Shagupta Makandar, 21, was five months pregnant when deadly floods swept into her village of Rajapur in Maharashtra’s Kolhapur district in August 2019. She tried to flee the rising waters, first slogging through the mud on foot and then trying to bike over the treacherous terrain.
The mental stress and physical strain of fleeing led to her going into labour prematurely. But by the time she got to the nearest hospital, it was too late: her baby was born prematurely and died within an hour.
Makandar remained in hospital for the next three weeks, dealing not only with the physical effects of her ordeal but also the emotional distress. She spent several more months with her mother, unable to face returning to the home she shared with her husband where the flooding had occurred.
“I was so traumatised that I barely spoke,” she later recounted.
From floods to drought to extreme heat, the physical impact of climate change on pregnant women is well documented. A paper published in Nature found that from 2010-’20, exposure to floods was responsible for 107,888 excess pregnancy losses every year in 33 low- and middle-income countries, with South Asia accounting for the highest proportion of cases.
One study found that stillbirths in India increased by 28.6% between 2015 and 2021, as the effects of climate change intensified.
But there is also a growing body of research documenting its impact on maternal mental health. Studies from several countries and the experiences of community healthcare workers point to extreme weather events aggravating mental health conditions such as perinatal depression. Studies have shown that women who experience pregnancy loss face a higher risk of depression and anxiety symptoms in their subsequent pregnancies.
One study of 103 expectant mothers in Australia found “a fair amount of women’s depression and worry they experienced during pregnancy was accounted for by climate change anxiety”, according to Amy Lykins, an associate professor at the University of New England in Australia and the lead author of the paper.
In a call for action issued in 2023, the World Health Organization and other United Nations agencies working on maternal health warned that exposure to climate hazards and their aftermath during and after pregnancy could “increase stress, anxiety and depression – known risk factors for adverse perinatal outcomes” and increase the risk of intergenerational trauma.
For India, which has made huge strides in slashing maternal and infant mortality rates in recent decades, the threat is particularly acute. Home to some 378 million women of childbearing age, India has been hit hard by climate change. Floods alone have affected hundreds of millions of people in recent years, while the country has also suffered from drought and rising heat.
Hope from ASHA workers
While expertise on the impact of climate change on maternal mental health may be limited in the research world, India’s community health workers are all too aware of the phenomenon. With their deep knowledge of their communities, they offer a kind of early-warning system.
Since 2009, Noushadbi Mujawar has worked as a community health worker in the village of Rajapur. Mujawar is an Accredited Social Health Activist, or ASHA, an army of workers considered the backbone of India’s rural healthcare system. ASHAs are appointed as part of India’s National Health Mission and work often long hours in arduous conditions for low pay. Collectively, over a million of them care for primarily women and children who might not otherwise have access to health care.
Mujawar has cared for hundreds of pregnant women over the past 15 years, and has seen for herself the impact of climate change.
“I’ve witnessed how floods add another layer of stress for pregnant women,” she said. “Since the past few years, it’s not just about how these floods are impacting their physical health, their mental health is deeply affected, too.”
Even Makandar’s decision to shelter at her mother’s home could have negative impacts: displacement sometimes poses physical and mental health risks, according to Jennifer Barkin, a professor of community medicine and obstetrics and gynecology at Mercer University School of Medicine in Georgia in the United States.
“During pregnancy and postpartum, frequent medical visits are essential,” Barkin said. “However, if you’re displaced due to extreme weather, lose your home, or face injuries within the family, these disruptions can severely affect your medical routine and can destabilise your economic and social support system.”
Emily Harville, a perinatal epidemiologist and professor at Tulane University School of Public Health and Tropical Medicine, says pregnancy and reproductive health should be incorporated into all phases of disaster management – preparation, mitigation, and response. “In the aftermath of a disaster, getting people back to their communities quickly is as important as any direct intervention,” she said.
For pregnant and postpartum women, disaster response must include ensuring support for breastfeeding and formula feeding, providing baby food, ensuring shelters have safe sleeping arrangements such as cots or cribs for infants, and adequate supplies of diapers.
Lykins suggested developing programmes to help build resilience and teach people to cope. “We must find ways to mitigate its impact and manage stress while maintaining hope for the future because it’s not going away,” she said. “All signs indicate it will continue to worsen throughout our lifetimes.”
In India, that’s where community health workers like Mujawar come in. ASHAs like her have deployed makeshift solutions to the seemingly growing problem of perinatal depression. The health workers caring for Makandar, for instance, applied the lessons of the past trauma to her next pregnancy, taking her for monthly checkups to monitor her blood pressure, diabetes risk, thyroid levels, and providing mental and emotional support that survivors of traumatic accidents often need.
‘I just couldn’t sleep’
When Makandar was back home and pregnant again in December 2021, she kept worrying about rain. “Every day, I would think about what would happen if it flooded again,” she said.
The constant fear started affecting her mental and physical health. She started getting headaches every day, then was diagnosed with hypertension. “I just couldn’t sleep, which made me anxious all day,” Makandar said.
The ASHAs increased their visits, but Makandar mostly didn’t respond to their enquiries about how she was. “In such cases, you must first befriend the person,” Mujawar said. “If you go with a standard checklist of questions, no one will talk about their stress and struggles.”
When they couldn’t travel to see her, Mujawar and her colleagues would try to initiate phone conversations to stay in touch even if their efforts didn’t initially seem fruitful. “We didn’t see any positive results for four months,” said Shafiya Mujawar, a fellow health worker, who is no relation to Noushadbi Mujawar.
Makandar’s case shows how anxiety about potential weather events can have an impact independent of the events themselves. Barkin believes health workers need to be much more aware of that – particularly in areas affected by extreme weather, like India.
“This isn’t a new issue, but we must learn to treat it with urgency,” she said. “Unfortunately, we are in a position of playing defence rather than offence.”
Many ASHAs from regions experiencing extreme weather events have started screening women for depression. Mangal Kamble has been an ASHA in Maharashtra since 2009, overseeing a significant reduction in infant and maternal mortality in her village. Every day, she sees at least 20 people from the community, and she credits her years of experience with allowing her to tell when a patient is struggling mentally.
Kamble recalls how one 21-year-old patient named Nayanatai became anemic and malnourished during her pregnancy due to drought on the family farm, and was unable to sleep because of the heat. When the young woman’s mental health started to decline, Kamble paid her frequent visits, enquiring about her wellbeing and bringing her food.
Nayanatai experienced a complicated birth, but she credits Kamble with saving her and her baby. “Had she not helped me, I would not have survived,” she said simply.
The ASHAs who cared for Makandar also worked to gain her confidence, and she ultimately felt comfortable calling them to discuss her fears. They offered reassurance, reminding her of the evacuation plans in place in case of another disaster.
The health workers would also bring together all the pregnant women from the flood-affected communities and organise games and activities. “This simple thing helps them destress and forget about their problems,” said ASHA Surekha Vader, who also worked with Makandar.
They shared stories of how other pregnant women had recovered from similar experiences and also kept a close eye on her physical symptoms, suggesting meditation and breathing exercises, said Mujawar.
Makandar started reporting being calmer and seemed finally to be recovering from her anxiety and depression. But the real test came when another flood struck her village in the summer of 2022.
The ASHAs were prepared for the next flood. They had listed all the pregnant women in the village months beforehand. “We started calling all their relatives and found a safe place where they could be moved well in advance,” said Shafiya Mujawar.
Makandar moved to her mother’s house, 160 km away from her village, when she was seven months pregnant. She was not present when floods destroyed her house again. And this time, she said, “I was scared, but now I had the courage to deal with it.”
Makandar gave birth to a baby in August 2022 without any complications and soon returned to her village. “I never imagined I would be so happy again,” she said.
The community health workers deal with their own stressors, which can include 10-12 hour days in addition to other work to supplement the meager income. ASHAs in Maharashtra, India’s wealthiest state, average a monthly income of Rs 4,000-Rs 6,000. But Mujawar, after helping others escape floods, stayed behind herself, reasoning: “If we leave, who will save the ones stranded?”
Still, Mujawar loves her job. “Whenever I see a smile on the faces of people like Shagupta [Makandar], it gives me more energy to keep doing my work,” she said. “I can sleep peacefully after I look at them.”
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