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 Table of Contents  
REVIEW ARTICLE
Year : 2019  |  Volume : 35  |  Issue : 1  |  Page : 47-54

Trajectory of perinatal mental health in India


1 Department of Psychiatry, BGS Global Institute of Medical Sciences, Bengaluru, Karnataka, India
2 Department of Psychiatry, Srinivasa Institute of Medical Sciences, Mangaluru, Karnataka, India

Date of Submission18-May-2018
Date of Decision16-Jun-2018
Date of Acceptance17-Jul-2018
Date of Web Publication27-Mar-2019

Correspondence Address:
Dr. Mithun Sadashiva Acharya
Department of Psychiatry, Srinivasa Institute of Medical Sciences, Srinivasnagar, Mukka, Surathkal, Mangaluru - 574 146, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_30_18

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  Abstract 


The global burden of psychiatric disorders in women is on the rise, especially in the perinatal period. Despite this, the recognition of the need and delivery of health care in women of reproductive age group is scarce and still met by unscientific treatment modalities. Such a scenario is luring in India as well. We have focused on discussing the impact of culture on the treatment practices, different challenges faced, nosological status, and management principles of different perinatal psychiatric disorders. We mainly employed the Google Scholar search engine to look into articles of all sorts (review articles, case reports, expert opinions, newspaper extracts, and Indian government websites) and reviewed them. We also acknowledged the information extracted from these articles which were highly valuable and enlightening. The perspective of the health-care delivery in the perinatal group of population has been changing over the years, but still there is lot to change. A holistic, scientific, evidence-based approach is a definite need toward attaining this goal.

Keywords: Mental health, perinatal psychiatry, women


How to cite this article:
Harsha G T, Acharya MS. Trajectory of perinatal mental health in India. Indian J Soc Psychiatry 2019;35:47-54

How to cite this URL:
Harsha G T, Acharya MS. Trajectory of perinatal mental health in India. Indian J Soc Psychiatry [serial online] 2019 [cited 2019 Sep 22];35:47-54. Available from: http://www.indjsp.org/text.asp?2019/35/1/47/254998




  Perinatal Mental Health Within Mental Health Top


Neuropsychiatric disorders in India contribute to about 11.6% of the global burden of disease (GBD) (WHO, 2008) and have the highest number of suicides in the world. The lifetime prevalence of any form of mental illness in Indian population is 13.7%.[1] According to a WHO report, 250,000 suicides were reported in 2012, with over 40% of those in individuals under the age of 30 years.[2] As per Austin (2010), prevalence estimates for maternal disorder in the perinatal period are similar to that at other times in the childbearing years.[3] In the Indian scenario, prevalence of mental disorders in the age group of 13–17 years is 7.3% and nearly equal in both genders, wherein 9.8 million of young Indians aged between 13 and 17 years are in need of active interventions.[1] Indicators of morbidity and disability indicate that mental and behavioral disorders are the largest contributors to disease burden in women of childbearing age.[4] The GBD of mental disorders among women aged between 15 and 44 years is 7%.[5] In Indian women and teenage girls aged 15–19 years, suicide has surpassed maternal mortality as the leading cause of death.[6] Despite an increase in the age of marriage, 61% of all women (69% in rural regions and 31% in urban areas) are married before the age of 16 and the median age at first pregnancy is 19.2 years.[7],[8] As evident from the above statistics, this particular age group as such is vulnerable to mental morbidity which becomes more problematic when combined with the phenomenon of pregnancy. Hence, mental health of perinatal women is the need of the hour.

Objectives

The main objectives of this narrative review are:

  1. To get an overview of the perspective of perinatal mental health in the Indian context
  2. The provisions and lacunae for the nomenclature, diagnosis, and management of the perinatal psychiatric disorders at the global and national levels.



  India, Culture, and Perinatal Mental Health Top


Gender is a critical determinant of mental health and mental illness. In the Indian culture, several factors determine the mental health of women such as joint family system, patriarchy, marriage a must, preference for the male child, practice of dowry, lower educational status of women, strict code of conduct for females, and primary roles of women being childbearing and child-rearing.[9],[10] In mental health of women, reproductive mental health has received the maximum attention. In India, events related to pregnancy are perceived as “normal phenomena” and usually medical help is sought at times of emergencies or crisis,[11] thus leaving minimal role for preventive measures. Sometimes, adversities are believed to be a part of pregnancy, wherein a fatalistic attitude of any sort of medical help would yield no beneficial changes, is common.[12] Any ill health is less explained on the lines of modern medicine and more in terms of religious faiths and curses or fate.[11]

Cultural attitudes and stigma significantly affect the mental health of the mother. The fundamental difference in the definition of the experience, as a disease or as a normal transient state, colors the perception of the concept of illness in the people. Rituals are usually a routine phenomenon wherein special diets, massage, warm environment, and traditional healing foods are offered to the mother and many times the extended family members are given the responsibility of taking care of the infant. Modern medicine practices appear to be out of the norm and considered to be non-Indian, which cause conflicts between the mother and her extended family and may hinder the social support. On many occasions, woman-centered approach in treatment modality is missing due to which the disturbances seen during illness are blamed on the women rather than supporting her.[13] Also known is the aspect that in the absence of expected support after childbirth, unavoidable instances of abusive parenting by either the father or mother may overlap with perinatal psychiatric disorders.[14] Marital violence against women by their husbands is an additional hurdle our women have to face to sustain their health.[15]

However, gradually, modern medicine has been adopted by educated people.[16] Mental illnesses were perceived to being pathological or even criminal as was evident in India's legal system, wherein attempted suicide was considered punishable under Section 309 of the Indian Legal Code, which has now been decriminalized in the Mental Health Care Act 2017.[6] According to Hema et al., 2008, in India, incorporation of postpartum depression (PPD) into maternal child health services has been a new initiative overcoming the various cultural issues and stigma associated with the treatment.[17]


  Challenges Faced Top


As such, perinatal psychiatric disorders are distinct and variable in their clinical conditions as emphasized by Brockington. Difficulties in the integration of perinatal health care with other arms of the health care or national health-care systems are evident. Preliminary care is given by midwives, gynecologists, and pediatricians due to the enormous challenge of extreme shortage of workforce.[15]

As per the second situational analysis of the PRIME study, some findings seen in the maternal health in India are as follows:[18]

  1. National Mental Health Policy included maternal mental health (MMH)
  2. No dedicated MMH services available
  3. No existing MMH care available, wherein referral to tertiary care center will be made
  4. No prescribing guidelines for psychotropic medications in pregnant and breastfeeding women
  5. No statistics regarding the proportion of perinatal women with mental health disorders in contact with services
  6. India's mental health policy did not directly address MMH
  7. MMH clinics were separate from general health clinics
  8. Lack of training and stigmatizing attitudes of primary health care (PHC) staff toward mentally ill patients hindered treatment
  9. Cultural practices such as confinement for about 40–80 days after birth put constraints on seeking medical help
  10. No availability of health sector personnel to deliver psychosocial interventions
  11. Community explanatory models of MMH disorders showed that depression was attributed to economic and marital difficulties rather than medical model
  12. No screening tools used in clinical practice for screening depression
  13. Health staff available for delivery of mental health care services were PHC medical officer, auxiliary nurse midwives (ANMs), accredited social health activist (ASHA) workers, and community health workers
  14. Lack of political will or lack of communication between researchers and health planners and managers.



  Nosological Status of Perinatal Psychiatric Disorders Top


The term “perinatal” means to include MMH in the antenatal and postnatal phases affecting developing mother–infant relationship.[19],[20] The current psychiatric nosology has not classified postpartum psychosis (PP) as a distinct entity. The two main classificatory systems which we follow in India are: (1) World Health Organization's-International Classification of Diseases (ICD) and (2) Diagnostic and Statistical Manual of Mental Disorders (DSM) by American Psychiatric Association. Significant changes have been made in the nature of classification of these perinatal psychiatry disorders which have been highlighted in the following lines, as follows:

International Classification of Diseases system

In the World Health Organization ICD-10 (1992),[3] puerperal disorders are located under the “Mental Disorders associated with Physiological disturbances and Physical factors” block (F50–59), with subset F53 “Mental Disorders associated with the Puerperium, not elsewhere classified.” These episodes are subdivided into “postnatal depression” (termed “mild”), “puerperal psychosis” (termed “severe”), and “other.”

These episodes are defined as follows:

  1. Episodes commencing within 6 weeks of delivery
  2. Episodes not meeting criteria for other mental disorders because of: (a) insufficient or (b) additional features making classification elsewhere inappropriate due to separate etiology (implied) and additional phenomenology.


American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders system

In this,[3] there was a mention of Puerperal psychosis in the DSM-III (1980, 1987), as an example of “atypical psychosis” (298.90) under “psychotic disorders not elsewhere classified.” Later, over the years in DSM-IV (1994, 2000), the term “postpartum onset” (within 4 weeks) as a specifier attached to mood disorders (major depression, bipolar I or bipolar II disorder) and brief psychotic disorder came into picture. However, the postpartum state cannot be numerically coded, thus having less clinical documentations. DSM-IV highlights significant comorbidity such as depressive or anxiety disorders in perinatal period (Austin, 2004).

Changes in the classification of perinatal psychiatric disorders are needed as there is lack of clarity to its nomenclature, few of the reasons are as follows:[3]

  1. Rationale for the 4 to 6-week postpartum-onset specifier not clearly mentioned in both ICD and DSM systems, especially when there is evidence that the risk of postpartum mental illnesses may be high in the first trimester to the 1st year after childbirth
  2. Nonpsychotic episodes are included but with no adequate reasons mentioned
  3. For depressive disorders, the postpartum-onset specifier will need to be extended
  4. Some of the episodes in the postpartum period are believed to be influenced by hormonal changes (and associated neurotransmitter changes); however, long-term outcome studies suggest that episodes of PP are most often an initial manifestation of bipolar disorder. However, the abrupt onset and characteristic phenomenology could suggest the researchers to consider a biological etiology for this condition
  5. Postpartum psychiatric disorders may manifest weeks beyond the 1st month or 6 weeks after delivery.[21]


Recommendations for changes in the further editions of both classificatory systems are being considered.


  Perinatal Psychiatry Disorders: over the Years Top


Postpartum psychiatric disorders have come to be dealt mainly with two mainstreams: first being the community-based studies focusing on PPD and second hospital-based studies focusing on clinical descriptions of PP.[22] Postpartum phenomenology can range from transient mood lability, irritability, and crying spells to marked agitation, delusions, confusion, and delirium.[23] Earlier, perinatal psychiatric disorders were identified into maternity blues, PPD (“postnatal”), and Postpartum 'psychoses'. As per Brockington, it can be dealt as psychoses, mother–infant relationship disorders, depression, and a miscellaneous group of anxiety and stress-related disorders.[24] A thorough clinical neurological examination along with relevant blood investigations needs to be done to rule out organic etiology for the same. However, the positive predictive value of the available antenatal screening tools is low, making it difficult to address the mental health needs of women as a routine care.[13]

Furthermore, many studies have shown the use of population-specific screening tools such as “Edinburgh Postnatal Depression Scale” (EPDS) or “Mood Disorder Questionnaire”(MDQ) which have shown increased detection rates of many perinatal psychiatric disorders.[25],[26],[27],[28] The EPDS is a cost-effective tool to detect the symptoms of depression;[29] however, 21.4% of patients who screened positive on EPDS also screened positive on MDQ; hence, MDQ has been used for screening for bipolar disorder as suggested by CANMAT guidelines.

The salient ones among these have been highlighted as follows:

Postpartum depression

As per Rai et al.,[23] about 10%–15% of postpartum women have PPD, making it the most common disorder in postpartum women. PPD can occur during pregnancy or within the first 12 months following delivery. Major depression can be identified better in comparison to minor depression and the rates of depression are not much different in women between postpartum period and in the other nonreproductive phases.[30],[31] Depression and postpartum period does not have a good epidemiological association as the features to diagnose PPD are difficult to differentiate from major depressive disorder; also PPD is a heterogeneous group of disorder which includes dysthymia, prepartum depression leading to PPD, adjustment disorder, and bipolar depression. Some features pointing toward PPD over depressive disorder are negative thoughts toward the child, anxiety symptoms being more common, and some having only obsessional and stress disorders without per se depression.[23],[24]

Postpartum psychosis

Women up to 3 months' postpartum period are prone to develop PP with a mean duration of an episode being about 40 days; the risk is higher with similar history in previous pregnancies, history of bipolar disorder, family history of psychotic illness, lack of social support, stressful life events, and sleep deprivation.[23],[30],[32],[33] The onset of an episode is usually within 2 weeks of delivery and is relatively less common compared to PPD occurring at an estimated incidence of 1.1–4.0 cases per 1000 deliveries, wherein up to 20%–30% of births in women can get episodes with a history of bipolar disorder or affective psychosis.[25],[34] It can mainly can be either of organic/infective coded under F05 or psychogenic/bipolar type coded under F23.3 in ICD-10. The clinical features are highly variable involving psychotic, mood symptoms, catatonia, suicidal attempts, and infanticide, but commonly bipolar symptomatology is seen, thus hinting a close evidence between puerperal and bipolar disorders.[24],[35] PP may be the first episode of bipolar disorder. However, puerperal psychosis have more atypical features, severity of mania symptoms are higher, Schneiderian first-rank symptoms are prominent, and perplexity, disorientation depressive, and anxiety features are common.[30]

Bipolar disorder

Bipolar disorder is a major risk factor for PP. The women are at a high risk for relapse during and after pregnancy, being about 3 times more compared to nonpregnant women who are not on mood stabilizers and being euthymic at the time of conception. The majority of episodes were depressive or dysphoric and seen during the first trimester. Perinatal bipolar disorder diagnosis takes a backstep when any patient presents with depression, which is further complicated by insomnia, poor mother–infant interaction, and obsessions regarding the baby, delusions, suicide, etc.


  Changing Concepts in Management Top


Setting

The conventional model of psychiatrist solely handling the treatment as a whole has been shifted toward a multidisciplinary modality of treatment involving psychiatrists, psychologists, and social workers. As per the UK NICE guidelines, women requiring inpatient care for mental illness, within 12 months of childbirth, should be admitted in a specialized mother–baby unit (MBU)[36] because it has the multidisciplinary staff care; encourage mother–infant bonding, psychoeducation, and psychotherapy; enhance family support system; and prevent the development of attachment disorders. Along with inpatient facility, emphasis is getting focused on outpatient and day-care basis care to ease the burden on the health-care personnel. Lack of such dedicated MBUs may result in separation disorders, difficulties in diagnostic evaluations, longer inpatient stays, and increased illness relapse rates. In India, the very first MBU was established in NIMHANS unit in 2009. As per Prabha et al., 2015, MBUs are much better than other inpatient units in terms of clinical management and mother–infant interactions as they reduce the duration of hospital stay, improve clinical outcomes, and reduce the rates of readmissions.[37]

General principles of management

The general principles include a detailed documentation regarding the women's menstrual history, informed consent decision regarding the conception and medications, treatment recommendations, consistent monitoring of patients for adequate therapeutic control and preventing toxicity, addressing psychosocial factors, and encouraging to normalize daily activities such as sleep hygiene and healthy lifestyle modifications.

Nonpharmacological treatment

Involving the patient and family members about the nature of treatment definitely helps in handling the responsibilities of motherhood better. Individual, interpersonal, group psychotherapy, reassurance, psychoeducation, and emotional support have shown to improve social adjustment in mothers.[38],[39]

Pharmacological treatment

Medication management during pregnancy and lactation gets complicated by concerns about teratogenicity (congenital malformations), neonatal complications, and by pharmacodynamic or pharmacokinetic interactions of the drugs. Electroconvulsive therapy is another therapeutic option for severely ill patients but does not replace pharmacotherapy. The need for medications is more when the illness is severe. The benefits and risks of giving medications need to be considered during pregnancy and lactational periods.[40] Pharmacodynamic and pharmacokinetic metabolic factors of the mother and infant determine the extent of medication exposure in the infant.[41] In premature infants, breastfeeding can be avoided if the mother is on psychotropic medication. Breastfeeding can be minimized at times when the breastmilk drug concentration is lowest, like just before or after taking medication.[42]

Breastfeeding

Women may be suggested to avoid breastfeeding as this may cause sleep deprivation, which may precipitate disturbances in mood, also that all psychotropic drugs are excreted in breastmilk at various concentrations. However, in view of the infant's health demand, breastfeeding can be followed. Infant drug exposure generally is higher during pregnancy than during lactation. However, premature infants and infants with neonatal complications may be vulnerable to such exposure.[43] The relative infant doses of psychotropic drugs are a major consideration in drug selection for lactating mothers.

Management of individual disorders

Postpartum blues

They are commonly seen in Western countries than in the Indian scenario.[44],[45] They usually do not cause dysfunction and are self-limiting with no requirement for active intervention except social support from the family members.[23]

Postpartum depression

PPD responds to similar treatment interventions as depression at other times, with few exceptions in the guidelines for this special population. Selective serotonin reuptake inhibitors (SSRIs) are recommended as the first-line therapy in PPD, for postpartum dysthymia, panic disorder, and obsessive-compulsive disorder.[46],[47] As per a retrospective multisite study design among the 118,935 deliveries from 2001 to 2005, 6.6% of women were given antidepressants, among which SSRI usage increased from 1.5% in 1996 to 6.4% in 2004 and 6.2% in 2005.[48] Preliminary evidence suggests that SSRIs such as mirtazapine, bupropion, and venlafaxine do not appear to be major teratogens during pregnancy with the exception of paroxetine, which can be associated with a small risk of congenital abnormalities, especially cardiac defects.[49]

In women with bipolar disorder

During pregnancy

Antidepressants should generally be avoided. In women already taking antidepressants, decision regarding continuation of the drugs should be judged on clinical, pharmacological, and social support profile of the patient. Abrupt withdrawal of the antidepressants may precipitate emergence of (hypo) manic or psychotic symptoms, wherein the use of psychotropic medications such as olanzapine, quetiapine or mood stabilizers may be warranted.

Postdelivery

Antidepressants need to be used with caution and better be avoided.[50]

Bipolar disorder

Along with the general principles of management, medications may be warranted when the severity of illness is high for adequate control of the mood episodes and minimizing the potential risks to the mother and infant. Out of these, lithium, valproic acid, lamotrigine, and 2nd-generation antipsychotics such as olanzapine and quetiapine are used extensively as mood-stabilizing agents.[51]

Important Drugs

Lithium

The efficacy of lithium in pregnancy and lactation is well established.[52] Maternal serum levels should be maintained in the therapeutic range during pregnancy with frequent monitoring of lithium levels, initially monthly and optimally weekly in the last month. One of the main concerns regarding its use is the congenital malformation of Ebstein's anomaly, but no causal relationship has been established. The estimate risk is about 1–2/2000 livebirths against the background rate of 1/20,000 livebirths. However, anomaly scans are advised at 16–18 weeks based on the possibility that lithium therapy increases the risk of heart defects.[53] Maternal serum, breastmilk, and infant serum daily trough concentrations of lithium were lower than the preceding former levels by approximately one-half.[54] Other possible complications by lithium therapy can be “floppy infant syndrome,” neonatal hyperbilirubinemia, hypothyroidism, cardiac rhythm disturbances, diabetes insipidus, and neurodevelopmental defects.[51]

Valproic acid

The Food and Drug Administration (FDA) issued a warning in 2009 that valproic acid be avoided in women of childbearing potential and be used only when other treatments are not effective/acceptable. The calculated risk for congenital malformations with valproic acid was 2.59 when compared with other anticonvulsants and 3.77 when compared with risk in the general population. Also, this risk is dose dependent, wherein at doses up to 600 mg per day, the neural tube defect risk may be 2%–3% (compared to population rate of 0.2%–0.3%). However, at doses used for bipolar prophylaxis (1000 mg per day or more), the risk is between 6.5% and 9%, as per various studies[55],[56],[57],[58] Other complications include fetal valproate syndrome, facial clefts, cardiac defects, limb defects, nasal defects, abnormal ears, and neurodevelopmental effects such as autism/autism spectrum disorder.[59],[60]

Antipsychotics

In 2011, the FDA labeled all antipsychotic drugs with the risk of neonatal complications following the third-trimester exposure such as extrapyramidal signs, breathing and feeding difficulties, sedation, and agitation.[61] These complications may resolve spontaneously or may require additional hospital care. Many newer antipsychotics have been used for the treatment of bipolar disorder which are supported by many studies which show combined data rather than drug-specific information. Different studies showed varying results with the use of several classes of antipsychotics. One such study showed the rate of congenital malformations in the antipsychotic exposed group to be 0.9% compared to 1.5% in an unexposed control group. In another study, the rate of major malformations was 4.1%, which was similar to the rate following exposure to older antipsychotics. In a prospective study, no statistically significant difference was seen in the rate of malformations between babies exposed to newer compared to older medications; however, there was an increased relative risk of malformation in babies exposed to newer drugs compared to the unexposed control group.[62],[63],[64] Other complications with antipsychotic exposure were an increased risk of heart defects, preterm delivery, smallness for gestational age, and decreased birth weight.[65]

Way forward

Global level

According to the World Bank List of Economies (2007) in low-to-middle-income countries (LMICs) in which India is included, information on perinatal mental health problems is <10%, making it very clear regarding a dearth of research work in this aspect of mental health. Research studies need to be carried out in low-income, illiterate women who do not get adequate antepartum and postpartum care to generalize the results as it is prudent that the impact of perinatal mental on mother and infant health is huge due to the high prevalence of maternal mental disorders in LMICs, and also the impact on infant's health manifests due to delay in psychosocial development, low birthweight, reduced breastfeeding, malnutrition, and lower compliance with immunization schedules.

To uphold the importance of perinatal mental health, the WHO has explicitly included maternal health in the Millennium Development Goals (MDGs) but not mental health in particular, which is mentioned as follows:[5]

  1. MDG 3: Promoting gender equality and empowering women
  2. MDG 4: Reducing child mortality
  3. MDG 5: Improving maternal health


Integration of perinatal mental health into maternal and child health programs by task sharing and stepped care approaches by the WHO is definitely effective in improving MMH. On the lines of this intervention is the PRIME research consortium which aims to improve MMH treatment programs at the district level in LMIC including India.

National Level

Perinatal health-care system in India

The postpartum care has different models across countries wherein the rituals among Indian communities focus on the physical, mental, and spiritual health of the mother and infant. In the UK and Australia, the postpartum care is focused mainly on the medical benchmarks such as normalization of the physical status of the mother and infant and health-care support network offers home visits from a community midwife. In contrast, the main focus of the Indian model care is to mobilize social support through the family.[23]

As per a systematic review and meta-analysis in world health bulletin, in LMICs, mental health interventions given by supervised nonspecialists proved to be more beneficial than the routine maternal and child care which showed a lower prevalence of moderate depression in interventional groups of perinatal women in northeastern states of India.[66],[67] Culturally and locally adapted methods of improving perinatal mental health need to be innovated as evident in the intervention done by Tripati et al. who had trained local women to educate mothers about pregnancy, birth, neonatal health, and health-care seeking through culturally designed stories.[68]

Some of the initiatives taken are:

  1. As per the Health Care For All initiative under the Ministry of Health and Family Welfare, there is a 27.7% increase in the budget allocation for health care sector from Rs. 37,061.55 crores in 2016–2017 to Rs. 47,352.51 crores in 2017–2018
  2. In the National Health Mission, for 7498 renovations of health facilities, 43,726 ASHA workers were selected
  3. Mission Parivar Vikas was launched for effective family planning, aiming to provide services and contraceptives to nearly 146 districts of 7 high-focus states in North India; in which nearly 30 lakh postpartum intrauterine device insertions were done from 2014 to February 2017
  4. Janani Suraksha Yojana and Janani Shishu Suraksha Karyakram aimed at minimizing maternal and neonatal mortality ratios
  5. In Mental Health Care Act 2017, a special clause for women and children regarding admission and treatment has been emphasised
  6. The Constitution included a special provision in Article 15, permitting the state to positively discriminate in favor of women by enacting laws/provisions so as to ameliorate their social, economic, and political condition and to accord them parity
  7. In the premiere institutions such as AIIMS (New Delhi), NIMHANS (Bengaluru), and others, provisions have been made for postdoctoral fellowship courses.



  Conclusion Top


The need of the hour is for the provision of standardized and operationalized criteria for identification, diagnosis, referral, management, and follow-up of perinatal psychiatry disorders which are culturally sound. Attempts have been made in these aspects as mentioned earlier at various levels, i.e., global and national level, political and policy level, medical and nonmedical level, and social and family level. Better integration of perinatal health care at all these levels would be warranted for a holistic care of women in India.

Acknowledgment

We would like to thank the Department of Psychiatry, BGS GIMS, Bengaluru, and authors of all articles reviewed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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India, Culture, ...
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