Early-stage development of a complex, community-based intervention to improve women's perinatal health in rural communities in India

Perinatal mental health is a global public health priority. It is estimated that 1 in 5 women has a mental health problem during the perinatal phase (pregnancy to one year after birth), and the rates are even higher for women in low- and middle-income countries (LMICs). In India, between 14-31% of women experience anxiety, depression, stress, or suicidal ideation (common perinatal mental disorders; CPMDs). In rural India, women are also affected by social determinants of CPMDs and intersecting issues, such as gender inequity, poverty, domestic violence, caste, and stigma. Yet, most women with CPMDs do not receive care, with little research exists on how to best address CPMDs in low resource, rural settings.
Integration of mental health into maternal health services is often not thought feasible in LMICs, where health systems are overburdened and under-resourced. Task-shifting of mental health care from specialist health workers to peer workers has good evidence and underused potential to support weak health systems in LMICs.
The Perinatal Mental Health project (PRAMH) aims to develop an intervention to address the significant challenge of preventing, detecting and supporting women with CPMDs in rural India, by integrating mental health into maternity care. Our aim is to develop a clear theory of change and pathway for future development, implementation, and evaluation.

This early-development study will develop a community-based, technology-enabled, task-shifting intervention. Using the community-initiated care approach, we will: train community health workers to use digital technology to identify women with CPMDs and link community and health care system; train peer-workers to administer the Thinking Healthy Programme in village support groups; develop a community anti-stigma campaign. We will be guided by the community mental health model of care and a continuous revision of a Theory of Change (ToC) programme theory.
Our research question is: Can a complex, community-based intervention support women with CPMDs in rural India? We will use mixed methods and a learning health systems approach, working in close partnership with women with lived experience of CPMDs, families, local communities, and key stakeholders, such as policy and non-governmental organisations. The work will be carried out in two rural districts in the states of Haryana and Telangana (India) in four primary health centre catchment areas (population n=30.000 each).
The study aims to build a systems approach that identifies and targets perinatal mental health (PMH), stigma and critical social determinants of perinatal mental health. Iterative, multi-sectoral collaboration will guide the development of the intervention, training, data collection, and evaluation. PRAMH is part of the ongoing, large randomised controlled SMARThealthPregnancy trial (clinicaltrials.gov NCT05752955).
If proven feasible and acceptable, PRAMH can be tested and evaluated in a randomised controlled trial. The intervention has the potential to improve promotion, prevention and treatment for CPMDs in rural India and other LMICs.