Beyond the city limits — the mothers nobody is talking about

When we talk about postpartum depression in Pakistan, we are most often talking about it in the language of urban awareness: social media campaigns, clinic waiting rooms, and conversations among women who have access to the internet, education, and at least the possibility of professional support.

But step beyond the city limits into the mountain villages of Gilgit-Baltistan, the remote valleys of Khyber Pakhtunkhwa, the sparse plains of interior Sindh and southern Punjab, and the picture changes entirely. Here, postpartum depression does not have a name. Here, a mother who is struggling is considered weak, ungrateful, or spiritually lacking. And here, the consequences of that silence are not just emotional. They are physical. They are generational.

Crisis Hidden in Plain Sight

In rural Pakistan, many mothers begin pregnancy already malnourished. Nearly 42 per cent of Pakistani women of reproductive age are anaemic before the physical demand of carrying a child even begins.

The children born into this scarcity carry its weight as well. UNICEF’s 2024 report found that 40 per cent of Pakistani children under five are stunted, their growth and development permanently affected by poor nutrition in their earliest years. In Balochistan and Sindh, the figures rise to 46 per cent and 45 per cent respectively. Pakistan has the third-highest number of stunted children in the world. And the pace of change? Roughly half a per cent improvement per year.

When There Is No Word for What You Feel

In many of Pakistan’s remote communities, there is no vocabulary for postpartum depression. There is no cultural framework that allows for the idea that a new mother can be physically present and emotionally absent at the same time because she is unwell.

Instead, a mother who cannot bond with her baby may be told she is not grateful enough. A mother who weeps without knowing why may be accused of bringing bad energy into the home. A mother who cannot get out of bed may simply be told to pray harder and try more.

These are not cruel communities. They are uninformed ones. And the difference matters, because uninformed communities can learn—but only if someone reaches them.

The Double Weight: Mental Health and Malnutrition Together

Research has established a deeply troubling link between maternal malnutrition and postpartum depression. A body depleted of iron, folate, and omega-3 fatty acids is more vulnerable to the neurological and hormonal disruptions that underlie PPD.

In rural Pakistan, where both conditions are widespread, they compound each other into a cycle that is extraordinarily difficult to break.

A malnourished mother experiencing postpartum depression is less able to care for and feed her infant. Her baby begins life at a disadvantage that follows them through childhood, school, and beyond. Behind both is a mother who needed support she never received.

The Reach Problem

Even when awareness exists, even when a health worker is trained to recognise postpartum depression, the infrastructure to act on that awareness is largely absent.

Pakistan has just 0.19 psychiatrists per 100,000 people—one of the lowest ratios in the world. In rural areas, that translates to roughly one psychiatrist for every one million people.

Only 0.4 per cent of Pakistan’s total health budget is allocated to mental health. The result is a treatment gap of nearly 90 per cent, meaning 9 out of 10 people who need mental health support receive none. For rural mothers, who already face barriers of distance, mobility, and stigma, the gap is even wider.

The View From the Other Side of the Desk

Dr Amina Iftikhar, a psychologist from Lahore, said one pattern she has consistently observed in her clinical work is that women from rural areas present with significantly more severe and longer-untreated cases of postpartum depression compared to those from urban backgrounds.

She recalled a patient, Saira, 24, from Rahim Yar Khan, who was brought to her office in Lahore after a 12-hour bus journey, with her husband describing it as a general checkup. It took three sessions before Saira was able to describe what had actually been happening, she said.

After her delivery, she said she felt nothing—not sadness, but emptiness, as though she were watching her own life from outside it. For eight months, she remained silent, as the only explanation offered by her community was that she was not being grateful enough.

It later emerged that she had been anaemic through both pregnancies, undetected and unaddressed. The postpartum depression and malnutrition were not two separate problems; they were compounding each other, and neither had been named until she reached her clinic.

Saira, Dr Iftikhar said, was not unusual. What was unusual was that she reached treatment at all. Most women in similar situations never do. They remain in their villages, are labelled as weak or spiritually failing, and quietly deteriorate while continuing to care for everyone around them.

She noted that while urban women often present within weeks, rural women come, if they come at all, after the condition has significantly worsened. By that stage, she said, treatment is no longer only about postpartum depression, but about the consequences of prolonged silence around an illness in a body already exhausted before pregnancy.

“There is a serious gap in this country between awareness and access,” she said, adding that while awareness has gradually improved in cities, access to care has not expanded nearly enough, particularly in the areas that need it most.

So Where Does That Leave Us?

It is easy to read these numbers and feel overwhelmed. The geography is vast. The stigma is deeply rooted. The infrastructure gaps are real and not easily closed.

But the mothers of rural Pakistan—the woman in Tharparkar whose baby cries while she stares at the ceiling, the woman in Kohistan who has not smiled since delivery, the woman in interior Punjab who believes her suffering is punishment rather than illness—deserve to be part of this conversation.

An estimated 24 million people in Pakistan need psychiatric support today. Most will never receive it—not because the need is absent, but because the support has never reached them.

Which raises a question that becomes harder to ignore the more clearly we see the scale of what is happening:

In a country where millions of mothers cannot reach support, can support be brought to them instead? Can government, civil society, and even the corporate sector—through communication reach, CSR platforms, and public influence—work together to bring postpartum depression out of silence and ensure that more mothers in Pakistan feel seen, heard, and supported?

It is a question worth sitting with. Because the answer, if it exists, could change everything.