Recognizing disability associated with perinatal depression as a precursor of women’s rights violations under the UN Convention on the Rights of Persons with Disabilities

Abstract

Functional disability is concomitantly present in women affected by perinatal depression (PND). PND is not recognized as a public health issue in many countries, especially low- and middle-income countries. This makes it imperative to understand the unique positioning of perinatally depressed women within the framework of the United Nations Convention on the Rights of Persons with Disabilities (CRPD) and the signatory state’s obligations. The present study is an exploratory review that utilizes comparative content analysis to map the manifestation of disability in perinatally depressed women, using the six domains of disability described under the World Health Organization (WHO’s) WHODAS 2.0 Manual alongside the findings of epidemiological studies. By adopting the normative juridical method, the provisions of the CRPD were examined in relation to women’s unmet perinatal mental health needs, untreated disability, and resulting violation of women’s rights. The manifestation forms and consequences of disability associated with maternal PND are multitudinal and multifarious. Perinatal disability resulting from mental health disorders must be recognized as a subject matter under the CRPD. In the absence of laws and policies that address and provide for the management of PND, the signatory States are in breach of their treaty obligations under the CRPD. Policymakers and women’s rights protagonists can push for law and policy reforms relating to PND by highlighting the gross violation of the CRPD.

Plain Language Summary

Since the manifestation forms and consequences of disability associated with maternal PND are multitudinal and multifarious, it must be recognized as a subject matter under the CRPD.

Non-recognition of maternal PND as a public health issue, and its non-addressal and non-management must be regarded as a violation of different provisions of the CRPD.

The policymakers and women’s rights protagonists can advocate for the urgent introduction of relevant legislative instruments by underscoring the gross violation of the CRPD by signatory States.

Keywords

perinatal depression disability WHODAS 2.0 CRPD human rights

Introduction

Depression accounts for the largest proportion of the burden associated with mental disorders in women of reproductive age groups.¹ Women during the perinatal period are more exposed to debilitating mental health conditions, and social determinants of health play a cardinal role in altering their mental health status.² Due to these facets, adopting a gender-based approach while formulating mental health policies is warranted.³

Since women are uniquely and disproportionately affected by perinatal depression (PND), the gender neutrality of health laws and policies can result in “indirect” discrimination.^4,5 Moreover, the special needs of women should be underscored while formulating mental health policies because they are “more exposed,” and become “more vulnerable” to psychosocial determinants of health.^6–8

Maternal mental health (MMH), regardless of its multitudinous nature, has not received the befitting political and programmatic attention, especially in low- and middle-income countries (LMICs).⁹ The lack of integration of maternal health services, child health services, and mental health services creates a wide gap in the detection, prevention, and treatment of maternal mental disorders.¹⁰ Community-based interventions have been reported to be effective in reducing depressive symptomology related to MMH conditions even in LMICs.¹¹

PND has been recognized as a public health issue because of the multitudinal and multifarious adverse effects it has on the health of women and infants.^12,13 PND also compromises the maternal capacity of women, making them less responsive to their child’s needs while also triggering self-harm or suicidal tendencies in affected women.^14,15 The physical, mental, emotional, and cognitive development of children of perinatally depressed women is impeded if their mothers do not receive the requisite support and treatment.¹⁶ Infanticide and extended suicide are some of the gravest consequences associated with PND.^17,18

Though PND is transmittable intergenerationally, apart from having enormous economic and human costs associated with it, still it remains conspicuously absent from maternal and child health frameworks, and mental health and rights frameworks.¹⁹ This makes upstream discourse about perinatal mental health crucial.²⁰ More so, the World Health Organization (WHO) has been propagating the adoption of the rights-based approach to address and manage PND as a public health issue.²

The International Classification of Diseases (ICD)-11 describes non-psychotic perinatal mental disorders (PMDs) as a “syndrome” involving “significant mental or behavioral features, most commonly depressive symptoms,” while differentiating it from postpartum blues.^21,22 It has been demarcated that it results in “significant impairment in personal, family, social, educational, occupational, or other important areas of functioning,” where such functioning, if maintained, can only be a result of “significant additional effort.”^21,22 Since PND also results in functional disability, it is imperative to prioritize affected women for treatment administration.²³

Objectives of the study

The disability in women concomitant with PND, and the absence of health laws and policies that can ensure the provision of standard protocols and treatment, make it imperative to understand the unique positioning of perinatally depressed women within the framework of the United Nations Convention on the Rights of Persons with Disabilities (CRPD), and the implications of such policy gap for the rights enshrined under the CRPD.

Methods

The present study is an exploratory review that utilizes comparative content analysis to map the manifestation of disability and associated consequences of PND, using the six domains prescribed under the WHO’s WHODAS 2.0 Manual for assessing disability²⁴ alongside the findings of evidence-based studies focused on PND. Using the normative and operational system of International Human Rights Law, and by adopting the normative juridical method, the provisions of the CRPD were read in reference to unmet perinatal mental health needs of women affected by depression, consequently arising sustained, untreated disability, and resulting violation of their rights under the provisions of the CRPD.

Results

PND, and consequential disability in affected women: correlation with domains prescribed under the WHODAS 2.0

To comprehend the gravity of the multifaceted adverse effects of PND, an understanding of functional disability associated with the perinatal period is essential. Functional disability can be distinguished from non-disability based on one’s ability to perform daily activities and chores or to evaluate if they function normally.²³ Under the WHO’s disability assessment manual, WHODAS 2.0, disability encompasses six domains: (1) understanding and communication, (2) self-care, (3) mobility, (4) interpersonal relationships, (5) work and household roles, and (6) community and social participation.²⁴

The following table reflects on the facets of the manifestation of disability in perinatally depressed women using the six domains prescribed under the WHODAS 2.0 Manual, and epidemiological studies dealing with PND (Table 1)

Table 1.

Assessing disability associated with perinatal depression using WHODAS 2.0 manual and findings of epidemiological studies.

Six disability domains under the WHODAS 2.0	Disability witnessed in perinatally depressed women	Manifestation form	Consequences
Cognition	Compromised understanding and communication	Excessive crying,²⁵ difficulty in concentrating,²⁶ compromised problem-solving,²⁷ and communication,²⁸ loss of self-confidence,²⁹ recurrent depressive episodes,³⁰ feeling guilty,³¹ aggression toward child,³² suicide ideation,³³ infanticide ideation³⁴	Compromised maternal ability, and impaired parenting^15,35,36: compromised sensitivity and responsiveness, inconsistent with or discontinuation of breastfeeding,^37–39 self-harm/suicide,^12,40,41 infanticide, and/or extended suicides^42,43
Self-care	Do not undertake or lose interest in self-care activities	Loss of appetite,⁴⁴ insomnia,⁴⁵ unable to comprehend their mental health needs,⁴⁶ negative perception about health care and health personnel⁴⁷	Do not seek medical assistance.^48–50 nutritional deficiencies,⁵¹ risky health practices like poor nutrition and hygiene, substance abuse or lesser number of antenatal visits⁵²
Mobility	Restricted/limited movement which may be self-imposed or may be attributable to socio-cultural norms, biomedical needs, etc.	Long durations of confinement within the home,⁵³ Restrictions on movement within, and outside the house due to obstetric factors like cesarean births, adverse birth events, etc.^54–56	Tend to remain isolated⁵⁷
Getting along	Reduced quality of interpersonal relationships, aggravation of disputes, internalization of disputes (have a cyclical nature, act as an influential (risk) factor, and as an outcome)	Not seeking/receiving social support,^58–60 the existence of depression/depressive symptoms in both mother and father,^35,61 non-disclosure of the existence of intimate partner violence²⁶	Discord with a partner,^29,35 and/or family members, family maladjustments,^62,63 lose guardianship of children since they are deemed as “unfit mother” or a threat for the child⁶⁴
Life activities	Work and household roles are affected/compromised	Unable to return to employment,⁶⁵ women perform an increased burden of household chores along with child care^60,66	Reduced quality of life,^67,68 productivity loss, and high societal costs⁶⁹
Participation	Community and social participation are affected/compromised	Lack of awareness about the cruciality of perinatal mental health,^46,70 fear of being labeled/stigma,⁷¹ absence of health laws and policies for managing perinatal mental disorders,⁷² women come into conflict with the law, and may be incarcerated⁷³	Impaired social functioning,⁷⁴ indirect discrimination^64,74

The CRPD and the transmuted paradigm of disability and human rights

Under the International Human Rights Law, the principles of non-discrimination and equity are interlinked, which makes States responsible for elevating population-level health status and protecting and promoting the “right to health.”⁷⁵ However, this further makes it incumbent that the needs of those groups of the population who are disproportionately experiencing or are exposed to mortality, morbidity, and disability are taken into specific consideration by the State.⁷⁶

Since generic approaches to their health issues can “perpetuate and reinforce existing inequality,” it becomes imperative to focus on vulnerable groups under the human rights approach to health.³ The CRPD was adopted and implemented in the backdrop of the “social model of disability” to curtail the socio-economic and cultural barriers that work as constraints, instead of regarding “disability,” in itself, as a barrier.⁷⁷ It has globally reshaped mental health legislative instruments to ensure the adoption of a rights-based approach and support paradigm shift for promoting personhood, autonomy, and inclusive communities.³

The disability is defined under art. 1 of the CRPD includes “long-term physical, mental, intellectual or sensory impairments, which during an interface with various barriers hinders full and effective participation of PwD in the society.” The CRPD recognizes “disability” as an evolving concept that results from the interaction between an individual’s actual or perceived impairment and psychosocial and environmental barriers.³ Hence, in reference to the description of PND under ICD-11, it can be pertinently covered under the definition of disability under CRPD.

More so, since psychosocial factors reportedly play a more pertinent role in the onset of PND, in comparison to biological factors,^6,29 the disability arising from PND must be understood using a medico-social model. Also, since PND is directly linked with the violation of women’s rights,⁶⁴ the purpose of CRPD is to “protect, promote, and ensure full and equal enjoyment of human rights by PwD, and to promote respect for their inherent dignity” (art. 1), becomes significant in the context of perinatal women.

Furthermore, the CRPD outlines a substantive model of “inclusive equality,” where PwD should have the same rights as other individuals in the society, and policy frameworks should “remove barriers, support participation, and embrace diversity.” The CPRD, under art. 4, obligates its signatories to include mental health issues in the mainstream, and sustainable development strategies, under which quality mental healthcare should not remain an invisible quotient.

The CRPD reinforces the protection offered by other core human rights treaties about mental health by providing the “most advanced international human rights standards” related to PwD, including individuals with mental health disabilities and psychosocial disabilities.³ It has been highlighted under art. 6 of the CRPD that “women and girls with disabilities are subject to multiple discrimination,” which further makes it imperative for signatory States to introduce “special” measures to ensure that they enjoy their rights and freedoms on par with others. This makes the role of legislative instruments that are focused on PND critical in nature.

Significantly, the CRPD expands the understanding of legal personhood within the International Human Rights framework, whereby a paradigm shift is provided to PwD to ensure their autonomy and expand their capacities.³ “Reasonable accommodation,” which is intrinsically related to non-discrimination, has been covered under the CRPD, where

Reasonable” denotes “the relevance, appropriateness, and effectiveness of the accommodation”⁷⁸;

Under Art. 2 of the CRPD, “Reasonable accommodation” implies “any necessary and appropriate modification and adjustments, not imposing a disproportionate or undue burden, where needed in a particular case, to ensure the equal enjoyment or exercise of rights.”

Also, procedural accommodation here becomes significant for ensuring necessary and appropriate pathways for accessing justice, and for ensuring participation of PwD on an equal basis with others.³

Violation of CRPD resulting from absence of health laws and policies for addressing and managing PND

In countries where the absence of health laws and policies focused on PND and perinatal mental health is witnessed, the intrinsic nexus between the consequent disability witnessed in perinatal women and their human rights remains obscure. Resultantly, the rights of perinatal women provided under the CRPD are consistently and (inadvertently) systematically violated. Moreover, such violations remain unrecognized or underrecognized also due to a pervasive lack of awareness, and a knowledge gap among healthcare workers, women and families, and even in law enforcement agencies.^64,73

The findings of epidemiological studies cited earlier in this study were utilized to underscore how provisions of the CRPD are susceptible to violation in those countries where PND is not recognized as a public health issue or where there is an absence of guidelines and protocols for addressing and managing PND.

The following table provides details about provisions of the CRPD which are violated by signatory States owing to the policy gap relating to PND, and perinatal mental health (Table 2).

Table 2.

Non-recognition of disability associated with perinatal depression as a public health issue, and resulting violation of provisions of CRPD

Provision	Subject-matter	Implications/consequences of the policy gap for perinatal women resulting in violation of their rights
Art. 1	Equal enjoyment of human rights and freedoms at par with others, and recognition and promotion of their inherent dignity	Perinatally depressed women cannot enjoy their right to health, which in itself becomes a pathway for the non-realization of their other rights and freedoms as well.⁷²
Art. 2	Discrimination and reasonable accommodation	Perinatal women become exposed to indirect, systematic discrimination owing to their gender, disability, and the cumulative effect of both factors existing together, and are also not provided reasonable and procedural accommodation.⁷⁴
Art. 3	Principles encompassed under the ambit of CRPD	All the principles enlisted under this provision are directly or indirectly violated in the following manner^72,74: a. Respect for inherent dignity, autonomy, and independence: Due to gender-related power imbalance in relationships, women’s autonomy and independence are frequently hampered. More so, when such women are further affected by mental disability and do not receive the requisite support and treatment at the same time, and especially if they come in conflict with the law (if they attempt to commit or commit neonaticide, infanticide, or filicide), then resultantly they lose their dignity, autonomy, and independence. b. Non-discrimination: Non-recognition of the unique nature of PND, and its management, automatically, results in discrimination against women since they are uniquely positioned to the disproportionate disease burden arising from it. c. Full and effective participation and inclusion in society: Perinatally depressed women are unable to fully and effectively participate in economic, social, political, and family life in the absence of treatment for PND. Perinatally depressed women are not able to return to work, and conversely, non-depressed perinatal women have been reported to have higher rates of employment. Also, if they come into conflict with the law, the “glorified motherhood” and tarnished image of “not being a good mother” or “being a criminal” leads to their non-inclusion in society. d. Respect for difference, and acceptance of PwD: Since motherhood is “glorified” in societies, and perinatal women are more subjected to social and cultural norms, if they develop PND, it adversely affects their position in society. e. Equality of opportunity: In the absence of requisite support and treatment, perinatally depressed women cannot have access to or optimally utilize the opportunities available to the non-perinatal population. f. Accessibility: Most importantly, their access to healthcare and services is impeded since they tend to remain in isolation, and do not seek medical assistance, which in turn makes treatment facilities less accessible or inaccessible. g. Equality between men and women: Since perinatal women are more exposed to depression, and biologically and psychosocially are more prone to bear the associated disease burden, their right to equality is violated.
Art. 4	Utilizing legislative instruments to fulfill State obligations under the CRPD	Due to the policy gap relating to the absence of health laws and policies for addressing and managing PND,^74,79 signatory States cannot fulfill their treaty obligations under the CRPD.
Art. 5	Equality and non-discrimination	Perinatally depressed women (in the backdrop of a policy gap relating to PND) do not receive a reasonable accommodation, and resultantly, tend not to receive procedural accommodation as well, which impedes their equality within society. If they come into conflict with the law, they are treated on par with the non-perinatal population. This results in indirect, systematic discrimination against perinatally depressed women.^64,74
Art. 6	Women with disabilities	Those signatory States who fail to address PND as a public health issue grossly violate this provision in a two-fold manner: • They fail to underscore the multiple discrimination, affected women would have been subjected to owing to their gender and disability arising from PND.⁷⁸ • Also, these States fail to provide enough platforms for the “development, advancement, and empowerment” of affected perinatal women.
Art. 7	Children with disabilities	Children of perinatally depressed women are more exposed to and face impediments in achieving different developmental milestones.⁸⁰ Such exposure or arising disadvantages continue since their “primary caregiver,” that is, the mother, continues to be affected by functional disability arising from PND²³ without receiving the requisite support and treatment.
Art. 8	Awareness-raising obligations of the signatory States	In the States, where a policy gap exists in recognition of PND as a public health issue, there is an ensuing obscurity, and a lack of awareness about PND witnessed among medical practitioners, perinatal women and families, and also among law enforcement agencies.⁶⁴
Art. 9	Accessibility	Due to the policy gap, perinatally depressed women and their families face inaccessibility or less accessibility to perinatal mental healthcare services and information.⁸⁰ Such information plays a critical role in the management of severe depression since pharmacological treatments have to be administered alone or in conjunction with psychological interventions.
Art. 10	Right to life	Perinatally depressed women and their families face violation of the right to life in multitudinous ways at different stages due to compromised quality of life.⁸⁰
Art. 12	PwD enjoy the right to exercise legal capacity on an equal basis as other persons in all areas of life	Due to diminished functionality and increased vulnerability arising from psychosocial factors, in the absence of perinatal mental health services and treatment, affected women are not able to exercise their “legal capacity on an equal basis in all areas of life.⁸⁰
Art. 13	State parties will ensure effective access to justice for PwD on an equal basis with others	Due to the lack of awareness among healthcare providers (which in turn is related to the absence of health records and administered treatments), law enforcement agencies, and largely in society, perinatally depressed women do not have “effective” access to justice.^74,73
Art. 14	PwD enjoy the right to liberty and security on an equal basis with others, and “the existence of disability shall in no case justify deprivation of liberty.”	Against the backdrop of the lack of protocols providing for perinatal mental health treatments, affected women might not be diagnosed correctly or receive the wrong treatment.^64,79 More so, incarcerated women affected by PND, who allegedly commit infanticide, neonaticide, or filicide, also lose their liberty instead of receiving treatment and rehabilitation services.^64,73
Art. 15	Freedom from torture or cruel, inhuman, or degrading treatment or punishment	In the absence of standard protocols for diagnosing, treating, and managing PND in the background of a lack of awareness among healthcare workers and society, perinatally depressed women are more exposed to and suffer from torture and unlawful administration of treatment like electroconvulsive therapy, which may be administered without the consent of the perinatal women⁶⁴ or with the intent to torture them,⁶⁴ especially in absence of required protocols.
Art. 16	Freedom from exploitation, violation, and abuse	In the backdrop of gender-imbalanced relations and the absence of perinatal mental health services (which further restrains the provision of gender-sensitive assistance and welfare services), functional disability arising from PND becomes even more pervasive, which automatically impedes and exposes perinatal women to abuse and exploitation. More so, the separation of new mothers from their infants (if not specifically prohibited by law) or forceful discontinuation (direct or indirect, like by not providing nutritious food to the mother) of breastfeeding also results in their abuse.⁸⁰
Art. 17	Protecting the integrity of the person	The physical and mental integrity of perinatally depressed women is largely affected by the pervasive policy gap and the absence of mental healthcare services.⁷⁴
Art. 19	Living independently and being included in the community	Since perinatally depressed women fail to meet societal expectations and norms about motherhood and may come into conflict with the law, their inclusion and participation in the community are hampered.^74,73,79
Art. 20	Personal Mobility	Due to a pervasive lack of awareness in society and among healthcare workers about PND, the cultural norms of confinement and immobility owing to obstetric factors like cesarean surgery can exacerbate the disability in perinatally depressed women, for which such women do not have access to enough support or quality perinatal mental health services.
Art. 21	Freedom of expression and opinion, access to information	Perinatally depressed women, owing to the lack of self-awareness about PND, societal norms about motherhood, and lack of awareness and requisite training of healthcare workers, face violation of these rights,^72,74 which are aimed to be protected under this provision. Also, this facet may affect the breastfeeding practices of perinatal women whose breast milk production is affected by perinatal mental health conditions⁷⁹ and who need special support and nutritional information for themselves and their infants.
Art. 22	Respect for privacy	Owing to the lack of standard protocols for managing and treating PND, the health records and information about perinatally depressed women, if available, are not subject to the right to privacy.
Art. 23	Respect for home and family	The perinatally depressed women face sustained violations of their right to marry, right to have a family, right to family planning education (which becomes significant due to their debilitating mental health), and right to guardianship.^64,74 Due to the lack of awareness about the treatable nature of PND, personal laws relating to marriage and family tend to place PND on par with other untreatable mental illnesses, recognizing them as grounds for divorce.^64,74 Also, due to the obscurity of PMDs witnessed in judges, perinatally depressed women might be precluded from getting custody or guardianship of their children.⁶⁴
Art. 25	Right to health	Perinatally depressed women face a gross, and systematic violation of this right due to absence of laws and policies for addressing and managing PND since it results in lack of requisite healthcare services, mental health literacy, affordable treatment options, impeded accessibility, and quality of healthcare services, absence of health insurance coverage, and respectful treatment from healthcare workers.^64,73
Art. 26	Habilitation and rehabilitation	In the absence of health laws and policies, perinatally depressed women, especially those who come into conflict with the law, may face rehabilitation issues.⁷⁴
Art. 27	Work and employment	It has been reported that perinatally depressed women tend to isolate themselves and are unable to return to their employment.⁸¹ Also, work environment⁸¹ and employment status have been reported to be associated with perinatal mental disorders.⁸² Also, to tackle the challenges posed by new motherhood while intending to maintain work-life balance, perinatal women need extended partner and social support, which, due to gender-based roles and under psychosocial factors, tends to remain absent.⁶⁰ Due to the absence of health laws and policies in the backdrop of a pervasive lack of awareness in society, and the stigma attached to mental health, perinatally depressed individuals are more exposed to violation of their right to work, employment, promotion, and increment, and may not receive the requisite support.^74,81
Art. 28	Adequate standard of living and social protection	Owing to the absence of requisite health laws and policies, social protection programs for perinatally depressed women and girls are not given enough importance, and neither are adequate economic resources allocated for them. Due to debilitating mental health conditions, there is a web of poverty, loss of opportunities, and further exacerbation of mental health conditions that is created.
Art. 31	Statistics and data collection	The WHO has recommended that women should be screened for postpartum depression and anxiety and also provide for preventive interventions from the antenatal stage itself.⁸³ However, in various countries, especially in LMICs, PND remains an underrecognized or unrecognized public health issue, which is evident from their health laws and policies.⁸⁰ This results in the absence of protocols for treating and managing PND,⁸⁴ which further results in States’ failure to collect and store data about the prevalence of PMDs, and the treatment administered, if any.⁸⁵ Also, there is an absence of data about perinatal suicides in such a scenario, which further prevents recognition of PND as a principal cause of maternal mortality.⁸⁵
Art. 33	National implementation and monitoring	The signatory States, due to the absence of health laws and policies, do not designate any entities or authorities responsible for addressing and managing PND.

PND: perinatal depression; CRPD: Convention on the Rights of Persons with Disabilities; LMICs: low- and middle-income countries; WHO: World Health Organization; PMDs: perinatal mental disorders.

Discussion

The WHO’s 2022 Recommendations⁸³ explicitly provided that depression and anxiety in women are the leading causes of disability, and the treatment gap continues to aggravate owing to different psychosocial factors. The ICD-11’s detailed description of the impact of PMDs, along with findings reported by Srisurapanont et al.²³ and Park et al.,⁸⁶ underscores how functional disability is concomitantly present with PND, which makes its addressal, treatment, and management pertinent. In this context, the present study novelly describes how disability associated with PND is intrinsically associated with the six domains of the WHODAS 2.0. Furthermore, it details how various provisions of the CRPD are violated by signatory States due to their failure to address and meet the mental health needs of perinatal women, besides systemic violation of women’s rights.

This warrants an understanding of the direct relationship between the absence of health laws and policies or their nonadherence or ineffectiveness in meeting the perinatal mental health needs of women, high rates of disability-adjusted life years and years lived with disability in perinatal women, and violation of their human rights under the CRPD. It is imperative to underscore the role of legislative instruments in recognizing PMDs as a public health concern and in protecting the human rights of perinatal women. The legislative instruments will consolidate the position of perinatal women as vulnerable women under the human rights framework and will be effective in limiting the influence of social determinants of mental health.

Advocating for meeting the mental health needs of perinatal women through ensuring compliance with the CRPD will help underscore the urgency attached to the introduction of interventions for perinatally depressed women, especially legal interventions. These legal interventions in the form of health laws and policies must provide for screening, diagnosis, treatment, and management of PMDs. Also, the largely hidden and obscured nexus between perinatal disability and the CRPD can be utilized for advocating for policy changes even in low-resource settings.

The Optional Protocol to the CRPD provides a complaint mechanism that allows individuals or groups who believe that their rights under the CRPD have been violated to submit a complaint to the Committee on the Rights of Persons with Disabilities. However, under the Optional Protocol, a complaint will not be admissible unless a State has ratified the protocol (Art. 1), and all the domestic remedies are exhausted by the individual or the group before filing the complaint (Art. 2). This requirement can hinder the process owing to the obscurity of national health laws and policies in recognizing PND as a public health issue or its multifarious consequences^19,80 which will make available national remedies counterproductive.

More so, the complaint must relate to a violation of a substantive right/s under the CRPD, which makes the findings of this study highly pertinent. Also, in this scenario, the role of non-state actors working in the area of women’s mental health, like the Maternal Mental Health Alliance, Postpartum Support International, etc., becomes critically important. Furthermore, the adoption of a multisectoral cooperative approach to ensure that perinatal women’s mental health needs are met becomes imperative, wherein consistent professional development programs for healthcare workers, law enforcement agencies, and policymakers are critical.⁸³ This will facilitate the building of an ecosystem whereby consistent and sustained monitoring, evaluation, and grievance redressals, apart from reforms, can be suggested through defined protocols and guidelines.

This will also align with the CRPD’s recognition of “disability” as an evolving concept, which results from interaction between an individual’s actual or perceived impairment, and psychosocial and environmental barriers. Future studies can be undertaken to understand whether the signatory States to the Optional Protocol of CRPD are utilizing the prescribed complaint mechanism to protect the rights of perinatal women under the CRPD.

Limitations of the study

The present study is limited to maternal PND. Also, it only deals with the provisions of the CRPD and does not detail violations of other interlinked or associated rights enshrined under the other International Human Rights Treaties, since they were addressed in another study.⁷⁴

Conclusion

Integration of perinatal mental health services within the existing maternal healthcare framework has been recommended to ease the additional need for financial resources and infrastructure, besides facilitating the realization of women’s and children’s rights. In the present Sustainable Development Goals era, the nexus between PND, associated disability, and provisions of the CRPD should be vehemently used for realizing and safeguarding the rights of perinatal women and for meeting their mental health needs.

Footnotes

Acknowledgements

None.

ORCID iD

Ritika Behl

Ethical considerations

Not applicable.

Consent to participate

Not applicable.

Consent for publication

Not applicable.

Author contributions

Ritika Behl: Conceptualization, Data acquisition, Investigation, Writing and editing the manuscript.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

Not applicable.

References

Rahman

Surkan

Cayetano

, et al. Grand challenges: integrating maternal mental health into maternal and child health programmes. PLoS Med 2013; 10(5): e1001442.

World Health Organization. Guide for integration of perinatal mental health in maternal and child health services. World Health Organization, 2022.

World Health Organization. Mental health, human rights and legislation: guidance and practice. World Health Organization and the United Nations (represented by the Office of the United Nations High Commissioner for Human Rights), 2023.

Committee on Economic, Social and Cultural (ESC) Rights (Aug. 11, 2005) General Comment No. 16 on the Equal Right of Men and Women to the Enjoyment of All Economic, Social and Cultural Rights (Art. 3 of the International Covenant on Economic, Social and Cultural Rights). U.N. Doc. E/C.12/2005/4, 11 August 2005. https://www.escr-net.org/resources/general-comment-n-16-article-3-equal-right-men-and-women-enjoyment-all-economic-social-and

Committee on Economic, Social and Cultural (ESC) Rights (July 2, 2009) General Comment No. 20: Non-Discrimination in Economic, Social and Cultural Rights (Art. 2, Para. 2, of the International Covenant on Economic, Social and Cultural Rights). U.N. Doc. E/C.12/GC/20, 2 July 2009. https://digitallibrary.un.org/record/659980?ln=en&v=pdf

Committee on the Convention on Elimination of All Forms of Discrimination Against Women (CEDAW). General Recommendation No. 24: Article 12: Women and Health. U.N. Doc. A/54/38/Rev.1 chap. I. https://www.escr-net.org/node/387809 (1999).

Committee on Economic Social and Cultural (ESC) Rights (Dec. 9, 1994) General Comment 5: Persons with Disability. U.N. Doc. E/1995/22, 9 December 1994. https://www.globalhealthrights.org/wp-content/uploads/2013/10/CESCR-General-Comment-No.-5-Persons-with-Disabilities.pdf

Committee on the Convention on Elimination of All Forms of Discrimination Against Women (CEDAW). General Recommendation No. 18: Disabled Women. U.N. Doc. A/46/38. https://www.legal-tools.org/doc/ba95ff/pdf/ (1993).

Atif

Lovell

Rahman

Maternal mental health: The missing “m” in the global maternal and child health agenda. Semin Perinatol 2015; 39(5): 345–352.

10.

Honikman

van Heyningen

Field

, et al. Stepped care for maternal mental health: a case study of the perinatal mental health project in South Africa. PLoS Med 2012; 9(5): e1001222.

11.

Place

Billings

Frongillo

, et al. Policy for promotion of women’s mental health: insight from analysis of policy on postnatal depression in Mexico. Adm Policy Ment Health 2016; 43(2): 189–198.

12.

Ayre

Dutta

Howard

LM.

Perinatal self-harm: an overlooked public health issue. Lancet Public Health 2019; 4(3): e125.

13.

Wisner

Miller

Tandon

Attention to prevention-can we stop perinatal depression before it starts?. JAMA Psychiatry 2019; 76(4): 355–356.

14.

Guintivano

Byrne

Kiewa

, et al. Meta-analyses of genome-wide association studies for postpartum depression [published correction appears in Am J Psychiatry 2023; 180(12): 894. doi: 10.1176/appi.ajp.20230053correction.]. Am J Psychiatry 2023; 180(12): 884–895.

15.

Meltzer-Brody

New insights into perinatal depression: pathogenesis and treatment during pregnancy and postpartum. Dialogues Clin Neurosci 2011; 13(1): 89–100.

16.

Glover

Maternal depression, anxiety and stress during pregnancy and child outcome; what needs to be done. Best Pract Res Clin Obstet Gynaecol 2014; 28(1): 25–35.

17.

Rhodes

Segre

LS.

Perinatal depression: a review of US legislation and law. Arch Womens Ment Health 2013; 16(4): 259–270.

18.

Lee

Tien

Bai

, et al. Association of postpartum depression with maternal suicide: a nationwide population-based study. Int J Environ Res Public Health 2022; 19(9): 5118.

19.

Howard

Khalifeh

Perinatal mental health: a review of progress and challenges. World Psychiatry 2020; 19(3): 313–327.

20.

Prescott

Logan

AC.

Transforming life: a broad view of the developmental origins of health and disease concept from an ecological justice perspective. Int J Environ Res Public Health 2016; 13(11): 1075.

21.

World Health Organization. ICD-11 for Mortality and Morbidity Statistics, 6E20: Mental or Behavioral Problems Related with Pregnancy, Childbirth or the Puerperium, Without Psychotic Symptoms, https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f1124422593

22.

World Health Organization. ICD-11 for mortality and morbidity statistics: diagnostic criteria for research. 11th ed. World Health Organization, 2018.

23.

Srisurapanont

Oon-Arom

Suradom

, et al. Convergent validity of the Edinburgh Postnatal Depression Scale and the Patient Health Questionnaire (PHQ-9) in pregnant and postpartum women: their construct correlations with functional disability. Healthcare (Basel) 2023; 11(5): 699.

24.

Ustun

Kostanjesek

Chatterji

, et al. Measuring health and disability: manual for WHO Disability Assessment Schedule (‎WHODAS 2.0). World Health Organization, 2010.

25.

Shakeel

Eberhard-Gran

Sletner

, et al. A prospective cohort study of depression in pregnancy, prevalence and risk factors in a multi-ethnic population. BMC Pregnancy Childbirth 2015; 15: 5.

26.

Islam

Broidy

Baird

, et al. Intimate partner violence around the time of pregnancy and postpartum depression: the experience of women of Bangladesh. PLoS One 2017; 12(5): e0176211.

27.

Gao

Yang

, et al. Association of sleep quality during pregnancy with stress and depression: a prospective birth cohort study in China. BMC Pregnancy Childbirth 2019; 19(1): 444.

28.

Terrone

Bianciardi

Fontana

, et al. Psychological characteristics of women with perinatal depression who require psychiatric support during pregnancy or postpartum: a cross-sectional study. Int J Environ Res Public Health 2023; 20(8): 5508.

29.

Dagher

Bruckheim

Colpe

, et al. Perinatal depression: challenges and opportunities. J Women’s Health 2021; 30(2): 154.

30.

Khalifa

Glavin

Bjertness

, et al. Determinants of postnatal depression in Sudanese women at 3 months postpartum: a cross-sectional study. BMJ Open 2016; 6(3): e009443.

31.

Johansson

Benderix

Svensson

Mothers’ and fathers’ lived experiences of postpartum depression and parental stress after childbirth: a qualitative study. Int J Qual Stud Health Well-Being 2020; 15(1): 1722564.

32.

Patel

Bailey

Jabeen

, et al. Postpartum depression: a review. J Health Care Poor Underserved 2012; 23(2): 534–542.

33.

Insa

Weke

Rankin

, et al. Perceptions and attitudes around perinatal mental health in Bangladesh, India and Pakistan: a systematic review of qualitative data. BMC Pregnancy Childbirth 2022; 22(1): 293.

34.

Dlamini

Mahanya

Dlamini

, et al. Prevalence and factors associated with postpartum depression at a primary healthcare facility in Eswatini. S Afr J Psychiat 2019; 25: 1404.

35.

Field

Postpartum depression effects on early interactions, parenting and safety practices: a review. Infant Behav Dev 2010; 33(1): 1–6.

36.

Erickson

Julian

Muzik

Perinatal depression, PTSD, and trauma: impact on mother–infant attachment and interventions to mitigate the transmission of risk. Int Rev Psychiatry 2019; 31(3): 245–263.

37.

Watkins

Meltzer-Brody

Zolnoun

Early breastfeeding experiences and postpartum depression. Obstet Gynecol 2011; 118(2): 214–221.

38.

Emerson

Caulfield

LE.

Maternal psychological distress and perceived impact on child feeding practices in South Kivu, DR Congo. Food Nutr Bull 2017; 38(3): 319–337.

39.

Jain

Tyagi

Kaur

, et al. Association of birth of girls with postnatal depression and exclusive breastfeeding: an observational study. BMJ Open 2014; 4: e003545.

40.

Johannsen

Larsen

Laursen

, et al. Self-harm in women with postpartum mental disorders. Psychol Med 2019; 50(9): 1563–1569.

41.

Sharma

Thomson

Peripartum suicide: additional considerations. CMAJ 2018; 190(2): E57.

42.

Friedman

Resnick

PJ.

Postpartum depression: an update. Women’s Health 2009; 5(3): 287, 288–295.

43.

Liu

Agerbo

, et al. Depression and anxiety in the postpartum period and risk of bipolar disorder: a Danish nationwide register-based cohort study. J Clin Psychiatry 2017; 78(5): e469–e476.

44.

Schiller

Meltzer-Brody

Rubinow

DR.

The role of reproductive hormones in postpartum depression. CNS Spectr 2015; 20(1): 48–59.

45.

De Chiara

Mazza

Ricci

, et al. The relevance of insomnia in the diagnosis of PND: validation of the Italian Version of the Insomnia Symptom Questionnaire. Int J Environ Res Public Health 2021; 18(23): 12507.

46.

Ransing

Kukreti

Deshpande

, et al. Perinatal depression-knowledge gap among service providers and service utilizers in India. Asian J Psychiatr 2020; 47: 101822.

47.

Handerson

Jomeen

Redshaw

Care and self-reported outcomes of care experienced by women with mental health problems in pregnancy: findings from a national survey. Midwifery 2018; 56: 171–178.

48.

Rathod

Honikman

Hanlon

, et al. Characteristics of PND in rural central, India: a cross‑sectional study. Int J Ment Health Syst 2018; 12: 68.

49.

Romero

AMO

de Rodrígueza

de Cárdenasa

CHR

. Coping and adaptation process during puerperium. Colomb Med 2012; 43(2): 167–174.

50.

Gupta

Kishore

Mala

, et al. Postpartum depression in North Indian women: prevalence and risk factors. J Obstet Gynaecol India 2013; 63(4): 223–229.

51.

Thompson

Ajayi

Prevalence of antenatal depression and associated risk factors among pregnant women attending antenatal clinics in Abeokuta North Local Government Area, Nigeria. Depress Res Treat 2016; 2016: 4518979.

52.

Grote

Bridge

Gavin

, et al. A meta-analysis of depression during pregnancy and the risk of preterm birth, low birth weight, and intrauterine growth restriction. Arch Gen Psychiatry 2010; 67(10): 1012–1024.

53.

Baron

Hanlon

Mall

, et al. Maternal mental health in primary care in five low- and middle-income countries: a situational analysis. BMC Health Serv Res 2016; 16: 53.

54.

Klainin

Arthur

DG.

Postpartum depression in Asian cultures: a literature review. Int J Nurs Stud 2009; 46: 1355–1373.

55.

Ghaedrahmati

Kazemi

Kheirabadi

, et al. Postpartum depression risk factors: a narrative review. J Educ Health Promot 2017; 6: 60.

56.

Bell

Andersson

The birth experience and women’s postnatal depression: a systematic review. Midwifery 2016; 39: 112–123.

57.

Adlington

Vasquez

Pearce

, et al. ‘Just Snap Out of It’—the experience of loneliness in women with perinatal depression: a meta-synthesis of qualitative studies. BMC Psychiatry 2023; 23(1): 110.

58.

Lund

Brooke-Sumner

Baingana

, et al. Social determinants of mental disorders and the sustainable development goals: a systematic review of reviews. Lancet Psychiatry 2018; 5: 357–369.

59.

Lanjewar

Nimkar

Jungari

Depressed motherhood: prevalence and covariates of maternal postpartum depression among urban mothers in India. Asian J Psychiatry 2021; 57: 102567.

60.

Fellmeth

Kanwar

Sharma

, et al. Women’s awareness of perinatal mental health conditions and the acceptability of being asked about mental health in two regions in India: a qualitative study. BMC Psychiatry 2023; 23(1): 829.

61.

Schlabritz

Jain

SB.

Maternal mental status and pregnancy—importance of the missing peace. J Depress Anxiety 2015; 4(2): e109.

62.

Simas

TAM

Huang

Patton

, et al. The humanistic burden of postpartum depression: a systematic literature review. Curr Med Res Opin 2019; 35(3): 383–393.

63.

Patil

Bajaj

Supraja

, et al. Lifetime traumatic experiences and postpartum depressive symptoms in a cohort of women in South India. Arch Womens Ment Health 2021; 24(4): 687–692.

64.

Behl

Judicial interface with perinatal depression in india: an empirical analysis and thematic review of published judgements. Arch Womens Ment Health 2025; 28(3): 401–414.

65.

Babatunde

Moreno-Leguizamon

CJ.

Daily and cultural issues of postnatal depression in African women immigrants in South East London: tips for health professionals. Nurs Res Pract 2012; 2012: 181640.

66.

Agarwala

Rao

Narayanan

Prevalence and predictors of postpartum depression among mothers in the rural areas of Udupi Taluk, Karnataka, India: a cross-sectional study. Clin Epidemiol Glob Health 2019; 7: 324–345.

67.

Cleary

Orangi

Garman

, et al. Economic burden of maternal depression among women with a low income in Cape Town, South Africa. BJPsych Open 2020; 6: e36.

68.

Yin

Waqas

, et al. Quality of life in mothers with perinatal depression: a systematic review and meta-analysis. Front Psychiatry 2022; 13: 734836.

69.

Bauer

Garman

Besada

, et al. Costs of common perinatal mental health problems in South Africa. Global Mental Health 2022; 9: 429–438.

70.

Szajna

Tekkalaki

Nandagaon

, et al. Postpartum depression In India: perceptions by key stakeholders. Issues Ment Health Nurs 2023; 44(3): 194–199.

71.

Schmied

Black

Naidoo

, et al. Migrant women’s experiences, meanings and ways of dealing with postnatal depression: a meta-ethnographic study. PLoS One 2017; 12(3): e0172385.

72.

Behl

Nemane

Gurpur

. Legal interventions for perinatal depression in India: a qualitative study with clinical specialists having expertise in perinatal mental health. BMJ Open. 2025 Feb 2;15(1):e093027. doi: 10.1136/bmjopen-2024-093027.

73.

Behl

Nemane

Perinatal mental health and the justice delivery system in India. Med Leg J 2025; 93(1 Suppl): 78–81.

74.

World Health Organization. Thinking healthy manual: a manual for psychosocial management of perinatal depression. World Health Organization, 2015.

75.

Behl

. Perinatal mental disorders, mental health services, and human rights treaties: recognizing the state’s obligations. Arch Womens Ment Health. 28 June 2025. doi: 10.1007/s00737-025-01604-y. Epub ahead of print.

76.

Gostin

LO.

A theory and definition of public health law. J Health Care Law Polcty 2007; 10(1).

77.

Groce

NE.

Disability and the millennium development goals. United Nations, 2011.

78.

United Nations General Assembly. Mental Health and Human Rights. Report of the United Nations High Commissioner for Human Rights. A/HRC/34/32. United Nations Human Rights Council, 2017.

79.

Emerson

Tol

Caulfield

, et al. Maternal psychological distress and perceived impact on child feeding practices in South Kivu, DR Congo. Food Nutr Bull 2017; 38(3): 319–337.

80.

Behl

. Perinatal depression, perinatal mental health, and legal interventions: a medico-legal anthropological concept. Discov Ment Health. 2025 May 15;5(1):73. doi: 10.1007/s44192-025-00204-7.

81.

Wilkinson

Maternal (perinatal) mental health and employment: an agenda for research and practice. Hum Resour Manag J 2023; 3(2): 346–361.

82.

Aochi

Honjo

Kimura

, et al. Association between maternal employment status during pregnancy and risk of depressive symptomatology 1 month after childbirth: the Japan Environment and Children’s Study. J Epidemiol Community Health 2021; 75(6): 531–539.

83.

World Health Organization. WHO recommendations on maternal and newborn care for a positive postnatal experience. World Health Organization, 2022.

84.

Behl

Nemane

Sims

Perinatal mental disorders: the non-Liquet Facet of mental health legislative instruments in India. J Health Manag Epub ahead of print 19 March 2024. DOI: 10.1177/09720634241236834.

85.

Behl

Indicators of perinatal mental health of the Indian women, and the National Family Health Surveys: trajectory of obscurity. Asian J Psychiatr 2024; 102: 104263.

86.

Park

Leon

Zaidi

, et al. Family concerns and relationship problems in anxious pregnant women and their associations with postnatal functional disability in Pakistan. J Psychosom Res 2024; 181: 111674.