Given the limited access to medical facilities, impeding lockdown, and social isolation during the COVID-19 pandemic, an upsurge in postpartum depression among pregnant mothers in their puerperal period has become more apparent alongside an eventual increase in suicidal behavior. This article aimed to discuss the crucial aspects of different clinical case studies treated during recent periods throughout the COVID-19 pandemic via teleconsultations. We hoped to demonstrate tremendous opportunities for the application of healthcare via therapeutic tools online in telemedicine to manage such conditions in a developing country like Bangladesh with a severe scarcity of healthcare infrastructure and resources.

The current coronavirus (COVID-19) outbreak resulting in physical distancing and social isolation has precipitated feelings of anxiety, stress, and worry globally. This has been increasingly evident among vulnerable populations such as expectant mothers. For most women, pregnancy alongside motherhood is a joy. But few mothers also experience additional worry, guilt, frustration, anger, and even fear. Postpartum Depression (PPD) is an emotional disorder that occurs in the first week after giving birth (Stewart et al, 2003)[1]. Hormonal factors are considered the main reason; however, a complex group of psychosocial or environmental factors may augment the condition (Stewart et al., 2003) [1]. Effects of PPD can be devastating on mother-infant interaction (Slomian et al., 2019)[2], including those with other children in the home, and the partner or spouse (Ruffell et al., 2019)[3]. Beside medical intervention, prevention of the occurrence of PPD has been successfully tackled by the method of interpersonal therapy such as appropriate counselling with the strengthening of the social support system (Stewart et al, 2003)[1].

Evidence suggests that the prevalence of PPD is higher in the Middle East and Asian countries compared to the Western world (Shorey et al., 2018)[4]. The majority of PPD cases among Bangladeshi mothers were 39.4% within the first 12 months following childbirth in 2019 (Azad et al., 2019)[5]. PPD is experienced by up to 4 in 5 women within the first few days following childbirth and usually remits within ten days (Heron et al., 2009)[6]. However, the COVID-19 pandemic crisis installing impending fear of becoming infected in conjunction with overwhelming social distancing policies hinders the spontaneous healing of current clinical cases of PPD. Evidence suggests that PPD occurrence is significantly higher among mothers who gave birth during the pandemic (Mariño‐Narvaez et al., 2020)[7]. Additionally, current emotional states consisting of fear, the anxiety of being infected with COVID-19, and social distancing concerns disrupt societal rhythm, depriving individuals of regular coping mechanisms for stress, hence subjecting an individual's mental health to disproportionate risk (Gunnell et al., 2020)[8]. Moreover, depression and anxiety correlate with suicidality (Hawton et al., 2013)[9]. There is growing evidence that the pandemic has affected diverse populations globally (Pirkis et al., 2021)[10], women being a vulnerable cohort (Atkinson et al., 2020)[11]. Little research to investigate the correlations between suicidality and the postpartum period in a country like Bangladesh is evident, where healthcare facilities and resources are limited. Recent pandemic catastrophes may escalate the prevalence of PPD inducing suicidality. Consequently, there is much need for urgent interventions to manage and support such cases of PPD.

Case 1: A 23-year-old woman gave birth to a baby girl at home in June of last year during the COVID-19 pandemic lockdown. Due to fear of being infected with COVID-19, family members would not allow the baby's delivery in a hospital environment. However, the patient was accompanied by a local midwife during child labor, and the midwife checked on her periodically following the birth of her child. The patient in question began to feel very sad and overwhelmed in the weeks following the birth of her child. She ceased to cook and barely fed her baby. Family members became increasingly worried that the baby might die and called for a local doctor to check both the mother and baby in her residence. The physician diagnosed her condition as PPD and prescribed benzodiazepines as the mother was not breastfeeding. Her condition did not improve with medication administration following two weeks.

Case 2: A 29‐year-old female visited the government hospital outdoors for a post-caesarean postpartum check‐up last July during the COVID-19 pandemic crisis. Her healthy four-week-old baby boy accompanied her, born via elective caesarean section due to umbilical cord prolapse. The patient's husband complained about her lack of interest in usual daily activities and had not been feeding their baby correctly. The patient described constant handwashing and fear of COVID-19 contraction, the severity detailed washing hands up to one hundred times daily. She also repeatedly cleansed her baby and obsessed with reading information about COVID-19. The patient describes decreased appetite, increased anxiety, and insomnia even when her baby is sleeping, feeling like this since the birth of her child, gradually getting worse. She was treated with sertraline due to breastfeeding. After continued treatment with the prescribed medication for more than two weeks, her symptoms did not improve as one would have expected.

Case 3: A 32-year-old schoolteacher had been married for more than five years, giving birth to her first baby boy. Upon delivery, the baby had a high bilirubin level due to neonatal jaundice. The patient believed that the aetiology of her child's jaundice was hers to blame. She also stated concerns about her baby contracting COVID-19, expressing feelings of guilt and fear that the current pandemic may jeopardize her baby's health. These symptoms initially began in this manner, the patient expressing emotions of utter incapability of soothing her baby, with frustration and tearfulness ensuing. She displayed repeated episodes of crying, diminished appetite, and barely allowed herself to sleep. Her husband tried to be supportive but felt she was inconsolable. Treatment with fluoxetine and benzodiazepines was commenced for two weeks, but her condition remained unstable.

All mentioned PPD cases were monitored under video conference with an experienced medical doctor and continuous tele-counselling for more than four months to prevent complications related to PPD. Such complications included sleep disturbance, altered food intake, and reluctance to physical activity. Their family members supported and monitored patients daily and maintained a notebook to record patients' everyday activities. Tele-counselling via teleconsultations was conducted initially on alternating days for two weeks via a trained physician, followed by twice a week for a further two weeks with tapering once a week for three months. As the condition improved, the tele-counselling was terminated alongside an option for further consultations as required. All patients made a complete recovery, ensuring maintenance for optimal motherhood.

Unfortunately, tele-counselling to manage mental health issues in such patients has lagged far behind the telemedicine field. Indeed, online video consultation and close monitoring demonstrated much efficiency, cost-effectiveness, and accessibility for expectant mothers when managing mental health issues in a climate of limited medical facilities for face-to-face counselling. PPD patients detailed much ease as they were in their own safe space, rather than risking traveling. Patients depicted that they were more confident and comfortable using video conferencing for consultations, describing better healthcare experiences overall. They also mentioned being with support networks at home and companionship instead of feeling alone during their treatment module was more beneficial. Furthermore, tele-counselling has allowed patients to perform healing exercises according to their convenience, geographical area, and comfort. Patients mentioned similar experiences from other countries (Høifødt et al., 2013; Wagner et al., 2014)[12, 13].

Several challenges, such as a lack of communication skills, hesitation to share personal information openly, and fear of social abuse was encountered during the teleconsultation period. Hence to overcome these challenges, the spontaneous self-healing process of PPD in a country like Bangladesh, where digital technology has scope to flourish in patient management, remains the desired objective.

3.1. Future scope of online health tools or applications in Bangladesh

There is no doubt that human connection, as demonstrated by professional therapists or counsellors, alongside accurate diagnoses, remains a critical factor in treating PPD. However, mental health chatbots, e-Therapy Apps, e-Prescription, and e-Counselling may be a select few additional resources for patients seeking initial aid for healing spontaneously while preserving personal privacy and confidentiality. Additionally, the stigma of mental health disorders is difficult to dispel. It continues to hound environments and cultures in countries like Bangladesh, where medical assistance in such a mental health crisis is a social taboo. The stigma associated appears to deter many from seeking professional help. Given the strength of such cultural barriers, qualities inherent in tele-counselling, such as relative anonymity and physical distancing, could make it an attractive alternative for many who would otherwise remain untreated. Thus, healthcare-orientated apps or online electronic monitoring will aid patients and allow them to step forward to seek treatment in the initial stages, playing a pivotal role in the future mental health ecosystem.

With the wide use of mobile phones and internet connectivity, such anonymous and healthcare-orientated apps may become accessible in assisting hundreds of thousands of post-labor mothers in such crisis moments of the COVID-19 pandemic. Therefore, such healthcare-orientated apps or online therapeutic tools might equip individuals to adopt specific medical treatment options. In addition, these resources may be considered the first line of defense to alleviate some psychiatric symptoms exhibited by PPD mothers. This could potentially be an essential step in improving the well-being of post-childbirth mothers in Bangladesh.

Multiple technology-based healthcare applications and services are available for healthcare consumers for disease prevention and management. However, there is an absolute lack of information and support for PPD for the pregnant population. Moreover, currently, there is little evidence supporting teleconsultations in developing countries, and existing studies are very diverse. Therefore, more rigorous longitudinal research is required to improve mental health issues using technology-based healthcare applications and services to maximize patient benefits in Bangladesh.