On January 7, the Kasaragod police arrested a 23-year-old woman who had just given birth to her second child. The new mother, Shahina, had strangled her infant with her earphone wires. She later covered him with a cloth and put his body under her bed, which was found by the family when they searched the house.
The incident took place on December 16, 2020 in Kasaragod’s Badiadka, where Shahina lived with her husband Shafi and his parents.
A month before this, a 29-year-old woman from Thiruvananthapuram’s Nedumangad killed her newborn and buried the body behind her house. The crime came to light after the accused’s neighbours complained of a stench coming from the house after which the infant’s remains were discovered. Police suspect that the accused, identified as Viji, suffers from mental health issues.
In Shahina’s case, the police found that Shafi and his parents did not know she was pregnant. The investigating team says that Shahina delivered the child and killed him instantly, while Shafi and his parents were out of town. Shahina is now in judicial custody in Kannur, but unlike the Thiruvananthapuram murder, the police do not know what triggered her to kill her child.
“She was disappointed that she was pregnant soon after delivering her first-born last year. This is why she hid it from her family, and killed the child,” an official from Badiadka told TNM.
However, experts in postpartum psychiatric study say that this is simply not a good enough reason to drive a new mother to kill her offspring. The real reason, they believe, could be postpartum psychosis, a rare and severe mental health condition found in 3-5% of new mothers in the country.
Postpartum depression and psychosis
Within a few days of delivery, over 80% women go through mild to severe behavioural changes triggered by various factors, says Dr Arun B Nair, Assistant Professor of Psychiatry at the Government Medical College, Thiruvananthapuram.
For most new mothers, these are mild mood disturbances that occur within 3-4 days of delivery. It is a common phenomenon called postnatal blues, he adds.
“Postnatal blues don’t require any treatment, it generally goes away within a week, with emotional support from the family and the partner. But in a few cases, these mood changes can be intense and lasting,” he explains. This ends up in postpartum depression (PPD) or psychosis.
For 10% of new mothers, these mood changes turn into a disorder characterised by intense bouts of sadness, uncontrollable crying, anhedonia or lack of interest in pleasurable things, doubts over raising the child, anxiety, lack of sleep, drastic lack of appetite and suicidal thoughts. This is PPD and requires medical intervention either through psychotherapy (if mild) or medication (if the condition is severe).
In rare cases, this mood disorder becomes more dramatic or pronounced in the patients. It is characterised by unrealistic and delusional thoughts and hallucinations, and turns into psychosis, Dr Arun adds.
“With psychosis, the main symptom is intense fear. This fear can be anything – from the mother thinking that somebody is going to kill or harm her to a delusional belief that the child is going to harm her and the family,” says R Unnikrishnan, a psychiatrist associated with the District Mental Health Program in Thiruvananthapuram.
Patients could experience auditory hallucinations where they imagine someone whispering in their ear. They might even have visual hallucinations where they imagine seeing things when they wake up from a disturbed sleep, Dr Unnikrishnan explains.
Typically, it is the hormonal changes in the mother’s body that triggers such conditions – a dip in serotonin levels causing depression and a spike in dopamine levels causing psychosis. In cases of severe postpartum psychosis, the mother itself becomes a threat to the newborn as she starts to lose orientation with reality.
While women with low social support, women facing difficulties in their pregnancy, women with a history of mental health issues and those experiencing marital issues, etc. are more vulnerable to PPD or postpartum psychosis, sometimes the disorder can also be triggered in women outside of this bracket.
How the state is tackling the issue
In 2017, Kerala’s Department of Health and Family Welfare launched ‘Amma Manasu’, an initiative to address psychiatric disorders among women during pregnancy and post-delivery. The project was launched in collaboration with the National Mental Health Programme. Three years later, the initiative has grown in terms of increasing the conversation around pregnancy and mental health, as well as regularly surveying new mothers for signs of PPD or psychosis.
“Kerala has always had a low maternal mortality rate compared to the national average. We have been closely scrutinising both. But when we looked at the causes of maternal mortality, many were suicides. In 2018-19, matenal suicides were about 7 percent of the total maternal mortalities. 13 out of 187 new mothers who had died had killed themselves. It was to address this that Amma Manasu was launched,” says Dr Kiran PS, Nodal Officer, Mental Health Programme.
Under the initiative, each district has a mental health team to ensure that mothers with postpartum mental health issues are offered appropriate treatment. In each municipal body, couples who are eligible to have children are registered and when they do get pregnant, the women have three sessions in the antenatal period (during pregnancy) and in the postnatal period (after delivery) at the local community health centre to check for signs of depression.
“Each community health centre has a junior public health nurse who screens these women with questionnaires. The questionnaire includes queries about mental health and symptoms indicative of depression. The women are asked if they experience any of the telling signs of depression. And if a mild case of PPD is detected, then the medical officer is informed and the patient is offered counselling. However, for moderate to severe cases, the medical officer refers the patient to the District Mental Health Program clinics where the team of doctors will treat the patient either with medication or psychotherapy,” Dr Kiran adds.
The team also holds outpatient consulting in different clinics in the district, where they can personally meet and review new patients and follow up on cases.
The initiative has taken steps to spread awareness on mental health from the grassroots level, by training ASHA and other health workers to identify cases. These workers conduct house visits, speak to the families and ask them screening questions as part of a regular surveillance process, which increases awareness among the families.
Apart from this, leaflets, exhibitions, street plays and flex boards highlighting the importance of mental healthcare are also done to further awareness. “Some of our doctors also attend TV programmes to speak about awareness. These initiatives have proved beneficial as we’ve seen a small reduction in the number of treatment dropouts, which are generally high in psychiatry. However, we still have to increase our information, education and communication (IEC) activities when it comes to mental health disorders,” Dr Kiran adds.