On March 11, 2020, the World Health Organization declared the Novel Coronavirus Disease 2019 (COVID-19) outbreak a global pandemic. This highly infectious disease spread across the world in a short span of time, infecting millions of people around the world. The affected countries are using different strategies to contain the spread of COVID-19. In the absence of effective treatment protocols and a vaccine, total lockdown of cities, even entire countries, and mandatory social distancing between people are presently the only means to slow the spread of the disease.
The rapid spread of COVID-19 has impacted many aspects of human life and activities. The drastic restrictions on economic activities have resulted in enormous economic losses and consequent loss of incomes and livelihood. Consequently, mental health of the population has become a public health concern and should be studied.
In the broader discourse on public health discourse, both maternal health and maternal mental health are usually overlooked. Maternal mental health is a public health problem in India. It is estimated that 10-35% of women around the world including Nepal suffer from depression during pregnancy and postpartum. Pregnant women and new mothers are at an elevated risk of suffering from mental health problems. It has been observed that the uncertainty surrounding COVID-19 has led to higher levels of depression among women during and after pregnancy. Pregnant women may feel social isolation and have greater fear of infection for themselves, as well as their infants. Lack of health facilities and increasing number of home deliveries without the assistance of trained health workers heighten the distress and depression in these women. Owing to lack of sufficient and reliable evidence on the risk of transmission of infection of COVID-19 from mother to child, stress and depression among pregnant women and new mothers have increased.
Nepal's public health facilities are burdened with patients being treated for COVID-19. Combined with the complete lockdown, imposed throughout the country, pregnant women are finding it increasingly difficult to seek care and treatment from health facilities and providers. Here, it is important to note that more than half of pregnant women in Nepal seek antenatal care in private facilities and 54% of deliveries take place in health care institution (Institutional Delivery). With many private and small clinics shut, poor utilization of maternal healthcare services has resulted. Lack of access to maternal health care and the absence to face-to-face interactions with healthcare providers has added to the stress and depression that pregnant women are often prone to. Women with pregnancy complications and who had adverse pregnancy outcomes in earlier pregnancies may experience more severe depression which can have detrimental effects on the health and well-being of both women and fetus if not treated in the beginning.
The mental health issues and problems faced by women in rural Nepal are even more serious. Owing to the lockdown and enforcement of social distancing norms, it is not possible for local health workers to reach every woman. In rural areas, most of the time, antenatal care services are provided in groups. This is not possible in the present circumstances, and as a result, many pregnant and lactating mothers are left without medical care.
The United Nations Population Fund recently estimated that unwanted pregnancies have increased sharply during the lockdown and that women are at a considerably higher risk of violence. According to UNFPA, more than 47 million women could lose access to contraception, leading to 7 million unintended pregnancies in the coming months which will also increase the likelihood of unsafe abortions. This scenario has serious implications for women's health, especially their mental health. Women with unwanted pregnancy experiences are known to suffer from severe depression during pregnancy and in the postpartum period. If such women also experience violence during this period, the effects on their well-being can be catastrophic.
The problem of mental health of women is multidimensional and complex. The Government of Nepal had announced an immediate and total lockdown on 24 March, 2020, which was extended to 21 July, 2020. The lockdown was declared without proper planning and preparation which was clearly evident in the state's response to the plight of migrant workers who were left without food and shelter and no means of returning to their homes. These migrants were the worst affected due to loss of employment. Nearly half of the migrants seeking to return home were women in reproductive age. To reach their respective homes, thousands of migrant workers had started walking hundreds of kilometers back to their homes, exposing the women who were pregnant to even more stress and health risks.
Even in the past, the issue of maternal mental health was barely addressed by public and private healthcare providers. However, in a crisis situation similar to the present pandemic, it is necessary that health facilities give attention to pregnant and recently delivered women for possible symptoms of depression. Detecting and treating depression in the beginning could prevent detrimental long-term effects on maternal and infant health. Local healthcare providers should be trained to identify unwanted pregnancies and make available abortion facilities that are legal and safe, which could also reduce the burden of depression and unwanted pregnancies.
Pregnant and recently delivered women should also be provided appropriate information about COVID-19, as well as counseling, for reducing stress. They must also be supported by their partners and community and encouraged to exercise and remain active for their mental health. Migrant women in the receiving states should be provided with basic antenatal and postnatal services. It is the government's responsibility to ensure their well-being and make the necessary effort to minimize the uncertainty which is the major cause of depression.