• Equating mental well-being with absence of disease
• Limited awareness of psychological self-care, and low literacy in knowledge of mental health and of available mental health support services
• These mental health issues, if left unaddressed compromise maternal well-being.
• Risks foetal development, neonatal outcomes, and long-term child health

In Sri Lanka, pregnant females employ a mix of adaptive and maladaptive coping strategies, with a predominant reliance on passive coping such as avoidance and religious practices, and, while these strategies offer temporary relief, they may increase emotional distress over time. Therefore, there is an urgent need to integrate maternal mental health education into routine antenatal care, promote active coping skills, and address stigma. 

These findings and recommendations were made in an original paper on the "Prevalence and factors associated with antenatal depression, anxiety, and ways of coping with mental health problems among pregnant mothers, and the feasibility assessment of an intervention to improve antenatal mental well-being in the Colombo Regional Director of Health Services (RDHS) area" which was authored by S Mohideen, C de Silva, S Weliange and L Akuratiyage, and published in the Sri Lanka Journal of Psychiatry.

Pregnancy is one of the most transformative and emotionally charged periods in a woman’s life, marked by profound physiological, psychological, and social changes. While pregnancy is often portrayed as a time of joy and anticipation, for many women, it is also a period of heightened vulnerability to mental health challenges. Antenatal depression and anxiety rank among the most common mental health concerns during pregnancy, with prevalence estimates globally ranging from 10 per cent to over 40% depending on the population. These mental health issues, if left unaddressed, not only compromise maternal well-being but also pose risks to foetal development, neonatal outcomes, and long-term child health.

In Sri Lanka, maternal mental health concerns mirror global trends. 

"The burden of antenatal anxiety: A cross-sectional study of the prevalence and selected risk factors among antenatal women in a Government hospital in the Colombo District" report antenatal depression rates ranging from 16% to as high as 42% depending on the region and study design. Antenatal anxiety has been reported between 37%-46% in urban hospital-based populations. Despite Sri Lanka's notable progress in maternal and child health, antenatal mental health remains a relatively underexplored area, with the limited integration of mental health screening and interventions into routine care.

Coping strategies are critical in shaping maternal mental health. R Lazarus and S Folkman's "Stress, appraisal, and coping" describes coping as the cognitive and behavioural efforts to manage demands perceived as exceeding the resources. These include problem-focused coping, emotion-focused coping, and maladaptive or avoidant coping. Globally, J LoGiudice's "Meta-synthesis of the experiences of midwives providing care during the Covid-19 pandemic" reveals cultural variations, for example, religious coping is common in South Asia, while avoidance-based coping is associated with higher distress in Europe and North America. In Sri Lanka, a reliance on religious rituals and avoidance, alongside limited problem-solving, has been widely used as coping mechanisms by women.

Methodology

Mohideen et al.'s study adopted a qualitative exploratory design to understand how pregnant females in the Colombo RDHS area cope with psychological stress and pregnancy-related challenges. Data were collected through in-depth interviews, and key informant interviews. The study was conducted within the maternal and child health clinics of the Colombo RDHS Division, which serves a mixed urban - semi-urban population. Participants included pregnant females across all three trimesters attending routine antenatal sessions. Purposive sampling was used to ensure diversity in parity (the number of times that a female has given birth to a foetus with a gestational age of 24 weeks or more, regardless of whether this resulted in a stillbirth or a live birth), age, education, and obstetric history. In total, 25 pregnant females were recruited for individual interviews and six frontline maternal-health service providers (PHMs, a senior PHM [SPHM], a public-health nursing sister [PHNS], and an assistant medical officer of health [AMOH]) participated in the key-informant interviews. The eligibility criteria were being currently pregnant and residing within the RDHS Colombo area. Mothers with a diagnosed psychiatric illness or serious obstetric complications requiring admission were excluded.

Results

Socio-demographic profile

Twenty-five pregnant females participated in the in-depth interviews (mean age 32 years, standard deviation plus/minus 1.3). Most participants were Sinhalese (96%) and married. The education levels varied from Grade Eight to graduate, and both primiparous (producing a child for the first time, or having produced only one child) and multiparous women were included. The majority reported no complications, although a few experienced gestational diabetes, anaemia, or hypertension.

Themes from the in-depth interviews

The thematic analysis revealed multiple coping strategies, broadly categorised as emotion-focused, problem-focused, and dysfunctional. Avoidance was the most common approach, including ignoring medical advice or stressful realities. Emotional expression, often through anger towards spouses or children, was also prevalent. Religious and spiritual practices such as prayer and lighting oil lamps were widespread. A minority adopted positive reframing and optimism, while some engaged in maladaptive strategies such as impulsive spending.

Emotion-focused and passive coping

Avoidance and withdrawal

Avoidance emerged as the most common strategy. Many pregnant females preferred not to confront stressors or medical concerns, describing avoidance as a means of temporary relief but also of guilt and helplessness.

“I got married in my late 30s, so, I wanted to have children quickly. I'm a diabetic patient.  I don't want to check my blood sugar levels thinking that it'd be high. I can't accept it, the doctor has asked me to check monthly. I avoid it as I can't face the reality. I'm afraid of facing it and I can't bear it. I run away from it. I try to avoid as much as possible, sometimes, I even get scolded by my husband and my mother as well. They can't understand me; I'm the one who knows my feelings well,” a 40-year-old on her second pregnancy; parity two, child (number of living children resulting from previous pregnancies) one; and the period of amenorrhea (the absence of menstruation, often defined as missing one or more menstrual periods) / gestation (how many weeks pregnant from the first day of the last menstrual period) 15 weeks).

This pattern reflected the fear of negative outcomes and a desire to maintain emotional stability. Key informants confirmed that avoidance was pervasive and often hindered adherence to medical advice.

Emotional expression and displacement

Several pregnant females reported releasing frustration through anger towards spouses or children. Such behaviour served as an emotional outlet but often intensified guilt and distress.

“When I’m stressed, I get angry with my husband for no reason… later, I feel bad,” - a 32-year-old on her first pregnancy.

“I hit my daughter when I'm too tired; afterwards, I feel more stressed because of the guilt,” - a multiparous mother of 27 weeks.

Acceptance and endurance

A recurrent notion of bearing it – accepting hardship as inevitable – was noted. Pregnant females rationalised distress as karmic or transient: “Whatever the gods offer, we must accept without expecting more.”

Religious and spiritual reliance

Religious coping was deeply embedded across the participants. Daily prayer, lighting oil lamps, and temple visits were described as emotionally soothing and socially acceptable means of coping.

“I light an oil lamp every evening and pray to calm my mind,” a 31-year-old on the third trimester.

Problem-focused and adaptive coping

Although less frequent, some pregnant females engaged in active strategies such as reframing stress positively, seeking advice, and using relaxation techniques.

Positive reframing and optimism

Mothers with a higher education or previous pregnancies described intentional optimism – viewing pregnancy related difficulties as temporary challenges that would lead to joy.

“I always believe that everything will be fine; this thinking keeps me calm.”

Seeking social support and humour

Social interaction with empathetic friends, relatives, or other pregnant women served as a buffer against isolation. Humour and peer companionship during antenatal clinics promoted relief.

“While waiting at the clinic, we joke and laugh with other pregnant mothers; it helps me forget worries.”

Engagement in relaxation or recreational activities

Some participants read books, listened to music, or joined light exercise classes to divert attention from stress.

“I joined an exercise class to get my mind off stress… walking makes me feel lighter.”

Barriers to effective coping and mental-health help-seeking

Low mental-health literacy

Most participants equated mental well-being with the absence of disease. The awareness of psychological self-care was limited.

“We think that mental health means to live without illness. We don’t know what it really is,” a 30-year-old graduate on the second trimester.

Stigma and fear of judgement

Mothers feared being labeled as “mentally ill”, preferring silence to disclosure. This stigma discouraged help-seeking.

Limited awareness and perceived inefficacy of support services

Although aware of hospital counseling services, participants doubted their usefulness and were unaware of free telephone hotlines. Some believed that counselors could not fully empathise with their situation.

“Only another pregnant mother can understand my feelings.”

Flexibility and multiple coping modes

Many women reported adapting strategies to the context, mixing avoidance, prayer, and distraction depending on the situation.

“I avoid people who stress me, pray to stay calm, and then watch television to relax.”

Desire for positive change

Encouragingly, several expressed willingness to improve coping with proper guidance.

“Frequent reminders on positive thinking would help us handle stress better.”

Further, they revealed humour, relaxation activities (reading, music, exercise), and peer support as important coping resources. However, staying silent, the feeling of stigma, and the lack of mental health knowledge were common. Scolding or shouting at children emerged as a means of releasing stress.

Key informant interviews

Maternal healthcare providers, including PHMs, an SPHM, a PHNS, and an AMOH, described the frequent use of avoidance, inadequate family support, and stigma. They noted the limited knowledge of available mental health services and requested more training to support pregnant females effectively.

According to the identifications of the PHMs, it was revealed that one of the main strategies adopted by pregnant females during pregnancy is the avoidance strategy.

“When I go on domiciliary field visits, I noticed that for mothers who already have relationship problems, the situation has aggravated during the pregnancy. I personally know a mother who was very tactful in handling problems before the pregnancy but is now totally different and tries to avoid facing scenarios of a distressful nature. Understanding the reality of their own problems is very little among pregnant females in my area. Most of those who suffer from chronic illnesses find it exceedingly difficult to control themselves,” a PHM. 

A range of coping strategies employed by pregnant females was revealed. Passive coping strategies dominated, including the avoidance of stressors, silent endurance, and spiritual practices such as prayer. Emotional expression, often in the form of anger or guilt, was common. Some women engaged in positive reframing and sought support from family and friends, though stigma limited open communication. Active problem-solving was rarely used.

Further, the importance of social support, humour, relaxation activities, and distraction is highlighted. However, a lack of awareness of mental health services and the fear of stigma constrained help-seeking behaviours. Key informants confirmed that avoidance was a predominant strategy and emphasised low mental health literacy among pregnant females and families.

Discussion

Sri Lankan pregnant females predominantly rely on passive coping strategies. Religious coping was a major source of comfort. However, the overreliance on avoidance and silence risks compounding psychological distress. Active coping strategies, such as problem-solving and positive reframing, were under-utilised but associated with better emotional resilience. The lack of family support, stigma, and limited-service awareness emerged as systemic barriers.

Globally, there are similar challenges. Interventions promoting problem-solving, resilience, and social support have shown promise elsewhere. Culturally adapted interventions in Sri Lanka are urgently needed, particularly involving husbands and the extended family, and equipping healthcare workers with skills to support maternal mental health.

Limitations

The responses may have been influenced by the social desirability bias, as participants could have been reluctant to disclose sensitive experiences related to mental health. 

Conclusion

Interventions should be culturally sensitive, family-inclusive, and supported by trained healthcare providers.