference Chandran, Tharyan, Muliyil and Abraham2002) to 34% (Chainani, Reference Chainani2021) and 21.5% (Saldanha et al., Reference Saldanha, Rathi, Bal and Chaudhari2014) and 29% (Basu et al., Reference Basu, Budh, Garg, Singh and Sharma2021) in North India.
Discussion
This situational analysis evaluated the perinatal mental health context, policies and plans and services in India as well as locally in Telangana and Haryana. There is no specific national perinatal mental health policy or plan. No specific PMH services are available in either Telangana and Haryana. General mental health services for women who experience PMHCs exist in these states and within Siddipet and Faridabad.
The demographic differences between Haryana and Telangana may affect the prevalence of mental illness during pregnancy and may pose different challenges in establishing perinatal mental health provision.
Adolescent pregnancy is an acknowledged risk factor for PMHCs (WHO, 2008), and Adolescent Girls and Young Women (AGYW) may be subject to a number of other intersecting vulnerabilities, such as unintended pregnancy and exclusion from education (Palfreyman and Gazeley, Reference Palfreyman and Gazeley2022). Rates of adolescent pregnancy are lower in Siddipet (1.0% of 15–19 year olds) than in Faridabad (2.8% of 15–19 year olds). One study based in South India found increased odds of postpartum depression in women aged under 25 years (Doke et al., Reference Doke, Vaidya, Narula, Datar, Patil, Panchanadikar and Wagh2021). This population will be an important target for early intervention as an ‘at-risk’ group. Mental health services must be integrated into adolescent sexual and reproductive health services, as the Reproductive, Maternal, Newborn, Child and Adolescent (RMNCH+A) strategy advocates. This strategy addresses the major causes of mortality among women and children, aiming to ensure a ‘continuum of care’ for integrated service delivery across the life course.
Intimate partner violence (IPV) is strongly linked to PMHCs. A systematic review and meta-analysis looking at studies based in both HMICs and LMICs found that 88% of studies established an association between IPV and perinatal depression (Ankerstjerne et al., Reference Ankerstjerne, Laizer, Andreasen, Normann, Wu, Linde and Rasch2022). Data presented from the NFHS is likely an underestimate of the true prevalence of violence against women (Shah et al., Reference Shah, John, Chawla, Kvankar and Jaiswal2021). Indeed, IPV remains one of the few indicators of risk of PMHCs measured in the NFHS, which Behl (Reference Behl2024)) argues needs to be expanded. Despite a lower prevalence of reported intimate partner violence in the NFHS, the rate of reported rape in Haryana is the fourth highest in the country (National Crime Records Bureau, 2022). Haryana has historically had one of the worst sex ratios in the country, a patriarchal culture and a high rate of violence against women (National Crime Records Bureau, 2022; Parihar et al. Reference Parihar2015). Pressure to have a male child as well as the gender of the newborn has been found to have an impact on the risk for PMHCs (Shidhaye et al., Reference Shidhaye, Shidhaye and Phalke2017; Kar et al., Reference Kar, Samantaray, Patnaik, Mishra and Lakshmi2024; Kumari and Basu, Reference Kumari and Basu2024) although this is not uniform across the country (Doke et al., Reference Doke, Vaidya, Narula, Datar, Patil, Panchanadikar and Wagh2021). Research is needed in Haryana, in particular, into what state-specific risk factors exist. Women are affected by high rates of intimate partner violence in both states, which will be a key area to target in reducing the burden of PMHCs.
Poor sanitation is linked to adverse pregnancy outcomes (Padhi et al., Reference Padhi, Baker, Dutta, Cumming, Freeman, Satpathy, Das and Panigrahi2015), and complications during pregnancy can negatively affect women’s mental health (Badiya et al., Reference Badiya, Siddabattuni, Dey, Javvaji, Nayak, Hiremath, Upadhyaya, Madras, Nalam, Prabhakar, Vaitheswaran, Manjjuri, JK, Subramaniyan, Raghunatha Sarma and Ramamurthy2020). A systematic review and meta-analysis by Yang et al. found both lower educational level and poor economic status of families to be risk factors for perinatal depression across 31 studies (Yang et al., Reference Yang, Wu and Chen2022). The percentage of homes with sanitation and clean water is similar across both districts. Faridabad is a majority urban district, whereas 86% of the population is rural in Siddipet. This may have an impact on support systems (Kishore et al., Reference Kishore, Satyanarayana, Ananthanpillai, Desai, Bhaskarapillai, Thippeswamy and Chandra2018) as well as accessibility of services (Kar et al., Reference Kar, Samantaray, Patnaik, Mishra and Lakshmi2024) and coverage of technology. Rural residence has also been found to be a risk factor for perinatal depression (Easwaran et al., Reference Easwaran, Orayj, Goruntla, Mekala, Bommireddy, Mopuri, Mantargi, Bhupalam, Thammisetty and Bandaru2025), and there may be lower levels of awareness about PMHCs in this population. A lack of familial and social support has been associated with depression during pregnancy (Basu et al., Reference Basu, Budh, Garg, Singh and Sharma2021; Pasricha et al., Reference Pasricha, Kochhar, Shah and Bhatia2021). Policies aimed at improving the socio-economic status of women should be considered an integral part of any perinatal mental health strategy. Multisectoral approaches that tackle poverty, social protection, violence prevention, education and gender disadvantage are called for (Scott et al., Reference Scott, Arrieta, Kumar, Menon and Quisumbing2020; Insan et al., Reference Insan, Weke, Rankin and Forrest2022; Behl, Reference Behl2024; Handa et al., Reference Handa, Gaidhane and Choudhari2024). Some of these are detailed in Figure 2. In 2015, the government launched the Beti Bachao, Beti Padhao programme with the objective of saving and educating the girl child, which has been associated with significant improvements in the sex ratio at birth in Haryana (Gupta et al., Reference Gupta, Nimesh, Lal Singal, Bhalla and Prinja2018). However, the success of other programmes is not so clear. Despite the passing of the Dowry Prohibition Act, this is still widely practiced across India, and one study based in Maharashtra found more than a third of pregnant women admitted that a dowry was exchanged at the time of marriage (Shidhaye et al., Reference Shidhaye, Shidhaye and Phalke2017). Unsatisfactory reaction to the dowry and a difficult relationship with the in-laws were significantly related to antenatal depression (Shidhaye et al., Reference Shidhaye, Shidhaye and Phalke2017).
Maternal and infant mortality is lower in Telangana than in Haryana. Indeed, the MMR in Telangana is less than half that in Haryana, and worryingly, the MMR in Haryana has risen to 110 in 2018–2020 from 91 in 2016–2018. Goli et al. found a clustering of high MMR in North-eastern and central regions (Goli et al., Reference Goli, Puri, Salve, Pallikadavath and James2022). The strongest correlates with MMR were found to be postnatal care, maternal age and nutrition and poor economic status (Goli et al., Reference Goli, Puri, Salve, Pallikadavath and James2022). In addition, health infrastructure, fertility levels, sex ratio at birth and years of schooling were significantly related to MMR. Indeed, many of these are risk factors for PMHCs as well, and targeting both nutrition and mental illness together is a strategy being implemented currently in Telangana (UNICEF, 2023). The leading causes of maternal deaths are haemorrhage, infection and hypertension (Meh et al., Reference Meh, Sharma, Ram, Fadel, Correa, Snelgrove, Shah, Begum, Shah, Hana, Fu, Raveendran, Mishra and Jha2022). However, suicide is also a leading (Oates, Reference Oates2003) and often an underestimated cause of maternal death. There is a need to understand the factors influencing MMR across these states, and targeting these to reduce maternal mortality in Haryana in particular is crucial; efforts can go hand in hand with strategies aimed at reducing the burden of PMHCs.
A high proportion of women attend antenatal and postnatal assessments in both states. However, at around 60%, attendance at antenatal clinics (ANC) is well below the 90% target set by the EPMM Initiative. Improving this is important as antenatal clinic appointments provide the opportunity for mental health intervention as part of integrated care. There are also concerns that the focus on at least four ANC visits distracts from the content and quality of care. One study based in Telangana found low coverage of gestational diabetes and syphilis testing, substantial deficiencies in symptom checking and communication, and only one woman was asked about her mental health (Radovich et al., Reference Radovich, Chaudhry, Penn-Kekana, Raju, Mishra, Vallabhuni, Jarhyan, Mohan, Prabhakaran, Campbell and Calvert2022). The WHO has released new guidelines recommending an increase from four to eight or more ANC visits and emphasising the importance of person-centred care and well-being (WHO, 2016). Particularly in LMICs, pregnancy is a time of high healthcare attendance in a woman’s life. It is well established that integrating mental health into routine maternal care is an important strategy. The WHO (WHO, 2022) recommends this strategy and has published guidance for the integration of perinatal mental health into maternal and child services.
Location of perinatal care is another important factor to consider. The institutional birth rate is higher in Siddipet than in Faridabad, with 47.3% of institutional births conducted in a public facility in Siddipet compared with 42.9% in Faridabad (NFHS-5, 2022). Private hospitals are favoured for care (Kamath et al., Reference Kamath, Poojary, Shetty, Umesh, Kar, Lakshmi Ramesh, Hajare, Thomas, Brand, Jahangir and Kamath2024). Despite initiatives like the national health insurance scheme (Rashtriya Swasthya Bima Yojana RSBY) and then later the Prime Minister’s people’s insurance scheme and Pradhan Mantri Jan Arogya Yojana (PMJAY) (Sharma and Nambiar, Reference Sharma and Nambiar2024), India continues to exhibit one of the highest rates of Out-of-Pocket Expenditure (OOPE) worldwide (National Health Accounts, 2022). Out-of-pocket expenditure reflects the household’s financial burden for healthcare services. Southern Indian States have higher levels of development and OOPE (Sharma and Nambiar, Reference Sharma and Nambiar2024), and rural areas also often have higher rates and burden of OOPE relative to household expenditure (Vasudevan et al., Reference Vasudevan, Akkilagunta and Kar2019). Consistent with this, average OOPE per delivery is higher in Siddipet than in Faridabad (NFHS-5, 2021). In addition, women suffering from PMHCs may be driven to seek help from private hospitals due to stigma and often seek help when symptoms are more severe. These factors may also increase the financial burden of PMHCs faced by the individual or family.
Another important difference between the two districts is the percentage of deliveries by Caesarean Section (CS). The CS rate in Siddipet is roughly triple that of Faridabad (NFHS-5, 2022). Delivery by CS has been found to be a risk factor for the development of postpartum depression (Doke et al., Reference Doke, Vaidya, Narula, Datar, Patil, Panchanadikar and Wagh2021). It is also associated with increased OOPE (Mishra and Mohanty, Reference Mishra and Mohanty2019), and financial stress can be a significant burden on the family, and is reported to contribute to postpartum depression, particularly in men (Malik, Reference Malik2024). Expanding health insurance and improving the public healthcare infrastructure are important, particularly in rural areas (Kamath et al., Reference Kamath, Poojary, Shetty, Umesh, Kar, Lakshmi Ramesh, Hajare, Thomas, Brand, Jahangir and Kamath2024). Policy interventions, including perinatal mental health interventions, must provide cost-contained strategies and ensure equitable utilisation (Kamath et al., Reference Kamath, Poojary, Shetty, Umesh, Kar, Lakshmi Ramesh, Hajare, Thomas, Brand, Jahangir and Kamath2024).
The NMHP does not include a national perinatal strategy, and the National Mental Health Policy does not include a focus on maternal health. In addition, we found no PMH strategy included in any maternal or child health programmes. There is no formal perinatal mental health plan in either state. On a state and district level, patients can access mental healthcare at district hospitals during the perinatal period. In both Faridabad and Haryana, there are specialist mental health professionals; however, no specialist perinatal mental health services exist. There is an institute for mental health serving both states; however, these tertiary institutions may have varying capacity to develop specific perinatal mental health services such as mother and baby units. Travel to seek medical attention from more remote communities may be challenging as well as expensive. In addition, the stigma attached to seeking help for a mental illness prevents many women from receiving the care they need. This emphasises the need for care in the community.
A stepped-care model of mental health intervention is recommended by the WHO (WHO, 2022) and makes sense in a predominantly rural setting with relatively few specialist mental health service hubs (Bagadia and Chandra, Reference Bagadia and Chandra2017; Ganjekar et al., Reference Ganjekar, Thekkethayyil and Chandra2020; Ransing et al., Reference Ransing, Kukreti, Raghuveer, Mahadevaiah, Puri, Pemde, Karkal, Patil, Nirgude, Kataria, Sagvekar and Deshpande2021; Kukreti et al., Reference Kukreti, Ransing, Raghuveer, Mahdevaiah, Deshpande, Kataria, Puri, Vallamkonda, Rana, Pemde, Yadav, Nain, Prasad and Garg2022). This is the most efficient (Ho et al., Reference Ho, Yeung, Ng and Chan2016) way of delivering care as it involves delivering low-resource interventions to the majority of people while retaining the ability to provide more intensive treatment to those who need it. The stepped care package should include perinatal mental health promotion, prevention measures, identification and treatment. Once adequately trained, existing community health workers such as ASHAs and ANMs could have an important role in referral (Ganjekar et al., Reference Ganjekar, Thekkethayyil and Chandra2020; Ransing et al., Reference Ransing, Deshpande, Shete, Patil, Kukreti, Raghuveer, Mahadevaiah, Bhosale, Ramesh, Puri and Bantwal2020a; Shanbhag et al., Reference Shanbhag, Murugesan, Nagendrappa, Chandra, Percudani, Bramante, Brenna and Pariante2022), with mental health specialists in district/general hospitals acting as points of specialist intervention (Bagadia and Chandra, Reference Bagadia and Chandra2017). An example of a low-intensity intervention is the Thinking Healthy programme, a WHO-supported programme which can be effectively delivered by community health workers or peers (Fuhr et al., Reference Fuhr, Weobong, Lazarus, Vanobberghen, Weiss, Singla, Tabana, Afonso, De, D’Souza, Joshi, Korgaonkar, Krishna, Price, Rahman and Patel2019).
Delivering mental healthcare within maternal health services carries with it significant challenges. The most obvious challenge lies in training maternity care workers (Supraja et al., Reference Supraja, Thennarasu, Satyanarayana, Seena, Desai, Jangam and Chandra2016), among whom there is evidence of a knowledge gap concerning perinatal mental health (Ransing et al., Reference Ransing, Kukreti, Deshpande, Godake, Neelam, Raghuveer, Mahadevaiah, Kataria, Patil, Puri and Padma2020b). Mental health teams should have an outreach role in planning and delivering education and training, something which Shidhaye et al. note may require a ‘fundamental paradigm shift’ in the role of psychiatrists and mental health workers (Shidhaye et al., Reference Shidhaye, Shrivastava, Murhar, Samudre, Ahuja, Ramaswamy and Patel2016). Training programmes need to be developed that are sensitive to well-documented cultural factors, and prevailing perceptions and attitudes about mental health (Goyal et al., Reference Goyal, Gupta, Sharma, Dalal and Pradeep2020; McCauley et al., Reference Mccauley, Avais, Agrawal, Saleem, Zafar and Van Den Broek2020; Chainani, Reference Chainani2021; Shiva et al., Reference Shiva, Desai, Chand, Ganjekar, Vaiphei, Satyanarayana, Kishore, Thippeswamy and Chandra2021; Insan et al., Reference Insan, Weke, Rankin and Forrest2022). Virtual training courses have been implemented successfully (Shiva et al., Reference Shiva, Desai, Chand, Ganjekar, Vaiphei, Satyanarayana, Kishore, Thippeswamy and Chandra2021). Training was provided to PHC doctors and MCH supervisors by NIMHANS in Siddipet in October 2023. In Faridabad, mental health awareness raising sessions are run for ANMs, staff nurses and medical officers, as well as annual training on PMH for ASHAs were reported during informal interviews. Developing a sensitive workforce and a safe, non-judgemental environment is important in ensuring women feel positively about available services.
A stepped care model utilising existing antenatal staff has been trialled successfully (Kukreti et al., Reference Kukreti, Ransing, Raghuveer, Mahdevaiah, Deshpande, Kataria, Puri, Vallamkonda, Rana, Pemde, Yadav, Nain, Prasad and Garg2022). The Brief Psychological Intervention for Perinatal Depression (BIND-P) model is not only an intervention but also a pathway for stepping up care with universal screening in MCH settings, risk stratification and appropriate onward referral or brief intervention within the obstetric setting (Kukreti et al., Reference Kukreti, Ransing, Raghuveer, Mahdevaiah, Deshpande, Kataria, Puri, Vallamkonda, Rana, Pemde, Yadav, Nain, Prasad and Garg2022). There are appropriate psychiatric services in both districts, and if more specialist care is needed, larger state-level tertiary psychiatric care can be sought. Liaison between different specialties is an important part of care for PMHCs (Shanbhag et al., Reference Shanbhag, Murugesan, Nagendrappa, Chandra, Percudani, Bramante, Brenna and Pariante2022). Women are supportive of being asked about their mental health specifically and of obstetric staff facilitating psychiatric referrals (Shanbhag et al., Reference Shanbhag, Chandra, Desai, Bagadia, Dref and Bhat2023). A collaborative approach and streamlined referral systems between antenatal care and mental healthcare should be reinforced (Shanbhag et al., Reference Shanbhag, Chandra, Desai, Bagadia, Dref and Bhat2023).
A recent systematic review also found no specific policy or programme on maternal mental health and calls for a comprehensive approach to policy development (Kalra et al., Reference Kalra, Tran, Romero, Sagar and Fisher2024). Kalra et al. advocate for a range of strategies, including addressing female gender related risks such as inequity and socio-economic disadvantage, as well as addressing risk factors for PMHCs (Kalra et al., Reference Kalra, Tran, Romero, Sagar and Fisher2024). Due to the far-reaching public health implications, incorporation of perinatal mental health into maternity and mental health programmes is of high priority, and the development of perinatal mental health policy can in turn shape evidence-based and locally tailored initiatives (Kalra et al., Reference Kalra, Tran, Romero, Sagar and Fisher2024).
In the absence of a perinatal mental health policy, there have been several recommendations as to how one could be introduced. Priyadarshini et al. proposed three options: (1) strengthening and focused implementation of the NMHP, (2) integrating mental health in the RMNCH+A programme and (3) including a ‘maternal’ component in the NMHP (Priyadarshini et al., Reference Priyadarshini, Rao and Dash2023). Our review of antenatal clinic attendance suggests that in both states, although particularly in Telangana, there are already many opportunities for screening of mental illness throughout prenatal care. This literature review found that numerous authors advocated for the integration of mental health into routine maternal care. If this is to occur, inclusion of mental health in the RMNCH+A programme is essential, as the maternal health workforce will need to be up-skilled. Developing a perinatal mental health strategy will involve cross-sector participation and a perinatal mental health focus in both existing mental and maternal/child health programmes.
Strengths and limitations
This is the first integrated review, to our knowledge, of perinatal mental health to investigate maternal health and socio-economic context as well as systems and policies on a national, state and district level. This broad approach is helpful in understanding the wide range of factors that may influence the success of an intervention. It also systematically scopes policy and system recommendations that have been published in India. We acknowledge some limitations, including the collection of secondary data via desktop search, which may lead to incomplete or outdated data. Once major sites such as the national health mission and the ministry for family health and welfare (both national and state sites) were identified, these were reviewed for any relevant policies and programmes. In addition, by interviewing experts in the field on both a national and district level, major PMH policies and programmes should have been identified. A limitation of the literature search was that only one author screened the publications for relevance. The inclusion criteria were based on a subjective analysis of whether the publication made specific policy/health system/legislation recommendations. There is, therefore, a possibility that some papers were missed by human error. However, this scoping review captures an overview of existing publications and policy/health system themes successfully. An informal or conversational approach was taken to interviewing clinicians, which means that the information gleaned is more limited. But this approach has provided a good introduction to service availability and community beliefs.
Conclusion
This systematic review found very little evidence for existing perinatal mental health systems, policies, and services in the two districts in Haryana and Telangana. Across India, the evidence gap persists on prevalence, coverage and interventions for PMHCs. In order to adequately support women during pregnancy and after childbirth, it is important to understand their needs and socio-cultural context, and to gain evidence on what interventions are acceptable and effective. National and state-level perinatal mental healthcare plans and policies will be critical to provide guidance and support district managers, researchers and communities in implementing perinatal mental health support and to establish services to bridge the existing PMH treatment gap. The findings from this situational analysis will inform the development of a future intervention for PMH in rural communities in Telangana and Haryana.
Open peer review
To view the open peer review materials for this article, please visit http://doi.org/10.1017/gmh.2025.10021.
Supplementary material
The supplementary material for this article can be found at http://doi.org/10.1017/gmh.2025.10021.
Data availability statement
Data can be accessed through the provided links.
Acknowledgements
We thank all individuals who have shared information with us.
Author contribution
NV designed the study and oversaw data collection, analysis and write-up. LM led and conducted the review. LM, SR and SY collected the data. LM wrote and revised the article draft. SR, SY, DP, PM, JH and NV contributed to editing the draft for publication. All authors contributed to the article and approved the submitted version.
Financial support
This work has been funded by an MRC PHIND grant. NV is funded by the Medical Research Council (Grant MR/Y503319/1), the Oxford MSD Improving Equitable Access to Healthcare grant and is partially supported by the UK Medical Research Council (UKRI) for the Indigo Partnership (MR/R023697/1) award. JH is funded by a UKRI Future Leaders Fellowship. The funder has no role in study design; collection, management, analysis and interpretation of data; writing of the report; and deciding to submit the information for publication, including whether they will have ultimate authority over any of these activities.
Competing interests
The authors declare none.
Ethics statement
This study has approvals from the University of Oxford Tropical Research Ethics Committee (OXTREC reference number 539–22) and the George Institute for Global Health India Institutional Ethics Committee (IEC; reference: 09/2022).
Open access
Comments
Dr Lucy Mellers
Nuffield Department of Women’s and Reproductive Health
University of Oxford
Professor Judy Bass and Professor Dixon Chibanda
Co-Editors-in-Chief
Cambridge Prisms: Global Mental Health
22nd August 2024
Dear Professor Judy Bass and Professor Dixon Chibanda,
Re: Perinatal mental health in India in the states of Haryana and Telangana: A district level situational analysis
This submission is a situational analysis of perinatal mental health in two states in rural India. I would be very grateful if you could consider this original paper for publication.
The situational analysis presents the formative work of the SMARThealth Pregnancy and Mental Health (PRAMH) study, which aims to co-develop an intervention to support women’s perinatal mental health in Telangana and Haryana. The situational analysis investigates the nature and availability of maternal mental health policies, legislation, systems and services on a National, state and district level, as well as the relevant local context. The situational analysis applies a range of methods including desktop and policy review, scoping review and informal interviews, to understand the factors that may influence the success of an intervention, planned in later stages of the PRAMH study. As has been pointed out by Murphy et al. (2019) in your journal, a situational analysis is an essential first step when planning for research and implementation of a study in contexts where mental health services and systems are under-resourced or lacking.
We found very little evidence for existing perinatal mental health systems, policies, and services in the two districts in Haryana and Telangana. Across India, the evidence gap persists on prevalence, coverage and interventions for perinatal mental health conditions. In order to adequately support women during pregnancy and after childbirth, it is important to understand their needs and socio-cultural context, and to gain evidence on what interventions are acceptable and effective.
To the best of our knowledge, this is the first situational analysis of perinatal mental health in rural India to investigate maternal mental health and socioeconomic context as well as systems and policies on a national, state, and district level. None of our results have been previously published or are under consideration for publication elsewhere.
Thank you very much for your consideration for publication in Cambridge Prisms: Global Mental Health. I look forward to hearing back from you.
Kind regards,
Dr Lucy Mellers
(on behalf of all authors)