Perinatal Mental Health in India: A Policy Silence and Representation Analysis through Bacchi’s WPR Framework

Introduction

Perinatal mental illness includes psychiatric disorders during pregnancy and up to a year after childbirth, such as depression, anxiety, and psychosis (O’Hara & Wisner, 2014). Globally, about 10% of pregnant women and 13% of new mothers are affected (WHO, 2023). Despite increasing global evidence linking perinatal depression and anxiety to maternal morbidity, India still lacks a dedicated policy, strategy, or budget allocation for perinatal mental health (PNMH).

This absence itself demands analysis.
As policy scholar Carol Bacchi (2009) argues, policies are not mere responses to existing problems, that they construct problems by defining what counts as one, what does not, and who is responsible for it. Bacchi’s “What’s the Problem Represented to Be?” (WPR) approach thus provides a critical lens for what is left unsaid and the “policy silences” (Bletsas, A. & Beasley, C. 2012).

Applying the WPR framework allows us to interrogate how existing maternal and mental health frameworks implicitly construct or neglect PNMH, and what social, structural, and institutional assumptions exist.

Conceptualising Mental Health and Perinatal Mental Health

Mental health is not simply the absence of disorder, it is the presence of well-being and the ability to cope, learn, and contribute meaningfully to society (CDC, 2025). It is an essential determinant of health across the life course, especially during the perinatal period when women face intense biological, emotional, and social transitions.

The studies show the prevalence of postnatal depression ranges from 15 to 35% with an average of around 19 % in low- and middle- income countries (Gelaye et al. 2016). In India, perinatal depression is reported between 14% and 24%, while stress and anxiety can reach up to 30.9% and 23% respectively (Singh & Verma, 2023).

These rates may however vary with different geographical and socioeconomic factors.

Theoretical Framework: Bacchi’s WPR Approach

Q1. What’s the problem represented to be?

The literature portrays Perinatal Mental Disorders (PMDs) as frequent complications of pregnancy and the postpartum period, with higher prevalence in LMIC countries and significant associations with poor maternal-fetal attachment, adverse neonatal outcomes (low birth weight, preterm birth) (Leis et al., 2014, Howard & Khalifeh, 2020). However, stigma, lack of resources, insufficient training for healthcare workers, low awareness, the absence of culturally adapted tools and a system that often treats mental health as a separate issue rather than integrating it into routine maternal care are seen as barriers that prevent timely identification and response (Howard & Khalifeh, 2020). 

Moreover, the experiences such as domestic violence, tokophobia, marital conflict or lack of a partner, male child preference, poor social support, and major life events contribute to perinatal anxiety and depression, while poverty, substance use, unplanned pregnancy, past abuse, and prior abortion further increase the risk (Ghaedrahmati et al., 2017; Lancaster et al., 2010; Smorti et al., 2019). Yet, within the dominant representation, these social and structural determinants are rarely framed as part of the “problem”. 

Q2. What presuppositions or assumptions underlie this representation?

The dominant representation treats perinatal mental health on several assumptions that distress mainly “sits in the mother,” downplaying structural drivers like intimate partner violence, child with disability, financial constraints/debts, cultural stigmas, poverty and programs often assume a supportive husband but ignore in-law control, marital rape, abuse, single/adolescent mothers (Mellers et al., 2025).           

The assumption that frontline workers “have time” . ASHAs and ANMs already juggle extensive duties, so adding counselling or therapy often turns into an extra exercise rather than meaningful care (Khandre et al., 2023).                                                                                               

The assumption that everyone can use tele-care (Tele Manas) doesn’t hold in many real settings (Ministry of Health and Family Welfare, 2017). Shared phones, lack of privacy at home, and language barriers often prevent women from speaking openly or even taking a call. Assuming Tele manas number for complaint against domestic violence, abuse etc. 

Q3. How has this representation of the problem come about?

In India, perinatal mental health has evolved within broader discourses on women’s welfare and mental health rather than as a distinct policy area. Early national programmes focused mainly on physical and reproductive health, with little attention to psychological wellbeing. Recognition of maternal mental health gained momentum only in the 2010s, driven by global evidence on postpartum depression and calls for gender-sensitive care. Key milestones include the Mental Healthcare Act (2017), which linked mother–infant care and decriminalised suicide, and state and national initiatives like Kerala’s Amma Manasu (2019) and Tele Manas (2022), which institutionalised psychological support (Mellers et al., 2025). Thus, perinatal mental health in India has developed within broader maternal and mental health agendas rather than through targeted policy recognition.

Q4. What is left unproblematic in this problem representation? Where are the silences? Can the ‘problem’ be thought about differently?

The current policy framing of maternal health in India leaves several dimensions of perinatal mental health unproblematic

This silence is reinforced by what national systems choose to measure  the Health Management and Information Systems (HMIS), National Family and Health Survey(NFHS), and NITI Aayog dashboards record physical outcomes but exclude depression, anxiety, or suicidality, leaving psychological well-being.

Reimagining the issue through a socio-ecological lens shows that perinatal mental health is not just a clinical detection problem but a layered social and structural concern. At the individual level, women need supportive, stigma-free care; at the family and community levels, safety, empathy, and social support; at the health-system level, trained staff and integrated services; and at the policy level, explicit recognition, measurement, data storage and funding so, the broader view, the “problem” is not the woman’s distress itself but the absence of structural attention, accountability, and care infrastructure that could protect women’s  well-being and dignity.

Q5. What effects are produced by this representation?

Bacchi’s insight is that representations create social realities. However, untreated perinatal depression and anxiety produce physiological stress (HPA-axis dysregulation, elevated cortisol, inflammatory markers) that can affect pregnancy biology,  increasing risks for preterm birth, low birth weight and obstetric complications. 

Longitudinal studies have linked maternal perinatal depression to poorer infant attachment, delayed cognitive and socio-emotional development, and increased risk of behavioral problems, attention‐deficit/hyperactivity disorder (ADHD) and autism (Howard & Khalifeh, 2020). 

Question 6: How and where is this representation produced, disseminated, and defended?

This representation is produced and sustained through key policy texts such as the National Health Mission (NHM), RMNCH+A strategy, and National Mental Health Programme (NMHP), which collectively define maternal health. It is disseminated through Health data systems, training curricula, and program evaluation frameworks but as it mainly prioritises measurable physical outcomes.

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