In January this year, Lindsay Clancy, a labour and delivery nurse in the United States, fatally shot her three young children and then tried to take her own life. Her story has made international headlines because it is at the intersection of maternal mental health, criminal culpability and the capacity of health systems to diagnose severe mental illness after childbirth.

Ms Clancy’s defence lawyers say she was suffering from postpartum psychosis. Prosecutors have pushed back against how much weight should be given to her mental illness with respect to criminal culpability. That is a legal question for the courts to decide. However, the story has sparked discussions on how well health systems are able to diagnose and treat mental illness after birth.

Perinatal maternal mental health conditions include depression, anxiety and other psychiatric disorders that may arise during pregnancy or after childbirth. Postpartum depression is one such condition and is characterised by persistent low mood, anxiety, sleep disturbance, withdrawal, feelings of worthlessness or inadequacy and difficulty bonding with the baby. It is important to distinguish this from the temporary emotional changes that may occur after childbirth. Postpartum depression is a clinical condition that requires appropriate assessment and treatment.

Severe condition

Postpartum psychosis is a separate and much more severe condition. It may involve delusions, hallucinations and significant disturbances in thinking and behaviour, and can impair a woman’s ability to care for herself or her child. It should therefore not be conflated with postpartum depression. Most women experiencing postpartum depression are not a danger to themselves or their children.

These conditions are often missed because maternal healthcare does not consistently treat mental health as part of routine care. A woman may have repeated contact with the health system during pregnancy, delivery and the postnatal period, yet her emotional wellbeing may never be assessed in the same systematic way as her physical recovery or her baby’s health. This, in part, is because healthcare continues to focus on physical health outcomes. A woman can go to antenatal clinics throughout her pregnancy. She can give birth in a health facility and return for a postnatal check-up. She can bring the baby in later for vaccinations. And nobody asks her about her mood or feelings in a systematic way. Does she feel persistently sad? Anxious? Are there intrusive thoughts? Is she overwhelmed by exhaustion?

Women are often expected to experience motherhood as naturally fulfilling, even while navigating physical recovery, sleep deprivation, financial stress, relationship difficulties and disproportionate caregiving responsibilities. As a result, emotional distress may be normalised as part of motherhood rather than recognised as a legitimate health concern.

Gendered power relations also shape whether women can seek and receive care. Access to mental health support may depend on household income, control over financial resources, decision-making power, partner support, exposure to intimate partner violence and whether caregiving responsibilities are shared. A response to perinatal maternal mental health must therefore go beyond diagnosing an individual woman and prescribing treatment. It must also address the social and economic conditions that influence her mental health and her ability to access care.

The Mental Health Act recognises the right to appropriate, affordable and accessible mental healthcare, counselling, rehabilitation and aftercare support. It also requires national and county governments to strengthen community and family based care, provide mental health services within county facilities, allocate resources, reduce stigma and integrate prevention, early intervention, treatment and continuing care into the health system.

The question is whether these legal obligations are being translated into services that women can actually access during pregnancy and after childbirth. There is also a difficult legal question when severe perinatal mental illness intersects with criminal conduct. A diagnosis of postpartum depression or postpartum psychosis does not automatically remove criminal responsibility. Courts must consider the accused person’s mental state, capacity and understanding at the time of the alleged offence. Public health should identify risk early and ensure that women can access support before their condition worsens.

Postnatal clinics

Women routinely interact with antenatal clinics, maternity services, postnatal clinics, child immunisation services and community health workers. These are opportunities to screen for perinatal mental health conditions, provide information and identify women who may need further assessment. Screening should be accompanied by a clear response when a woman screens positive.

If perinatal mental health conditions are not routinely identified and recorded, they remain difficult to plan and budget for. Health information systems should capture maternal mental health indicators so that the government can understand the burden, allocate resources and monitor access to care.

Families and partners must be part of the response. A woman may struggle to recover if she returns to a household where she has little practical support, limited control over resources or an overwhelming burden of care. Social protection, protection from violence and economic security are therefore also relevant to maternal mental health. Kenya needs an ecosystem approach to perinatal maternal mental health.

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Dr Bosire is a medical doctor and lawyer. stebosi51@gmail.com