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Public Health Open Access Research Article 20 min read

Barriers and Challenges in Mental Healthcare Utilization among Pregnant Women in Rural India -A Narrative Review

Alok*, Pathak V, Verma D and Manglani A
* Corresponding author
ISSN: 2578-5001  10.23880/phoa-16000253  Received: September 27, 2023  Published: October 20, 2023
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Keywords
Intervention Stigma Health Mortality Neonatal
Abstract

Mental disorders during pregnancy affect the health of both mother and child and are considered a significant public health problem. It was found that household-related barriers, health facility-related challenges, lack of resources at primary health centres, poor screening facilities, stigma and discrimination, and poor knowledge and awareness are the most critical barriers to accessing mental health-related services in rural India. As stated by the World Health Organisation, four hundred fifty million people suffer from mental disorders globally. The prevalence of lifetime mental morbidity, as per NMHS 2016, is 13.9%. A significant public health issue is that approximately 150 million people in our nation need active mental health intervention, according to the 2016 National Mental Health Survey of India. Women are more susceptible to problems with their mental health. The review aims to identify and recognize barriers and challenges in receiving mental health services among rural pregnant women in India to assess and prioritize the most prevalent barriers and challenges within this population. Changes in the current policies and strategies related to poverty and health programs strengthening knowledge, awareness, and economy are a few suggested strategies in this article. This review article discusses how mental health issues affect pregnant women and their children. It's a significant problem in rural India due to household issues, lack of knowledge, stigma, limited healthcare facilities, etc. Around 150 million people in India need mental health help. This article suggests ways to improve this situation, through better healthcare facilities, awareness, and policy changes. It also emphasizes the need to focus on mental health during pregnancy to ensure the well-being of both the mother and the child: Mental health, Rural Health, Pregnant Women.

Introduction

Due to the adverse health impact on both the mother and the child, pregnancy-related illnesses are considered a major public health issue. According to estimates, 35 % of women worldwide, including India, experience depression during pregnancy and after giving birth [1]. Non-psychotic mental health illnesses like depression, anxiety, and somatoform disorders are common mental disorders (CMDs) that hamper day-to-day functioning [2]. Mental

disorders are often considered “invisible disorders.” Because of its poor visibility to others [3], women are more likely to have CMDs than males.[4, 5]. Women who are expecting or have just given birth are more likely to experience mental health issues. The lack of medical facilities and the rising frequency of deliveries at home without the help of skilled medical personnel exacerbate these women’s distress and depression. It is crucial to emphasize that 25% of deliveries in India occur in private healthcare facilities, frequently in small clinics, and that more than half of pregnant women seek antenatal treatment there. There has been a poor uptake of maternal healthcare services due to the closure of many private and small clinics. The absence of access to health care and in-person interactions with healthcare providers has worsened the stress and depression that pregnant women are usually prone to. If not treated early on, depression in pregnant women who have had complicated pregnancies may become more severe, harming the health and well-being of both the mother and the foetus.

Low and middle-income countries (LMIC) face a more significant burden of disease, where it is estimated that mental disorders affect 19.8% of postpartum women and 15.6% of pregnant women suffer from the mental disorder [6]. Antenatal depression has a wide range of prevalence in India, ranging from 9.8 to 36.7%, and antenatal anxiety has a prevalence of 55.7%. The prevalence reported for mental disorders during pregnancy in developed nations ranges from 7 to 15% [7]. According to a meta-analysis, 15.6% of pregnant women in developing countries had non-psychotic common mental illnesses [8]. The prevalence of depression among pregnant women in India varied from 10.25% to 55% in the first trimester, 8.4% to 48.4% in the second trimester, and 11.11% to 30.11% in the third. As per facility-based studies in India, the prevalence of CMDs during pregnancy has been found to range from 5.8% to 16% [6].

Pregnant women suffering from depression or CMDs are less likely to seek antenatal care. They might put on less weight throughout pregnancy, increasing the likelihood of a difficult delivery and unfavourable results for the baby’s health, including neonatal mortality, low birth weight and premature birth. CMDs during pregnancy may also have a negative impact on the neurological development of the foetus [6]. Mental illnesses that develop during pregnancy that are not treated may persist after childbirth, leading to decreased attachment to and hostility towards the new born. CMDs during pregnancy may contribute to child undernutrition and affect a child’s social, emotional, and cognitive growth [8, 9]. Little empirical evidence has been provided by the study conducted in the community regarding the prevalence of CMDs among pregnant women in India. The prevalence of CMDs among pregnant women in India has received little empirical support from community- based studies. Stressful situations like pregnancy are one of the reasons why women, especially those of reproductive age, are more likely to acquire mental illnesses [6]. Poor emotional involvement, neglect, and hostility toward the new born have been associated with the postpartum period, yet, more attention is paid to the mothers’ physical issues during the antenatal period than their mental and emotional health [9, 10]. Pregnancy-induced hypertension and other physical problems are treated as high-risk pregnancies, whereas mental illness is not addressed adequately unless severe. Reports have shown that rural communities experience mental health issues more frequently than urban ones [10].

Around 70%-80% of the total population in India currently live in rural settings, lacking access to good quality healthcare facilities. Knowledge about mental illness in the general public was poor and associated with negative attitudes, as per the study conducted in Southern India [11]. Another south indian study showed that the prevalence of mental disorders prevalence rate was 24.4%. The most associated reason behind the rising prevalence of mental health disorders among women is poor awareness, low socioeconomic status and stigma related to mental health disorders [10]. Public and private healthcare organizations hardly ever addressed the problem of maternal mental health in the past. Early detection and treatment of depression or other often-seen CMDs could avert negative long-term impacts on maternal and new born health. Against this backdrop, the present review aims to identify the probable barriers and challenges in providing high-quality mental health services to pregnant women in rural India. The review aims to identify and recognize barriers and challenges in receiving mental health services among rural pregnant women in India to assess and prioritize the most prevalent barriers and challenges within this population.

Methods

We searched for primary studies of barriers to, and challenges of, the utilization of mental healthcare among pregnant women in India.

Search Strategy

The following online research databases (PubMed, Google Scholar, and Scopus) were searched for articles published from 2019 to 2023. The words mental health, India, pregnancy, rural, and barrier were used in the literature search. Studies identified via the searches were examined by screening the article titles and abstracts. Only articles from India written in English were taken into account. The search was limited to the previous five years to maintain current hurdles and challenges to mental health treatments in remote locations. Reviews were screened to identify primary studies set in India and meet the inclusion criteria (Table 1).

Exclusion Criteria
Studies from rural IndiaBeyond 5 Year
Within five years (2019-2023),International Studies
Pregnant Women

Table 1: Inclusion criteria and Exclusion Criteria in India.

Results

The following factors have acted as a barrier to mental health services in rural India.

Community level barriers

  • Household Related Barriers
  • Poor knowledge/awareness
  • Stigma and discrimination

Poor Knowledge/Awareness

A cross-sectional study conducted to understand the pathway of care adopted by psychiatric patients and its relationship with the socio-demographic determinants in the study population found that poor results are caused by mothers’ ignorance of prevalent mental diseases that might develop during the prenatal period and their failure to recognize them in the early stages. Most mothers believed these symptoms were not common during pregnancy or, if they did, were caused by witchcraft and didn’t require medical attention. In rural areas, people still have more faith in traditional healers and faith healers, which usually increases the duration of approaching the right psychiatric help [17]. Poor channel of confidentiality between healthcare providers and consumer develops poor face validity and thus prevent the healthcare enabling environment [9]. Demand- side barriers include a lack of knowledge about mental illness and its treatment options, which leads to a lack of support from family or partners to seek treatment. When there is low demand for services, primary care providers often don’t prioritize providing services, resulting in misallocating resources across decades for mental health care [18].

Stigma and Discrimination

In India, people with mental health issues face many obstacles when accessing mental health services, like being stigmatized or discriminated against. The stigma associated with mental illness can lead to delays in seeking care, impede the timely diagnosis and treatment of mental disorders, impede the recovery and rehabilitation process, and ultimately impede the capacity to participate fully in life. The stigma and shame associated with being diagnosed with a mental illness, and the disadvantaged position of women in communities prevent them from seeking services, even when available. The stigma was often associated with witchcraft, particularly during pregnancy, and was particularly prevalent among those from poorer socioeconomic backgrounds with lower education and lack awareness [19]. In India, it is essential to create a set of evidence-based interventions to address negative perceptions of individuals with mental health issues and to ensure their implementation through the involvement of users, carers, community health professionals and mental health services providers. It has been observed that different attitudes and beliefs regarding the aetiology of mental health issues in pregnant or postpartum women are one of the major obstacles to accessing maternal mental health services at the community level, which was thought to impede health-seeking and referrals for perinatal women suffering from mental health issues.

Lack of Resources at Primary Centres

A longitudinal study in rural south Karnataka explained that the lack of access to prenatal and mental health care has been linked to an increase in the number of psychiatric disorders during pregnancy. It’s a major obstacle for pregnant women to get the help they need to manage mental health issues, especially if they’re from a lower-income group that usually struggles to get good mental health care [12]. The establishment of necessary and sufficient healthcare facilities in remote areas has been explained by a study conducted on women’s empowerment and socioeconomic status. It explains that it is necessary to ensure sustainable, high-quality pregnancy-related services in South Asian nations, including India [20]. In urban and rural settings, mental health services like trained man force, essential drugs and adequate screening mechanisms are often inadequate to address the mental health requirements. Majority of the population that falls in of low-income groups, utilize public or community-level health services. Consequently, many access mental health services through the primary care setting, however primary care providers differ in their expertise and capacity to manage adolescent mental health issues [21].

Poor Screening Facilities

The absence of a policy addressing mental health concerns related to prenatal screening of mental health issues is a significant obstacle rural India must overcome if we want to increase the uptake of mental health services by this stratum of women [22]. Awareness generation is crucial to increase the feasibility and acceptability of mental health screening. Women should be made aware the consequences of ill mental health on the pregnancy and newborn through counselling and health promotion activities. It is necessary to implement mental health screening in the same manner as established for HIV/AIDS and TB screening in the districts. Furthermore, health professionals should not be apprehensive that incorporating screening facilities for mental health issues would increase their workload, which is already disproportionately high.

Discussion

The prevalence of mental health disorders among women is twice as high as that of men. Maternal mental health is a major public health concern, as it directly affects the health of both the mother and the child “A weak body can carry a strong mind, but a weak mind cannot carry a strong body” [24]. Pregnant women who experience mental health issues may be less likely to visit antenatal clinics, more likely to engage in substance use and be less likely to gain weight during pregnancy, which can lead to adverse health outcomes such as reduced birth weight, premature birth, and neonatal death [12]. It has been observed that mental disorders during pregnancy can have a negative impact on a child’s nutritional status behavioral, emotional and cognitive development. If the mental disorder is not treated in prenatal period, then it may persist into the postpartum period, leading to decreased emotional involvement, neglect and animosity towards the newborn [25]. Severely depressed or pregnant women with psychosis may also be suicidal, affecting the care given to the children. However, there is still limited research on this, which is why it is important to create evidence on the burden and obstacles that women face when seeking mental health services during pregnancy in rural India [26].

Mental health issues that occur during the first few months of pregnancy justify routine screening and should also be considered in high-risk pregnancies [10]. According to a study on importance of mental health of mothers for child nutrition, psychological disorders were linked to poor nutrition in babies, and the authors argued that maternal mental health should be a part of maternal and child health programs. The treatment gap (which is roughly defined as the percentage of eligible patients who are not receiving treatment) is close to 80%. While the challenge is immense, it is encouraging to know that in the last 4-5 years, many efforts have been made in the country to close this gap [27].

Through various central and state-level programs, the government is trying to reduce the poverty rate in rural India. The Ministry of Rural Development (MoRD) is working on a multi-pronged approach to eradicate rural poverty and enhance the economic prosperity of the people living in rural areas, focusing on livelihoods, women empowerment, social safety net, skills development for rural youth, infrastructure, land productivity, etc [28]. (Strategy for Poverty Alleviation in Rural Areas | Ministry of Rural Development | Government of India) Improving the overall economy of the rural population can provide a better way for accessibility to healthcare and low out-of-pocket expenditure, hence better services for mental health-related issues [29]. Global research indicates that healthcare professionals (particularly physicians and nurses) are equipped to provide a comprehensive range of services to rural areas. Regular training should occur for the workforce deputed at rural healthcare facilities to keep them updated on current disease trends, including mental health services [30].

Ayushman Bharat’s comprehensive primary health care (CPHC) includes a mental health component as one of the twelve components. This training guideline aims to provide pathways for learning and implementing the mental health component in the CPHC. In India, however, screening and managing mental health conditions have not yet been implemented and incorporated into the standard of care during prenatal care [31]. In light of the increasing prevalence of mental health issues, it is essential to incorporate screening and management protocols for maternal mental health into routine antenatal care services in India. Currently, the Maternal and Child Health program focuses more on medical issues, neglecting maternal mental health. This could be due to a crowded outpatient department, lack of time, or work-related constraints. Screening common mental health issues during prenatal visits makes it possible to identify psychological issues early and refer them to mental health professionals, thus avoiding negative maternal outcomes. Furthermore, referring mental health specialists can improve awareness and remove misconceptions [32].

India’s economy continues to expand, rural infrastructure continues to improve, and the country’s access to technology has the potential to improve the health of its citizens significantly. Several state governments have developed and implemented novel approaches to address the challenges of accessibility and cost-effectiveness of healthcare [33]. Many non-profit organizations working in rural areas that are difficult to access have developed strategies to enhance access, responsiveness, and the quality of primary health care. Telecommunications-related teleconsultation services can benefit rural populations, thus necessitating a wide range of health care services and support. Awareness-raising strategies can be implemented [34].

Despite several political and programmatic initiatives over the past 30 years (i.e., National Mental Health Program in 1982, Mental Health Act in 1987, and the DMHP in 1996), the current state of mental health in India remains relatively unchanged. Recently, the first national mental health policy of India was released, while the Indian Parliament approved the Mental health care bill to replace the 1987 Mental Health Act [3]. However, there is still considerable progress to be made. This is the crucial juncture for launching the Ayushman Bharat initiative, which seeks to provide primary, preventative and promotive mental health services to the population through the HWC Centers nationwide [35].

NHP 2017 aims to accelerate the development of specialists through public funding, build community-based psychosocial support networks to enhance primary-level mental health services, and leverage digital technology where qualified psychiatrists are hard to come by. This is a significant step forward from the previous National Health Programme (NHP), which focused primarily on treating general mental health conditions and reinforcing institutions. If implemented, the proposals in NHP 2017 would address key issues in mental health services across the country [3].

Conclusion

Primary healthcare is the foundation for universal health coverage. Due to multiple barriers, many countries have failed to achieve universal health coverage for mental disorders [36]. This paper has developed a contextualized recommendation for maternal mental health in India. The

results of this study serve as a wake-up call to essential topics that are often overlooked in the case of maternal mental health. Maternal mental health is a critical growth area that needs research and policy development attention [37]. All the proposed strategies are needed for success. To provide ‘right care’ at the ‘right place’, services should be easily accessible. Mental health services among pregnant women can be extended beyond by extending a psychiatrist unit and adding these services for screening during the prepartum and postpartum consultation period at the subdistrict level to disseminate resources appropriately [38]. Addressing the leadership and motivation issues with programme officials, training, and incentivization is essential. Efforts towards community participation and IEC activities must be continued while involving stakeholders, focusing on health and program communication.

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@article{alok2023,
  title   = {Barriers and Challenges in Mental Healthcare Utilization among
Pregnant Women in Rural India -A Narrative Review},
  author  = {Alok, Pathak V, Verma D and Manglani A},
  journal = {Public Health Open Access},
  year    = {2023},
  volume  = {7},
  number  = {2},
  doi     = {10.23880/phoa-16000253}
}
Alok, Pathak V, Verma D and Manglani A (2023). Barriers and Challenges in Mental Healthcare Utilization among
Pregnant Women in Rural India -A Narrative Review. Public Health Open Access, 7(2). https://doi.org/10.23880/phoa-16000253
TY  - JOUR
TI  - Barriers and Challenges in Mental Healthcare Utilization among
Pregnant Women in Rural India -A Narrative Review
AU  - Alok, Pathak V, Verma D and Manglani A
JO  - Public Health Open Access
PY  - 2023
VL  - 7
IS  - 2
DO  - 10.23880/phoa-16000253
ER  -