Socio-demographic characteristics of the respondents
The study participants’ socio-demographic characteristics revealed that the highest percentage (64%) of study participant’s age was 30 years or above. Among the total participant’s 34.67% was male and 65.33% female. Most of the participants (86.67%) were Muslims and the rest of the participants (13.33%) were Hindus by religion. About one-third of study participants (32%) had higher secondary or above level education, 33.33% had secondary level education but one-fifth of the participants had no formal education. Among the study participants, 38.67% were housewives, 38.67% were service holders, 10.67% were businessmen, 8% were farmers, and 4% were teachers. There were also members of local governments such as Upazila Parishad, religious leaders, and retired persons. Forty percent of the participants had a monthly household income of more than 12,000 takas while 24% had a monthly household income of fewer than 3,000 takas.
Perception on maternal mental health problems
Most of the respondents said that maternal mental health problems are not a problem to them during the perinatal period of women due to their nature. The mood swings, dizziness, bad dreams in the sleep, and the fears of death for pregnancy, that the mother’s experience, are explained due to the extra burden for being pregnant and child-rearing this period and are viewed as usual symptoms of this period. Therefore, additional support or medications are not deemed necessary. These symptoms are regarded as usual for women not labeled as a disease condition to treat.
Mental health issues, on the other hand, are significantly related to the matter of social stigma for a woman in the community. If the woman has mental diseases, they call her “pagol” (mental sickness/mad). So, she has to seek treatment from Mental Hospital locally known as “Pagla Garod” (loosely translated as a sanctuary for the mad people). A few respondents said that they are reluctant to seek healthcare during this period to this perception of maternal mental health and any mental health in the study area. They do not know who serves this support or medication and practitioner in the community (primary level) for mental health, especially maternal mental health problems during the perinatal period of women. One respondent (mother) said that,
“I felt worried during pregnancy. I think, it is happening during this period of women. But I did not seek any doctor. Even I did not know who serves the treatment.” (Age: 19 years female, Education: class five, Occupation: Housewife)
Most community service providers said that they did not hear about the women’s perinatal mental health problems. They listened to some mental health diseases names from their colleague, such as depression, anxiety, stress, etc. They shared that they provide counseling for taking nutritious food, preparing for arranging money, and vehicles for the emergency period. Apart from these, they did not provide any psycho-social counseling during the perinatal period of women for their mental health and well-being. One community healthcare provider said that maternal mental health is closely related to their circumstances, social and physical factors during this period. Suppose they cannot treat any kind of symptoms of women. In that case, they can refer to the Upazila Health Complex (UHC), a high-level facility of primary level healthcare in Bangladesh. So, they cannot suggest any support and management for mental health-related problems like depression, anxiety, stress, and postnatal psychotic disorders in general due to the absence of training and treatment guidelines.
Maternal mental healthcare-seeking during the perinatal period
Recognitions of antenatal mental health and care-seeking
All of the respondents said that when women conceived, they locally called her ‘poati’ (pregnant), pet hoice (being pregnant), or ‘Maa hote cholechhe’ (would-be a mother). They inform their senior family members (mother-in-law if present, husband) after being confirmed. In most cases, husband and/ or senior family members decide to seek care if needed. The majority of the total participants reported that being pregnant is not a serious issue requiring doctors. In terms of maternal mental health problems, most of the respondents reported that pregnancy may be associated with would-be mother’s mental concerns. In this connection, many mothers have experienced anxiety for their upcoming child’s good health and well-being, the impending birth, during the pregnancy period. They also added that poor mental health conditions may lead to increased risk in childbirth, followed by postnatal mental illness and improper child care. Some women had a mental illness when they become pregnant, and some had mental health problems during the maiden pregnancy. One respondent described her experience as,
“After crossing my menstruation date, I felt a change in my appetite. I could not eat anything and felt uneasy; I thought about what had happened to my body! Then I had taken a quick pregnancy test and the result was positive. So, I was very nervous. My husband told me; he was happy about that. I could not express my mood at that time.” (Age: 18 years female, Education: class one, Occupation: Housewife)
One respondent (Husband) reported that ignorance of husband during pregnancy period created mental problems. A few mental sufferings of the pregnant women have been seen unexpectedly, reported by their husband. For an example
“One day my wife told me; please forgive me for my any fault if die while giving birth. My wife felt fear of her delivery and related danger signs. Sometimes, she dreamt like this Since I did not recognize that it was mental health problems.” (Age: 32 years male, Education: HSC, Occupation: Businessman)
The other dimension of mental health is closely related to the sex of the upcoming baby. For example, one respondent (Husband) reported that his wife was tensed due to her expectation for a boy baby. He quoted,
“They were very upset during the fourth pregnancy because they already have three daughters. If it is repeated, what will happen then? This made them anxious.”
Most of the respondents said (service user) that there are no mental service providers in our primary and secondary level hospitals in the health system in Bangladesh. Only one respondent out of twenty-one sought maternal mental healthcare from a gynecologist in a private hospital.
From the supply side perspective, at the community level, the service provider (CHCP) mentioned that they do not have any guidelines and knowledge to provide maternal mental disorders in the perinatal period of women. One respondent shared her experiences,
“When I was pregnant, I felt apprehension or dread, tense about my delivery, and panicked regularly. Then I shared it with my husband. He told me to go to CC for taking counseling but Apa (CHCP), could not provide any suggestions on these.”
A few respondents (services providers and stakeholders) opined that unintended pregnancies happened in most cases at the community level in our country, making pregnant women mentally depressed.
Delivery care-seeking
In terms of physical health, most of the respondents reported that they sought treatment during the delivery period from a private hospital, clinic, or Mother & Child Welfare Centre (MCWC) which is popularly known as “maternity” at the district level. A few respondents also revealed that they also went Upazila Health Complex for delivery purposes during the delivery period. Very few respondents informed that they sought delivery care from the district hospital. Among all the respondents, only one respondent went to Faridpur Medical College and Hospital, a tertiary level hospital for delivery care seeking due to prolonged labor pain. In terms of mental health care seeking,most of the respondents said that they felt tensed and became frustrated over the danger signs, fatigue, hopelessness, body pain, and labor pain during the delivery period. For these types of maternal mental crisis during the delivery period, they did not seek doctors’ treatment. They seem that it is a more natural process for human beings and will be cured naturally. Several respondents said that they are the follower of Atrashi pak Darbar Sharif (religious and spiritual place); they get talisman (spiritual healer) from this Darber Sharif for any kind mental health problems during the delivery period. Another two respondents opined that they took pani pora (blessed water) from the Imam (Muslim religious leader) of the mosque to cure worries during the delivery period.
Post-natal (6 weeks or 42 days after delivery) care-seeking
Most community service providers reported that they do not have any formal knowledge and treatment guidelines to deal with post-natal mental disorders such as depression, anxiety, stress, post-partum psychosis, post-partum blue, and related symptoms during the post-natal period in any way. Even if they have no idea that poor mental health conditions may lead to increased risk in childbirth followed by post-partum depression. One respondent said,
“I think maternal mental disorders have seen in the perinatal period, especially after delivery due to her physical poor health conditions and new kid’s crying and disturbance.” (Age: 18 years female, Education: SSC, Occupation: Housewife)
On the other hand, a few respondents said that they have experienced mental health problems during the post-natal period although they did not seek treatment. One mother reported that she thought of seeking mental health treatment during the post-natal period but she did not know where to go for the treatment. Only one respondent involved in the teaching profession revealed that depression, anxiety, postpartum blue, and psychosis are the most common mental health problems in the post-natal period but treatment management is not available in the community level facility.
Socio-cultural influencing factors
In the study area, most of the respondents revealed that healthcare-seeking behavior had been influenced by many confounding factors furthermore some factors have more significant influences on maternal mental disorders treatment seeking as follows; socio-cultural and religious beliefs, practices, taboos, and restrictions during the perinatal period of women. These factors have been elaborated by respondents’ experience below.
Beliefs and practices
most community people have different beliefs in social and religious entities on maternal health and mental health issues during the perinatal period. Often the traditional healers, religious leaders, folk, and spiritual healers are referred to as the sources for treatment-seeking. Some respondents revealed that they did not go to the doctor for seeking mental healthcare during the pregnancy period because the doctors might give tests for pregnant women that might be harmful to the unborn fetus. Besides, it was also costly to go to doctors. In that case, they had to abide by their mother-in-law and husband’s decision that led them to go to the religious leaders for spiritual blessings. Three respondents said that they sought treatment from Joli didi (Sasto Kormi (Health worker) of BRAC) because they knew her and took care of community people through household visits.
Support from neighborhood
Most of the respondents agreed on this common issue that social capital was a leading social determinant to motivate maternal mental healthcare-seeking behavior in the perinatal period of women. Through this relationship, a person gets support to improve the mental well-being of women in the perinatal period. Most pregnant women who participated in this study explained that they usually got help from their neighbors during pregnancy and in any critical situation. One pregnant woman said,
“I felt severe pain in the lower abdomen when the eighth month of my pregnancy was running. I did not find any way. I shared with my husband but he did not make it clear to me; then I went to my neighbors. She told me that it is very usual in the pregnancy. I got relief after hearing this”. (Age: 28 years female, Education: class seven, Occupation: Housewife)
Another female respondent who has one year’s child said,
“When I conceived, I did not know who will be better for medication at that period. My neighbor said to me to go to either Rabeya clinic or Maternity in Rajbari Sadar. After that, I went to maternity and got checked by Dr. Sumi Apa.” (Age: 18 years female, Education: class seven, Occupation: Housewife)
Most respondents opined that husbands’ support is the most trusted and closest support than female relatives and friends. So, his support is considered to be the most important support during pregnancy. Besides, the intimacy in the husband-wife relationship seemed to have a central role in social support received, and their sense of togetherness.