"Female mental well‑being begins in the womb"

“Women’s mental health across the MENA region remains profoundly shaped by socio‑cultural determinants, geopolitical instability, gender‑based inequities, and marked disparities in access to care. Notably, a recent WHO‑EMRO systematic review highlights exceptionally high prevalence rates of mental disorders among women in conflict‑affected and humanitarian settings in the region, with approximately 50 % experiencing any mental disorder, over 40 % depression, more than 65 % anxiety, and nearly 50 % PTSD. These figures significantly exceed global averages  (Rabbani F, 2024).”

Half of the women in the Middle East and North Africa affected by conflicts and humanitarian crises have some type of mental disorder

In practical terms, what this tells us is that these elevated rates reflect enduring exposure to conflict, displacement, limited-service availability, and structural gender inequalities, all of which collectively undermine women’s psychological wellbeing. The prevalence of perinatal health disorders is particularly concerning, with rates ranging from approximately 6 % to 30 % across the MENA (Middle East & North Africa) region (Doraiswamy et al., 2020). Taken together, these data position perinatal mental health as a critical public health priority in the region.

Looking forward, the challenges are expected to intensify, unless structural gaps in women’s mental health care are urgently addressed. Future challenges include worsening humanitarian emergencies, widening of socioeconomic gaps, and persistent stigma that continues to impede service uptake. The region’s health systems, already under strain, continue to struggle with limited funding, workforce shortages, and inadequate and inconsistent integration of women’s mental health into primary care. 

The evidence further underscores systemic weaknesses such as insufficient cross‑sector coordination and the scarcity of community‑based mental health support for women at risk. Without substantial investment in integrated, gender‑sensitive and responsive mental health strategies, these challenges are likely to deepen."

“Despite the staggering prevalence rates of common perinatal mental disorders, namely depression and anxiety, services are often centralized, reactive, and insufficiently integrated into routine maternal care. What is particularly concerning is that systematic reviews consistently show a disproportionately high burden of perinatal depression and anxiety in low‑ and middle‑income countries, including those in the Eastern Mediterranean, where approximately one in four women is affected. In practical terms, the gap between disease burden and service availability and accessibility results in delayed diagnosis, missed opportunities for early intervention, and long‑term adverse outcomes for mothers and infants (UNICEF MENARO, 2024).”

"Early detection and diagnosis of perinatal mental disorders in the Arab sociocultural context are shaped by a constellation of interrelated sociocultural, structural, and geopolitical factors. Deeply entrenched cultural norms strongly influence help‑seeking behavior, often discouraging women from disclosing emotional distress or seeking professional support, particularly during pregnancy and the postpartum period. 

Stigma remains one of the most significant barriers, silencing affected women and contributing to delayed help‑seeking, poor service engagement, and treatment discontinuation or avoidance during this critical window.

These sociocultural barriers are further compounded by geopolitical instability. Women living in contexts of conflict, displacement, and protracted insecurity face markedly elevated risks of perinatal mental disorders, including depression, anxiety, and post‑traumatic stress. In the MENA region, this burden is especially pronounced, with perinatal depression exceeding 30%, and postpartum depression particularly prominent

Risk factors influencing early identification are complex and cumulative, encompassing both health‑related and social determinants. These include intimate partner violence, exposure to conflict or natural disasters, pregnancy complications, low educational attainment, unplanned pregnancy, and inadequate social support. Such intersecting vulnerabilities often coexist with fragmented or inaccessible services, further delaying recognition and diagnosis.

Taken together, the substantial burden of perinatal mental disorders in the region underscores the urgent need for targeted, integrated, and gender‑sensitive mental health interventions embedded within routine maternal care. Addressing the sociocultural and structural determinants shaping women’s pathways to care is essential to improving early detection and advancing equitable, culturally responsive services across the region (ELNahas, 2026)."

“This is a crucial issue. Domestic violence and insufficient family and/or partner support are indeed critical determinants of postpartum depression in the region. The MENA/EMR region reports the highest documented global prevalence of intimate partner violence during pregnancy (≈11%)  (Simon et al., 2025) , prompting closer scrutiny of its implications for perinatal outcomes. In our (as‑yet unpublished) work, intimate partner violence (IPV) during pregnancy was highly prevalent and strongly associated with adverse maternal and neonatal outcomes. Exposure to IPV markedly increased the risk of postpartum depression and anxiety, with a nearly seven‑fold higher adjusted odds of postpartum depression, and was also associated with preterm delivery, fetal distress, gestational diabetes, and induced abortion. These findings underscore IPV as a critical, preventable determinant of perinatal psychiatric morbidity and obstetric adversity (ELNahas et al., manuscript in preparation).”

Systematic reviews show that sociocultural stressors, such as restricted autonomy, marital conflict, and exposure to gender‑based violence, substantially elevate the risk of maternal mental disorders in MENA countries. These vulnerabilities are intensified in conflict‑ and disaster‑affected settings, where weakened social structures and disrupted community networks further compromise women’s psychological wellbeing.

Strengthening family and community‑driven protective mechanisms alongside policy-driven interventions is therefore essential for mitigating adverse postpartum outcomes.

Importantly, these high prevalence rates are not uniformly generalizable across the region, as marked disparities exist both between and within countries. Nevertheless, growing recognition of the magnitude of the problem has translated into impactful national responses in several settings, including strengthened legislative protections, integration of IPV screening and referral pathways within health and social services, and community‑led initiatives aimed at shifting rigid gender norms through participatory and nationally coordinated programs.

“That is true, and regional data clearly signal the high rates of common perinatal mental disorders across the Eastern Mediterranean-as aforementioned, with conflict‑affected populations experiencing the highest burden. The combination of elevated prevalence and well-documented adverse consequences for maternal‑infant wellbeing, firmly positions perinatal mental health as a critical public health issue requiring national-level policy action. In response to this growing evidence, international bodies have elevated perinatal mental health to a recognized global public health priority. Despite these calls, mental health has long lagged behind physical health in attention and funding, meaning that recognition at the policy level has yet to translate into adequate care access on the ground..”

"There has been clear success stories in elevating mental health on regional policy agendas, yet policies specifically targeting perinatal mental health detection and treatment remain limited and uneven across countries. 

Building on cumulative evidence derived from national surveys and Demographic and Health Surveys (DHS), WHO has increasingly sought to develop EMR regional strategies to address persistent gaps in perinatal mental health service availability and coverage. WHO responses have focused on scaling up community‑based services through mhGAP and strengthening Mental Health and Psychosocial Support in humanitarian settings across 14 Member States; however, these initiatives are largely non‑specialized and not explicitly designed for perinatal care ( EMRO, 2024 ). While they have contributed to flagship regional initiatives, a reduction in suicide rates, and modest gains in integrating mental health into primary care, perinatal mental disorders remain insufficiently prioritized. 

Addressing mental health in maternal and child health services

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Many countries still lack comprehensive national strategies, with persistent gaps in funding, workforce capacity, and cross‑sector coordination that undermine the translation of policy into accessible, scalable perinatal mental health services."

“Prevalence rates vary enormously across the region, reflecting substantial disparities in case definitions, measurement tools, and reporting practices. What is important to recognize here is that this variability underscores the urgent need for careful cultural, linguistic, and contextual adaptation of screening tools originally developed in Western settings to ensure clinical validity in Arab populations. Such adaptation requires the use of culturally attuned language, incorporation of local idioms and expression of distress, and explicit attention to somatic expressions of psychological suffering, which are more commonly reported in Arab contexts. At the same time, and this is equally critical, there is growing recognition of the need for globally standardized and comparable screening approaches within perinatal mental health services, both to enable reliable estimation of true prevalence and to support robust evaluation of effective management and care strategies.”

"The most prevalent disorders include perinatal depression, anxiety disorders, and PTSD. Systematic reviews show an overall prevalence of perinatal mental illness ranging from nearly 6 % to 30 % across MENA countries when diagnostic tools are used, with substantially higher estimates reported when broad screening instruments are applied (Doraiswamy et al., 2020)."

I want to draw attention to the sharp rise in PTSD in these settings and the substantial, enduring mental health burden this imposes, not only on affected individuals, but also on already strained health systems and recovery efforts. Rising rates of PTSD are increasingly documented among populations fleeing disaster and conflict settings. Available evidence indicates exceptionally high prevalence, with PTSD rates exceeding 25 % and complex PTSD affecting over one third of displaced individuals in some contexts, and estimates approaching 80 % among populations exposed to extreme and prolonged violence. Women consistently report higher symptom severity.

Additional key risk factors include domestic violence, low social support, poverty, educational disparities, and unplanned pregnancy. Women living in fragile settings, with limited access to services and chronic exposure to humanitarian stressors, are significantly more vulnerable.

“What is increasingly evident is that emergencies amplify psychological vulnerability, exacerbating both the onset and severity of perinatal mental disorders. Scoping reviews demonstrate that climate change, conflict, and displacement interact in complex ways, creating cascading risks that disproportionately affect women. Climate‑driven displacement, food insecurity, and livelihood loss deepen maternal stress, reduce access to health services, and increase exposure to gender‑based violence ( Lasater et al., 2025 ). In this context, climate change in the region is advancing rapidly, intensifying water scarcity and increasing forced migration, with profound mental health implications.

The cumulative impact of conflict and displacement makes perinatal women one of the most psychologically vulnerable groups in the region.

As highlighted in the Frontiers’ editorial in 2025, extreme maternal morbidity and mortality in conflict zones, with women facing sexual violence, malnutrition, and disrupted healthcare systems, all contributing to deteriorated mental health outcomes ( Lange et al., 2025 )."

"I am glad you raised this point. Compelling evidence demonstrates how maternal stress profoundly shapes the developing fetal brain. Clear, sex‑specific vulnerabilities mediated through biological, physiological, and epigenetic mechanisms are observed particularly among female offspring.

Perinatal mental disorders have well‑established intergenerational effects.

Cumulative evidence flags the long-term impact of exposure to perinatal adversities, regardless of the nature of their causes. This impact is mediated through a range of pathways and processes that influence behavioral and emotional responses in a gender-specific manner ( Shaw et al., 2020 ). As I argued in a previously published editorial, 'female mental well‑being begins in the womb', emphasizing the importance of prioritizing maternal mental health as an early intervention across the life course ( ELNahas, 2026 ).

“Entrenched traditions and sociocultural norms in Arab societies strongly shape illness behavior and help‑seeking pathways, often delaying early detection and diagnosis. Stigma, alongside misconceptions framing mental illness as a personal weakness or family burden, collectively discourage disclosure, particularly during pregnancy and the postpartum period. Limited mental health literacy, gender‑based educational disparities, and sociocultural restrictions further hinder women’s access to timely care.

Yet these same sociocultural structures can serve as powerful enablers. When viewed from this perspective, and when appropriately engaged, strong family ties, extended kinship networks, and collective caregiving norms (central features of Arab societies) represent a strong resource for early recognition, support, and help seeking. Given the influential role of families and communities in healthcare decision-making, family‑based psychoeducation programs, community awareness campaigns, and culturally adapted perinatal mental health literacy initiatives can strengthen understanding and engagement with care. Such strategies can counter misconceptions, shift harmful norms, enhance social support, and facilitate earlier help‑seeking.

While coordinated policy and system level approaches are essential, establishing comprehensive care pathways that integrate perinatal mental health services within obstetric and pediatric care is particularly critical. This includes training frontline maternal healthcare providers to screen for perinatal mental disorders, engage families in care, and deliver brief psychosocial interventions within routine antenatal and postnatal services. Such integration has the potential to improve outcomes not only for mothers, but also for children, families, and the community at large."