A pregnancy is often a cause for celebration: a new life and a new addition to the family. But for the women who come to Garima Malik’s clinic in New Delhi, this is not the case. Some cry. Others appear angry, irritable, or frustrated. Usually the root cause is domestic violence: pregnancy is a particularly vulnerable time for this and, as an experienced counsellor, Malik is trained to spot the signs.
“They talk about suicide. Then they calm down. We talk about risk management and safe planning and advice. So somehow they get over it,” he says. Many of the women who come to the clinic, run by the NGO Doctors without borders (MSF), have suffered physical and emotional violence during pregnancy, explains Malik. Sometimes it is because they are unwilling to be intimate with a partner early in pregnancy or immediately after delivery. Others it is because they have given birth to a girl, which some see as less desirable. “This can cause loneliness in women, who can feel frustrated. They feel that he [el marido] she needed a man, that the family needed a man, and as a consequence she is the one who suffers,” she maintains.
Malik points out that the women who come to her clinic are the lucky ones: the majority of Indian women experiencing suicidal thoughts during or after pregnancy will not seek or receive help.
A study of low-income women in early pregnancy in southern India found that 7.6% were at risk of suicide, compared to about 0.4% in the US
So far, suicide is one of the leading causes of death among women of childbearing age in India. According to a study recently published in the medical journal The Lancetthe suicide rate among Indian women and girls is twice the world average.
Since the turn of the century, the country has made great strides in reducing overall maternal mortality, cutting deaths by more than half. In 2019, 103 mothers died per 100,000 live births, compared to 254 in 2004. The United Nations has set a goal of reducing global maternal mortality to 70 deaths per 100,000 in 2030.
That success has brought to light a previously largely unnoticed phenomenon: high suicide rates in the perinatal period, which includes pregnancy and the immediate postpartum period. A 2016 study of 462 low-income women in early pregnancy in southern India showed that 7.6% were at risk of suicide compared to about 0.4% in the United States.
The health experts consulted are of the opinion that the Government has done little to address this situation and that the action plan for the prevention of suicide designed in 2018 has never been applied. Lakshmi Vijayakumar, psychiatrist and member of the International Network for Research and Prevention of Suicide of the World Health Organization (WHO), denounces that India is losing “an enormous number” of young women, and that there is no effective mechanism, plan or strategy to address this problem.
Data is limited. India collects national maternal death statistics by extrapolating from a representative sample survey, but does not separate the data by cause of death. The police keep data on reported suicides, but do not record whether the person was pregnant. And anyway, suicides are often underreported.
Perinatal suicides are often linked to a history of psychiatric illness, but psychiatrist Vijayakumar notes that this does not appear to be the case in India. Instead, social factors such as early marriage, intimate partner violence, pressure to give birth to a son, and women’s lack of economic independence are determining factors.
A revealing success story
When it comes to the physical causes of maternal deaths, India’s success has been remarkable and is due in large part to an increase in births taking place in free public health facilities rather than at home. These went from 31.1% in 2005-2006 to 88.6% in 2019-2021, according to government figures, driven by awareness campaigns and small economic incentives for both women and health services.
The state of Kerala, in southern India, has been one of the most successful in reducing maternal deaths. With a maternal mortality of 43 per 100,000 live births, it is the safest place in the country to give birth. Also the only State that has investigated perinatal suicide data, analyzing the 1,076 maternal deaths recorded between 2010 and 2020. During that period, mortality fell from 66 to 43, but the proportion of suicides increased from about 2.6% in in 2010 to 6.6% five years later, and to 18.6% in the 2019-2020 period.
These data should be treated with some caution: Kerala’s relatively low maternal mortality rates are due to the small sample size. But, combined with the 2016 study in southern India, it indicates a trend, says Soumitra Pathare, psychiatrist and director of the Center for Mental Health Law and Policy. “It’s important for a number of reasons: We now have consistent data showing that suicide is a major problem among young women, especially those who are pregnant or have just given birth,” she says. “Maternal mortality has been reduced considerably, because interventions have been made to achieve it. So what this really shows is that we haven’t acted to prevent suicides,” she continues.
He warns that the data reflects only part of the problem. For every person who commits suicide, it is estimated that between 4 and 20 attempt it. So the number of suicide attempts [en India] it ranges from 0.6 million to six million,” says Pathare. “We don’t even collect data on it,” she concludes.
Early intervention essential
There has been little research into the reasons for perinatal suicide in India, although the Kerala study identified psychiatric illness, youth, singleness, and domestic violence as risk factors.
Nearly one in three Indian women between the ages of 15 and 49 who have ever been married have experienced intimate partner violence, according to government figures. About 3.1% of the women included in this category stated that they had suffered physical violence during pregnancy. Marital rape is not legally recognized, although this is being challenged in court.
Nearly one in three Indian women between the ages of 15 and 49 who have ever been married have experienced intimate partner violence, according to government figures.
Nayreen Daruwallahead of a program on the prevention of violence against women and children of the NGO Society for Action on Nutrition, Education and Health The Mumbai-based SNEHA explains that suicide during pregnancy often falls into one of two categories. “One is pregnant married women in which case the family insists on having a boy,” she says. “The category of single mothers is huge, mainly due to the lack of social support and, sometimes, the lack of support from the partner, who may be reluctant to marry when they find out that the woman is pregnant,” he says. she.
Shaji KS, dean of research at Kerala University of Health Sciences and part of the team that reviewed perinatal suicides in Kerala, cites the Indian network of health workers, through which all pregnant women in the country can be reached . Adding a psychiatric component to support their mental health would help prevent many deaths, he says.
MSF’s Malik believes that more professional training is needed to enable Indian women to become economically independent, which would make it easier for them to escape abusive situations. A study in Australia has found this to be effective in reducing suicides. In India, women’s participation in the labor market has been steadily declining, from around 30.4% in 2000 to 19% in 2021. “When we talk to those patients, when we talk about leaving their husbands and leaving a such a toxic environment and get out of that kind of relationship, they want to do it. They cannot because they are not financially independent,” she maintains. Studies also show that restricting access to pesticides, used in many suicides in India, could prevent some deaths.
Lakshmi, the psychiatrist and adviser to the WHO, was part of a task force set up by the Indian government in 2018 to suggest ways to reduce suicides overall, but her recommendations have not been implemented. When asked about funding for suicide prevention, the government stated in February that funds had been allocated and announced plans for a national telemedicine program for mental health. She but she did not commit to adopting the recommendations of the working group. “We have presented the plan,” Lakshmi insists. “But it’s still lying there. I hope one day it will see the light of day,” she concludes.
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