Article Text

Incorporating early pregnancy mental health screening and management into routine maternal care: experience from the Rajarata Pregnancy Cohort (RaPCo), Sri Lanka
  1. Thilini Agampodi1,2,
  2. Gayani Amarasinghe2,
  3. Anuprabha Wickramasinghe3,
  4. Nuwan Wickramasinghe2,
  5. Janith Warnasekara2,
  6. Imasha Jayasinghe2,
  7. Ayesh Hettiarachchi2,
  8. Dilshi Nimesha2,
  9. Thivanka Dilshani2,
  10. Subhashinie Senadheera4,
  11. Suneth Agampodi1
  1. 1 Center for Public Health, Anuradhapura, Sri Lanka
  2. 2 Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Anuradhapura, Sri Lanka
  3. 3 Department of Psychiatry, University of Colombo, Colombo, Sri Lanka
  4. 4 Department of Biochemistry, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Anuradhapura, Sri Lanka
  1. Correspondence to Dr Thilini Agampodi; thilinichanchala{at}


Early identification of mental health problems in pregnancy in low-income and middle-income countries is scarcely reported. We present the experience of a programme assimilating screening and management of antenatal anxiety and depression in conjunction with the Rajarata Pregnancy Cohort, in Sri Lanka. We adopted a two-stage screening approach to identify the symptoms and the reasons for anxiety and depression. Pregnant women (n=3074), less than 13 weeks of period of gestation underwent screening with the Edinburgh Postnatal Depression Scale (EPDS). Scores were positive among 23% and 14% of women in the first and second trimesters, respectively. Clinical (telephone) interviews (n=78, response 56.9%) were held for women having high EPDS scores to screen for clinical depression using the ‘mental health GAP’ tool. Targeted interventions including counselling, financial and social support and health education were employed. The procedure was repeated in the second trimester with in-person clinical interviews and inquiry into intentional self-harm. Our findings indicated that (1) the majority of mental health problems in early pregnancy were anxiety related to early pregnancy-associated conditions manageable at the primary healthcare level, (2) coupling mental health screening using psychometric tools with clinical interviews facilitates targeted patient-centred care, (3) the majority of intentional self-harm during pregnancy is not in the routine health surveillance system and (4) promoting women to attend the psychiatry clinic in tertiary care hospital has been difficult. Following the experience, we propose a model for mental health service provision in routine pregnancy care programme starting from early pregnancy.

  • Health services research
  • Mental Health & Psychiatry
  • Maternal health
  • Health systems
  • Public Health

Data availability statement

Data are available on reasonable request.

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Summary box

  • Mental health problems during pregnancy are a major concern in low-income and middle-income countries (LMICs), with inadequate screening and management strategies.

  • This paper introduces a program that integrated maternal mental health screening and management within the Rajarata Pregnancy Cohort (RaPCo) in Sri Lanka.

  • Findings reveal that a significant percentage of pregnant women in their first and second trimesters, experiencing symptoms of anxiety and depression, can be identified through screening. Additionally, it highlights the ability to detect and manage concealed attempts of intentional self-harm, often overlooked by routine health surveillance.

  • The feasibility of this approach, which combines straightforward EPDS-based screening by field staff, clinical interviews by qualified medical professionals, and targeted specialist referrals, has been demonstrated even in resource-limited settings.

  • The proposed model for integrating mental health services into routine pregnancy care programs holds immense potential.

  • Field testing is imperative, and if successful, it could change maternal mental health services in LMICs.


The Sustainable Development Goals era provides a historic opportunity to reframe the global mental health agenda.1 Perinatal mental health problems remain a devastating challenge globally, leading to deliberate self-harm (DSH) and suicide, a major underlying cause of maternal death, and exerting well-known intergenerational effects.2 Although researchers have contributed to ample evidence synthesis, pragmatic approaches for incorporating mental health into routine care are yet to be identified in low-income and middle-income countries (LMICs).3 Many countries lack routine screening programmes for the early identification of mental health issues, probably because of the difficulties faced in providing care after screening to support diagnosis and management. Integrating mental health services into routine maternal healthcare is subject to extensive dialogue and remains a global challenge.4

Perinatal mental health problems affect 18%–25% of women in LMICs.4 5 Although postpartum depression is emphasised, it is evident that antenatal depression and anxiety are common and are risk factors for postpartum depression.6 The prevalence of antenatal anxiety and depression in high-income countries is approximately 13%, whereas, in LMICs, it is much higher, at 19.8%.5 A recent pooled prevalence estimate of antenatal depression in 51 LMICs was found to be 25.3% (95% CI 21.4% to 29.6%).4 Currently, emphasis is placed on establishing a staging approach for the classification and treatment of mental health disorders, which outlines the different stages encountered by an individual before a fully defined mental health syndrome is established.1 7 This approach demands early identification, action and follow-up for the prevention of mental health problems. Identifying vulnerable women in early pregnancy is important to prevent maternal deaths in LMICs with cultural tendencies of impulsive self-harm and suicide.8

Sri Lanka is a lower-middle-income country with a better maternal care programme compared with other developing countries.9 Nonetheless, recent data indicate that maternal mental health is a growing problem, with a reported postpartum depression of 27%10 and antenatal depression of 16%,11 leading to many undesirable outcomes, including self-harm and suicide in the country.12 A cross-sectional hospital-based study in Anuradhapura indicates that 0.8% of women had attempted intentional self-harm (ISH) during the pregnancy period.13 Suicide has been identified as a leading cause of maternal death in Sri Lanka.8 14 Studies on antenatal depression are mostly carried out in the latter part of pregnancy, with scanty evidence of early pregnancy mental health. Although it has been identified as a major public health problem in Sri Lanka, a health system approach for screening or prevention of maternal mental health is still not available, and care seeking is poor due to the well-known stigma associated with maternal mental health issues in these settings.15 The incidence of ISH during pregnancy has not yet been estimated. Hence, there is a dearth of evidence on the estimation and prevention of ISH, suicide and mental health disorders in Sri Lanka.

In this paper, we report our experience, observations and lessons learnt from a comprehensive maternal mental health screening programme, and the feasibility and utility of a health system that integrates simple interventions to improve maternal mental health.



Screening for mental health and targeted interventions was carried out as a service component of the Rajarata Pregnancy Cohort (RaPCo) study together with the public health programme. The pregnant women registering in the district maternal care programme before 13 weeks of period of gestation (PoG) received the interventions. The interventions included a two-stage screening approach for antenatal anxiety and depression in early pregnancy and during the end of the second trimester, coupled with a package of personalised counselling, social and financial support and appropriate referral to the psychiatrist. The period of the intervention is July 2019 to June 2020.

Intervention area

The programme was carried out in the Anuradhapura district, a predominantly rural district in Sri Lanka, with pregnant women registered each year in the National Maternal Care Programme. Maternal healthcare services are provided through the Medical Officers of Health (MOH) at the divisional level in the public health system in Sri Lanka. Under the guidance and supervision of the MOH and Public Health Nursing Sisters, Public Health Midwives (PHM) provide domiciliary and clinical care for pregnant and postpartum women. The percentage of pregnant women registered in the routine maternal care programme in Anuradhapura is 95.1%.16 Pregnant women attend at least nine antenatal clinic visits during pregnancy under the routine public maternal care programme. Specialised mental healthcare in the selected study setting was available only at the Anuradhapura Teaching Hospital.


All pregnant women newly registered in the routine maternal care programme from July to September 2019 were invited to participate in RaPCo. The sample size calculated for RaPCo is 2400 and is presented in detail elsewhere.17 RaPCo included 90% of pregnant women who registered in the routine maternal care programme of the public health system in the Anuradhapura district.17 18 Mental health screening was done on 3374 cohort participants. However, the programmatic objective was to provide early mental health screening; thus, we analysed only those who were less than 13 weeks of PoG (n=3074). Online supplemental table 1 summarises the participant characteristics.

Supplemental material

Screening process

Stage 1: early pregnancy mental health screening

We developed a screening, management and referral algorithm integrated to the primary healthcare programme in parallel to RaPCo (figure 1).

Figure 1

Screening and management algorithm used for early pregnancy mental health promotion in the Rajarata Pregnancy Cohort. EPDS, Edinburgh Postnatal Depression Scale.

Step 1A: first trimester Edinburgh Postnatal Depression Scale screening

With the baseline assessments of the cohort, which included an array of demographic, medical, biological, anthropological and social variables, we performed a mental health assessment. The validated Sinhala and Tamil versions of the Edinburgh Postnatal Depression Scale (EPDS) (self-administered) were used to assess mental health with the cut-off score of 9/10 as indicated in the validation study for both antenatal and postnatal women.19 Step 1 A determined the baseline EPDS scores, which were used as the basis for subsequent follow-up.

Step 1B: follow-up clinical interviews with women who had high first trimester EPDS scores

All data of the completed EPDS were entered into a database, and the total scores were generated. Once the EPDS scores were generated, we conducted structured telephone interviews with pregnant women who were found to have high composite scores on the EPDS and those who had self-harm ideation, as in question 10 of the EPDS tool. The telephone interviews were conducted in the early-mid second trimester (15–20 weeks PoG) of pregnancy for further screening for depression and to explore the perceived reasons for having high EPDS scores in early pregnancy, so that the targeted interventions can be adopted. Interviews were carried out by two physicians and two research assistants (third-year medical undergraduates). We trained interviewers specifically on listening, basic counselling and communication skills. Interviews were held in an informal manner to inquire about their general health. They were informed about having high EPDS scores and inquired about the possible reasons for having high EPDS scores during the initial clinic visit. In each of these interviews, an opportunity to discuss their issues was offered to the women found to have features of psychological distress that were coupled with basic counselling. After explaining the procedure, all participants were screened for depression using the WHO Mental Health Gap tool20 (interviews were held in priority order and those who had high total and ISH scores were the first to interview).

While conducting the individual interviews, it was noted that women with a total score of 13 or less rarely mentioned that they experienced any mental health problem or distress at the time of the interview. This observation overlaps with the component contribution analysis (figure 2) performed in this study. Since the programme was service-oriented, we decided to have a threshold of a total EPDS score of 13 for the interviews based on the saturation point observed on the particular inquiry itself and the recent strong evidence synthesis available on EPDS score cut-offs for moderate to severe depression screening.21 Of the 133 women with EPDS scores more than 13 and an additional four pregnant women with self-harm ideation, 78 (56.9%) responded to telephone inquiries. Of the 22 pregnant women who had self-harm ideation, only nine were reached for telephone interviews. A considerable number of participants were not contactable through a given contact number. This issue was identified at the later stages of follow-up of the cohort as well amidst the COVID-19 pandemic as an obstacle to research using telephones.22

Figure 2

Percentage contribution of individual components (anhedonia, anxiety and depression) items to the total score in the first trimester and end of the second trimester. (The figure was prepared using the median score of each component contributing to the total score). EPDS, Edinburgh Postnatal Depression Scale.

Step 1C: offer support to women who need it
Addressing mental health problems

The clinical interviews were part of our interventions to offer help, someone to listen to, and to provide explanations, reassurance, and basic counselling. Other simple interventions, such as referring women for other medical problems if present, helping family members of pregnant women who had significant health issues in obtaining medical care, providing Information, Education and Communication (IEC) material, and providing help through the PHM, were incorporated into the programme. These were not included as RaPCo study components, but as a social responsibility of the researchers. We also assisted participants with financial problems with a voluntary donor programme organised by the members of the medical school to which the research team was attached. By the end of the second trimester, a total of 22 pregnant women having significant financial problems were supported through this donor programme.

Specialist psychiatric care

A consultant psychiatrist prearranged the referral system to ensure minimal discomfort to pregnant women. After the interviews, those who required specialist care were referred to a psychiatrist. As there is a well-known stigma attached to psychiatric clinic visits, a separate appointment system was established for pregnant women. In addition, transportation costs were also offered to pregnant women to attend specialist care if they were identified as having financial hardships during the interviews. This was required because specialist care was available only in the tertiary care unit, and the Anuradhapura district is the geographically largest district in the country. A postassessment discussion was carried out by team members with the pregnant women and with the psychiatrist to plan further management.

Pregnancy help hotline

A 24-hour helpline was established linked to the Maternal and Child Health Research Unit of the medical school, and it was open to pregnant women for any clarifications (not only mental health) related to their pregnancy. A dedicated member of the team was made available on a roster answering the calls to inquiries of women on medical, obstetric and mental health problems 24×7 to ensure consistent uninterrupted services. The telephone calls were monitored daily for follow-up calls, discussions and appropriate referrals (including psychiatric referrals). This service was maintained for 8 months until the unit was closed due to the COVID-19 pandemic. During this period, we answered 309 telephone calls from pregnant women predominantly dealing with minor ailments and miscarriages. Even though the service officially ended after the pregnancy period, mental health support was provided on demand even during the postpartum period for up to 1 year.

Stage 2: second trimester mental health screening

All RaPCo participants were invited to participate in the follow-up clinic at approximately 24–28 weeks of PoG. We reassessed the mental health status using the EPDS and clinical interviews. In addition to piloting the two-stage mental health screening intervention in pregnancy, we also inquired about attempts of ISH in pregnancy to better understand the magnitude of incidents of self-harm in pregnancy (as this is a potential harmful sequelae of anxiety/depression in pregnancy).


Analysing data about the implementation of the two-stage mental health screening process

We conducted the analysis with the aim of understanding the feasibility, acceptability and utility of the screening and whether it could be used in a clinically actionable way. The prevalence of EPDS scores at each trimester was assessed using the measures of central tendency and frequency distribution of scores of individual items. We conducted a comparative component analysis of factor structure and distribution of EPDS scores at both time points (<13 weeks and 24–28 weeks of PoG) in order to decide the type of interventions needed, hence informing the feasibility of conducting them at the primary healthcare level. Thematic analysis and a content analysis of clinical interviews further facilitated the utility of interventions and reflected the acceptability of the procedures. Self-harm ideation and incidence of DSH and suicide were assessed during the latter part of pregnancy as a proxy of utility. In addition, gathered learnings from the clinical staff conducting the interventions were incorporated in further refining the screening process. Gathered learnings from the clinical staff doing the intervention were conducted throughout as an evaluation of the process.

Calculating the incidence of ISH using hospital surveillance system data

During the first follow-up clinic of RaPCo, we inquired about self-harm during the current pregnancy. As the country was affected by the COVID-19 pandemic, which hindered field data collection since March 2020, we collected data from the hospital surveillance system to identify all pregnant and lactating women who presented to healthcare institutions in the district with self-harm incidents. This surveillance was carried out up to 1-year post partum (July 2021) to identify cohort participants with ISH during pregnancy and post partum. We also conducted predictive analyses of EPDS on ISH.

Observations and lessons learnt

Here, we present the observations of a pragmatic approach for screening and management of mental health problems during pregnancy and discuss the lessons learnt.

Feasibility, acceptability and utility of the two-stage mental health screening intervention in pregnancy

Existing evidence and our findings suggest that there is a clear need for this type of screening in early pregnancy. We have shown that the mental health screening process in early pregnancy (EPDS and the interviews) is feasible and acceptable to clinicians and women. Further, the screening is valuable for understanding mental health needs in early pregnancy and linking women with the support that they need. Specifically, EPDS can be successfully used to determine baseline mental health status in early pregnancy and identify women who need follow-up support, and we learnt some valuable lessons about the cultural adaptation of EPDS for this purpose.

Mental health screening using EPDS

At the baseline of the cohort, 23.4% of the participants had positive EPDS scores (figure 2). We examined the individual answers given to each question item. The distribution of these answers showed that items 3, 4 and 5 (items related to anxiety) had very high scores compared with the other items during the first trimester. The responses to the anxiety component items heavily contributed to the total scores during the first trimester (figure 2). Up to a total EPDS score of 14, the contribution of the anxiety component was more than 50%. Constant feelings of self-harm (EPDS item 10) were reported by 0.7% (n=22) of pregnant women, while another 1.2% (n=36) reported that they sometimes had self-harming intentions. Several reasons may underpin this finding. The majority of participants with high scores in the first trimester had symptoms of anxiety rather than depression, as indicated in figure 2. Second, by the time of the interview, the symptoms related to the nature of the first trimester, such as the ones due to physical discomfort, failure of family planning and fear of miscarriage, may have disappeared.

We emphasise the need for active screening for mental health issues during the antenatal period, as only one-third of pregnant women are aware of depressive symptoms and are willing to seek help.15 EPDS is a feasible tool to be self-administered as it is a short questionnaire with only 10 questions. Pregnant women accepted and completed the tool even within the busy antenatal clinic. In the Sri Lankan population, self-administration is possible as the literacy levels are high.12 Although the EPDS is the most widely accepted tool for perinatal mental health, there could be pragmatic issues in cultural adaptation, deciding the cut-off values and inappropriate usage of the tool, such as not coupling it with a clinical interview or repeated administration in women with incidental causes for poor mental well-being.23 Our approach using the EPDS for mental health screening during early pregnancy found that very few women with scores between 10 and 13 reported mental health problems during follow-up interviews despite the cut-off value being set at 9/10 for both antenatal and postnatal women in validation studies in Sri Lanka. This finding is compatible with global level evidence,21 and considering a score of 13 or above for the second step in screening will provide a pragmatic solution to the workload to be shared by the primary healthcare officers. However, as self-harm and suicide are commonly sought cultural behaviours in impulsive situations,24 and the total EPDS scores do not predict ISH, it is important to pay attention to women who answered positively for item 10 of the tool, irrespective of the total score. The initial interpretation of EPDS could be done by trained grassroots-level primary healthcare officers such as PHMs in Sri Lanka. However, proper guidelines should be developed in interpretation, especially on repeat administration for women who are facing incidental causes of distress, as indicated.23 It is also important that the scores are calculated and interpreted then and there at the site of administration as delay in the task can cause problems in accessibility to some participants.

Feasibility, acceptability and utility of coupling EPDS with interviews

It is feasible to conduct clinical interviews by telephone with pregnant women who had high EPDS scores, with the caveat of substantial lost to follow-up for telephone contact (described in the limitations). The pairing of EPDS and clinical interviews helped us better understand the challenges that affect women’s mental health in early pregnancy and link women with the appropriate support.

In our programme, clinical interviews were performed by medical officers and trained medical undergraduates. Training in basic counselling skills and inquiring about symptoms of moderate to severe depression was not a difficult task within the well-established Sri Lankan primary healthcare setting. The pregnant women felt that the interviews were a relief to them. Women mentioned that they need someone to talk to and express their problems, even via telephone. Coupling high EPDS with a qualitative inquiry into the underlying reasons for the high EPDS scores revealed the nature of poor mental well-being during early pregnancy. Anxiety and depression identified in the EPDS tool had a primary anxiety component in the first trimester but a mix in the second trimester. Biological, psychosocial and economic factors contributed to this phenomenon also were of two different kinds. Some of these factors, such as fear of miscarriage, unplanned pregnancy, family planning failures and nausea and vomiting, are limited to the early stages of pregnancy, and the prior address of these issues and health promotion could easily prevent first trimester anxiety. However, social and financial factors, which are chronic in nature, require broader interventions and psychosocial support. Interviews in person during the antenatal clinic visit are preferred to the telephone interviews pertaining to the response rate observed.

Utility of clinical screening during early pregnancy

While almost all the women interviewed had a range of worries, anxieties and distress, only two (2.5%) out of 78 pregnant women had definitive features of moderate to severe depression, according to the WHO Mental Health Gap tool. However, we used a comparatively low threshold and referred 14 women to a psychiatrist for a full evaluation. These included women with self-harm or suicidal ideation and a few others whom the interviewer recognised that special support would be needed apart from simple counselling at the primary healthcare level. Additionally, we identified 26 pregnant women who would benefit from the support mechanisms offered (table 1).

Table 1

Support mechanisms provided to pregnant women with high EPDS scores in the first trimester

Perceived reasons for poor mental health during early pregnancy

Pregnant women attributed their poor mental health to a range of reasons, which fell into the following categories; family conflicts (43.0%, n=34), minor ailments, such as nausea and vomiting (30.3%, n=24), unplanned or unwanted pregnancy (26.6%, n=21), financial problems (12.7%, n=11) and worry due to obstetric and reproductive issues (12.7%, n=11). Few pregnant women mentioned bereavement or other causes, such as the passing away of a family member, illness of a family member and change in residence. Figure 3 shows the word cloud prepared from the content analysis of the participants’ commonly used words/phrases to explain the underlying causes of their mental health status. The interviews were conducted after the first trimester, and by that time, we observed that issues due to first trimester-related psychological disturbances were mostly settled.

Figure 3

Description of the perceived underlying causes for mental health issues by first-trimester pregnant women.

Specialist care

Of the 14 pregnant women referred to the psychiatrist, only 6 attended the mental health clinic despite repeated reminders and follow-ups. Online supplemental table 3 shows the assessment, diagnosis and management details of the participants who consulted a psychiatrist.

Feasibility and utility of readministering EPDS in mid-pregnancy

EPDS can be feasibly readministered in the second trimester to obtain follow-up data on how women are doing and assess how women’s mental health status has changed over the course of the pregnancy. The distribution of the total EPDS score at the end of the second trimester differed from that in the first trimester (figure 2). Of the women (n=1295) who completed the assessment, 187 (14.4%) had scores more than 9. Responses to the individual questionnaire items (online supplemental table 2) were also considerably different from those in the first trimester. During the first trimester, approximately 20%–25% of the women had highest scores for anxiety items, whereas at the end of the second trimester, less than 5% had high scores for these three items. During the second trimester, self-harm ideation was reported often, sometimes, and rarely by 1.0% (n=13), 2.4% (n=31), and 1.4% (n=18) of the pregnant women, respectively. It was helpful to pair this with clinical interviews in order to probe for the risk of ISH.

ISH and suicides in pregnancy and post partum

We found that it is possible to get an approximate incidence of self-harm among pregnant women by extracting data from hospital surveillance, and the results clearly show an underestimation of the magnitude of the problem.

Among 1295 women who were followed up at the end of the second trimester, 15 reported ISH during pregnancy. Of these, 13 mentioned that they had suicidal ideation, and 10 had attempted suicide. Using a cohort design, the ISH incidence density was 11.6 per 1000 pregnant women during the first two trimesters. Similarly, the incidence density of suicide attempts was 7.8 per 1000 pregnant women during the first two trimesters. We also noted that the EPDS score was not a significant determinant of ISH ideation, attempts or suicide attempts. The hospital surveillance system in the district detected only 13% (n=2) of ISH incidents in the pregnancy cohort. ISH in pregnancy reported over the entire year in the district (>15 000 pregnancies) was 13. Based on our observations, we estimated that at least 90 ISH cases occur per year in the Anuradhapura district. No cases of suicide were reported among cohort participants who had undergone mental health screening and interventions (n=3374). However, the system reported seven completed maternal suicides of non-cohort participants (all during the postpartum period) in the entire district during the follow-up period.

The hidden nature of mental health issues during pregnancy

Our data and observations demonstrate the hidden nature of mental health issues during pregnancy, akin to the iceberg phenomenon. Based on our data, we estimated that for 10 000 pregnancies, only two completed suicides (or one in some scenarios) would represent the mental health burden of the underlying population (figure 4). While the tip of the iceberg is small, one or two suicides in the population might represent more than 100 ISH incidents, more than 800 self-harm ideation and more than 2300 women experiencing anxiety and depression in varying grades during early pregnancy. These findings underscore the importance of implementing mental health screening in early pregnancy and follow-up, particularly in similar contexts in which maternal suicide and self-harm attempts are prevalent.25 Our work further found that self-harm and suicidal ideation during early pregnancy were linked to common minor ailments and psychosocial problems that could be managed through counselling. Therefore, implementing brooder prevention strategies for maternal self-harm and suicide is critical. It would be valuable to evaluate the different types of interventions incorporated in RaPCo to understand ‘what works’ in different LMIC settings.

Figure 4

The mental health iceberg in pregnancy and postpartum. The upper section of the iceberg, depicted in a light blue shade, is typically within the purview of health services, readily observable.The lower part, with a slightly deeper shade of light blue, remains concealed from view. ISH, intentional self-harm.

Conceptual model

Based on our learnings from this implementation experience in Sri Lanka and combining previous evidence8 13 26 27 with our observations and experiences, we suggest a conceptual model for maternal mental health (online supplemental figure 1) that could be incorporated into maternal care programmes for mental health screening and service provision.

Supplemental material

We propose a two-step approach for mental health screening during pregnancy, which includes three specific time points (online supplemental figure 1). First, screening should take place during the first trimester of registration. Second, it should be carried out at the end of the second trimester, around 28 weeks of pregnancy. Lastly, screening should be conducted during the postpartum period, approximately 2–4 weeks after the delivery. During all three time points, the initial screening step can be carried out by a trained primary healthcare worker (PHW), such as the PHM in Sri Lanka. This step involves gathering information about the individual’s mental health history and utilising the EPDS questionnaire. Based on this assessment, pregnant women can be classified into three categories: low, moderate or high risk.

In the first trimester, women with an EPDS score of 13 or above and/or those who score three points for the item on self-harm ideation, along with any history of mental health problems, should be classified as ‘high risk’. These women should be referred to the primary healthcare medical officer for further screening in the second step. During the second and third time points, a cut-off level of 10 or above on the EPDS can be used. Pregnant women who do not fall into the ‘high-risk’ category, but show signs of other mental health concerns should be considered ‘moderate risk’. They should be referred for appropriate social care, financial support and any necessary interventions. It is important to follow up with these women to determine if they would progress to the ‘high-risk’ category later on. Pregnant women who do not meet the criteria for ‘high risk’ or ‘moderate risk’ should be categorised as ‘low risk’ and should be scheduled for the screening at the next time point.

In the second step of screening, a primary healthcare physician will assess the referred women using a clinical interview, utilising the WHO Mental Health GAP tool and exploring the reasons behind the high scores. The physician’s risk classification may differ from that of the PHW. After the physician’s assessment, pregnant women identified as high risk will include those displaying symptoms of moderate to severe depression or any other mental health problem requiring assessment by a psychiatrist. These individuals will be referred to a psychiatrist for further evaluation. Those who would benefit from counselling or non-specialist interventions will be classified as ‘moderate risk’ and provided with targeted interventions based on the interview. Pregnant women classified as ‘low risk’ will be referred back to the PHW for appropriate follow-up care.

Our data indicate that the proposed approach will detect more pregnant women who need support while reducing the burden on tertiary care. However, initial investment is required to train primary healthcare staff. We recommend training PHW for counselling and the use of carefully designed IEC materials to enhance the effectiveness of such interventions in the context of routine screening. By providing clear and concise information on common issues, such as minor pregnancy ailments and miscarriages, healthcare providers can better support pregnant women and manage their emotional well-being, which we experienced during this programme. Empowering PHW on mental health first aid and managing mild mental health problems would be feasible from the implementation standpoint and would be a better solution for LMICs such as Sri Lanka with a strong public health preventive network.


We could not perform an experimental study as RaPCo was incorporated into the routine maternal care programme. The clinical interviews are best conducted in person in LMIC settings with regard to equity purposes and behavioural factors such as non-responsiveness and frequently changing mobile devices. Although we conducted telephone interviews for feasibility purposes encountered during the follow-up of a multipurpose large maternal cohort, we recommend that it is possible to arrange in-person interviews within the system. However, pregnant women showing disturbed mental well-being and requesting mental healthcare services were referred to the psychiatrist through the routine healthcare system. We also conducted the clinical interviews coupled with the EPDS assessment during the first follow-up (end of the second trimester) in person on the same day as the service provision process. However, data on both above aspects are not systematically collated and hence not included in this manuscript.


Our work indicates that universal screening for mental health during pregnancy is feasible in LMIC settings within routine maternal care programmes. It is important to couple screening using psychometric tools with a clinical interview to plan targeted interventions. While our programme does not provid conclusive evidence, it highlights the potential of screening, follow-up and targeted simple mental health interventions in primary healthcare settings to promote maternal mental health and prevent maternal self-harm. Considering the challenges faced in facilitating referrals to specialists in rural communities of LMICs due to financial, cultural and human resource constraints, it is imperative to establish mental health services at the primary healthcare level. We recommend applied health research to experiment with the proposed mental health service delivery model in routine healthcare settings.

Data availability statement

Data are available on reasonable request.

Ethics statements

Patient consent for publication

Ethics approval

This study involves human participants and was approved by Ethics Review Committee, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka. Grant number: ERC/2019/07. Participants gave informed consent to participate in the study before taking part.


We acknowledge all public health staff of Anuradhapura district for their immense contribution to this work.


Supplementary materials

  • Supplementary Data

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  • Handling editor Seye Abimbola

  • Twitter @ayesh_hetti, @sunethagampodi

  • Contributors TA, GA, NW and SA designed the programme, TA, JW, AH, IJ and GA planned and mediated field implementation. TA, AW, IJ, GA, DN and TD conducted clinical interviews. SS, AW, TA, NW, AH, JW, GA and IJ mediated interventions. TA, SA and GA wrote the initial draft of the manuscript. NW, SA and AW edited the manuscript. All authors accepted and approved the manuscript.

  • Funding This study was funded by Accelerating Higher Education Expansion and Development (AHEAD) Operation of the Ministry of Higher Education, Sri Lanka funded by the World Bank. (DOR 77).

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.