{"paper_id":"8ced3574-416c-43ba-9608-4694202932c9","body_text":"OFFICIAL\n1 No maternal health without mental health: suggested \n2 indicators to monitor perinatal mental health globally\n3\n4 Francesca Palestra1*, #a, Allisyn C. Moran 1, #a, Neerja Chowdhary 2, #a, Tatiana Taylor Salisbury 3, Tarun \n5 Dua 2&,#a, Shanon McNab 4&, Elly Layton5&, Elissa C Kennedy5&, Caroline SE Homer5&, Jane Fisher 6&, \n6 Simone Honickman 7&, Zelee Hill8&.\n7  \n8 1. Department of Maternal Newborn Child and Adolescent Health and Ageing (MCA), World \n9 Health Organization (WHO), Geneva, Switzerland \n10 2. Department of Mental Health, Brain Health and Substance Use (MSD), World Health \n11 Organization (WHO), Geneva, Switzerland \n12 3. Centre for Global Mental Health, King's College London, London, United Kingdom\n13\n14 4. MOMENTUM Country and Global Leadership, Jhpiego, Washington, District of Columbia, \n15 United States of America\n16 5. Burnet Institute, Australia\n17 6. Public Health and Preventive Medicine, Monash University, Melbourne Australia\n18\n19 7. Department of psychiatry and mental health, University of Cape Town, Cape Town, South Africa \n20 8. Institute for Global Health, University College London, London, United Kingdom \n21\n22 #a current address: Avenue Appia, Geneva Switzerland \n23 *Corresponding author: Francesca Palestra, fr.palestra@gmail.com \n24 FP is the senior author who wrote and conceived the paper \n25 AM, NC and TTS are joint senior authors and supported in the process and development of the paper\n26 & contributed equally to this work. \nfor use under a CC0 license. \nThis article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available \n(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. \nThe copyright holder for this preprintthis version posted October 6, 2024. ; https://doi.org/10.1101/2024.10.04.24314919doi: medRxiv preprint \nNOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.\n\nOFFICIAL\n27 Abstract\n28 Perinatal mental health refers to the psychological wellbeing of women during pregnancy and up to one \n29 year postpartum. Perinatal mental health conditions as depression significantly affect maternal, newborn \n30 health, and child development worldwide. However, the absence of standardized indicators limits \n31 effective monitoring and evaluation. This paper introduces a framework with indicators for global \n32 perinatal mental health monitoring.\n33 The framework development involved a scoping review, expert consultations, and stakeholder surveys. A \n34 global expert group, guided by evidence and the World Health Organization (WHO), identified an initial \n35 set of indicators. Two rounds of online surveys were conducted, allowing stakeholders to rank these \n36 indicators and suggest additional ones. Indicators were chosen based on their validity, reliability, \n37 relevance, feasibility, and potential impact for advocacy purposes on perinatal mental health. The WHO \n38 expert working group finalized the set of indicators.\n39 Six perinatal mental health indicators were identified for future testing. These include three primary \n40 indicators: policy presence, screening coverage, and prevalence of perinatal mental health conditions. \n41 Three secondary indicators cover mental health expenditure, healthcare professional training, and \n42 provision of care. \n43 Challenges to implementing standardized monitoring include resource limitations and data collection \n44 methods. Strengthening health workers and facility capacity to measure, report, and interpret perinatal \n45 mental health data, including the use of screening tools, is crucial. The integration of these indicators into \n46 existing systems, such as health information management systems (HIMS) and national surveys, will be \n47 key.\n48 Monitoring perinatal mental health is essential for improving maternal and newborn outcomes. The \n49 proposed framework offers a means to enhance global monitoring and guide policy interventions. Global \n50 stakeholders are encouraged to integrate perinatal mental health into their policy, program, and \n51 monitoring agendas.\n52\n53 Key words\n54 Perinatal mental health, maternal health, newborn health, depression, mental health conditions, health \n55 monitoring, indicators  \n56\nfor use under a CC0 license. \nThis article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available \n(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. \nThe copyright holder for this preprintthis version posted October 6, 2024. ; https://doi.org/10.1101/2024.10.04.24314919doi: medRxiv preprint \n\nOFFICIAL\n57 Introduction\n58 Perinatal mental health (PMH) is one of the most neglected issues in maternal health [1]. PMH refers to \n59 the psychological wellbeing of individuals during pregnancy and up to one year postpartum [2]. This is \n60 not to be confused with the perinatal period of a newborn which is seven days after birth [3]. \n61 A variety of mental health conditions may be experienced during the perinatal period, including but not \n62 limited to depression, anxiety, psychoses and alcohol and substance use [4, 5]. Perinatal mental health \n63 conditions pose a significant burden globally, affecting millions of women each year. Globally it is \n64 estimated that 10-20 % of pregnant women and those who just have given birth experience depression and \n65 rates are highest in low- and middle-income countries [8, 9], Different cultural practices, poverty, biological \n66 and social factors have been associated with influencing women’s vulnerability to perinatal mental health \n67 conditions [10].\n68 Poor PMH not only has adverse effects on the woman's quality of life but also impacts the health \n69 outcomes of newborns and children [11]. For example, perinatal depression has been linked to suicide and \n70 adverse birth outcomes, such as preterm birth and low birth weight, as well as long-term developmental \n71 and behavioral issues in children [12, 13].  Perinatal mental health is therefore crucial for the wellbeing of \n72 women and their babies.\n73 Despite the prevalence and impact of perinatal mental health conditions, there is a lack of standardized \n74 indicators for global monitoring. No perinatal mental health indicators are currently tracked routinely \n75 across countries in health information management systems (HIMS) or through standardized national \n76 health surveys as Demographic and Health Surveys (DHS) or Multiple Indicator Cluster Surveys MICS).  \n77 Existing indicators, mainly from high-income countries, vary widely between countries and regions, \n78 making it challenging to compare data and assess the effectiveness of interventions [14, 15, 16]. \n79 Moreover, many indicators focus predominantly on the diagnosis and treatment of perinatal mental health \n80 conditions (mainly postpartum depression) rather than on the services provided and the access of women \n81 to those services, ensuring preventive measures and appropriate referral. There is also a need for more \nfor use under a CC0 license. \nThis article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available \n(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. \nThe copyright holder for this preprintthis version posted October 6, 2024. ; https://doi.org/10.1101/2024.10.04.24314919doi: medRxiv preprint \n\nOFFICIAL\n82 comprehensive and integrated approaches to perinatal mental health monitoring that address the \n83 complexity of healthcare systems and policies across countries ensuring integration across levels of care \n84 and within maternal, newborn and child health services [17]. Standardized indicators are essential for \n85 assessing the burden of perinatal mental health conditions globally and should show progress to address \n86 perinatal mental health issues, as well as guide policy and resource allocation.\n87\n88 Overview of the Global PMH Theory of Change and scoping review on PMH \n89 indicators\n90 A Global PMH Theory of Change (ToC) was published in 2022 [18] providing a strategic roadmap for \n91 developing standardized indicators for perinatal mental health monitoring.  It outlines the underlying \n92 assumptions and pathways through which the proposed indicators are expected to bring about positive \n93 changes in the monitoring and management of perinatal mental health conditions. By identifying key \n94 inputs, activities, outputs, outcomes, and impacts, the ToC serves as a guide for understanding how the \n95 proposed indicators can contribute to improved maternal and newborn health outcomes. The ToC is based \n96 on a social ecological model where its domains are in order: individual, interpersonal relationship, \n97 community, service delivery ecosystem and policy landscape. \n98 Further a scoping review conducted in 2023 aimed to identify existing perinatal mental health indicators \n99 used in monitoring systems worldwide [17]. The search in the scoping review was conducted in accordance \n100 with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping \n101 Reviews. After consultation with WHO it was decided to exclude indicators related to risk factors for PMH \n102 or did not measure PMH directly. Additional indicators which measured mental health but were not specific \n103 to the perinatal period were excluded, as these are well described in WHO Mental Health Atlas [19]. Results \n104 were compiled and mapped to the relevant level in the Global PMH ToC. The review considered the \n105 indicators which: (1) aligned with the Global PMH ToC and landscape analysis definition of perinatal \nfor use under a CC0 license. \nThis article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available \n(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. \nThe copyright holder for this preprintthis version posted October 6, 2024. ; https://doi.org/10.1101/2024.10.04.24314919doi: medRxiv preprint \n\nOFFICIAL\n106 mental health (during pregnancy and up to one year after childbirth); (2) had a definition, including how it \n107 could be measured; and (3) was published from 1 January 2000 to 6 September 2023.\n108 Nine indicators were identified which addressed individual (six indicators) and service-level (three \n109 indicators) characteristics (Table 1). In order to be reflective of global differences in the feasibility and \n110 availability of data to determine if indicators are met, stakeholder engagement in determining a final set \n111 of indicators is needed. \n112 Table 1. List of PMH indicators identified in the scoping review\nTheory of change domain Indicator\nIndividual 1. Proportion of women with postpartum depression \nIndividual 2. Proportion of women with depression in perinatal period\nIndividual 3. Proportion of women with postpartum psychosis\nIndividual 4. Proportion of women with adjustment and distress in perinatal \nperiod\nIndividual 5. Proportion of women with PTSD in perinatal period\nIndividual 6. Proportion of women with mental health conditions in perinatal \nperiod\nService delivery ecosystem 7. Proportion of women screened for mental health conditions in \nperinatal period \nService delivery ecosystem 8. Proportion of women with access to mental health services during \nthe perinatal period \nfor use under a CC0 license. \nThis article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available \n(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. \nThe copyright holder for this preprintthis version posted October 6, 2024. ; https://doi.org/10.1101/2024.10.04.24314919doi: medRxiv preprint \n\nOFFICIAL\nService delivery ecosystem 9. Proportion of healthcare providers trained to provide mental \nhealthcare in perinatal period\n113\n114\n115 The purpose of this paper is to present the process for developing a set of primary and secondary \n116 indicators for countries in monitor PMH, discuss challenges in implementation of screening methods and \n117 training providers, and provide policy recommendations for integrating perinatal mental health indicators \n118 into existing monitoring frameworks. \n119 Methods\n120 The development of a set of indicators for perinatal mental health involved a multi-stage process to ensure \n121 robustness and inclusivity of all World Health Organization (WHO) regions. This was a four-phase \n122 process (Table 2) guided by a WHO working group of experts and included online surveys based on the \n123 identified indicators of the scoping review and in consultation with the WHO Mother and Newborn \n124 Information for Tracking Outcomes and Results (MoNITOR) advisory group.  This process brought to the \n125 finalization of global indicators on PMH with primary and secondary indicators for further reflection and \n126 adjustment.\n127 Table 2. Phases to develop global PMH indicators\nPhase 1\nEstablishment of WHO \nexperts group on PMH \nmonitoring and discussion \non identified indicators of \nthe scoping review\nPhase 2\nFirst survey with WHO experts \ngroup on PMH monitoring\nPhase 3:\nSecond survey with WHO \nexperts group on PMH \nmonitoring and additional \nsuggested stakeholders from \nglobal, regional and country \nlevel\nPhase 4:\nConsultation with WHO experts \ngroup on PMH monitoring and \nthe WHO MoNITOR advisory \ngroup and development of global \nPMH indicators \n128\nfor use under a CC0 license. \nThis article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available \n(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. \nThe copyright holder for this preprintthis version posted October 6, 2024. ; https://doi.org/10.1101/2024.10.04.24314919doi: medRxiv preprint \n\nOFFICIAL\n129\n130  In phase one, a WHO working group of experts, comprised of 21 experts in perinatal mental health and \n131 monitoring and evaluation, from diverse regional backgrounds, was convened to provide guidance on \n132 indicator selection. The role of the WHO working group included providing feedback on the scoping \n133 review, on the list of proposed indicators and relevance in relation to the ToC; feedback and review on the \n134 findings from surveys, and of the proposed indicators, including feasibility of implementation.\n135 In phases two and three, two rounds of surveys were conducted through an anonymized online form, \n136 among an international group of stakeholders, including healthcare professionals, researchers, \n137 policymakers, and representatives from civil society organizations. In phase two with the first survey, \n138 respondents were asked to select the top three PMH indicators for global monitoring from the list of nine \n139 indicators identified through the previous scoping review [17] and to propose any additional indicators \n140 used at the country-level which may be useful for global monitoring. During phase three the second \n141 survey included a wider group of stakeholders invited to order the list of indicators, selected from the \n142 previous survey, from the most to the least important indicator; and to propose additional ones if relevant. \n143 After each round of survey, the WHO working group of experts had online consultations to provide \n144 feedback on the findings. The specific questions of the two surveys are reported in S1 First and second \n145 surveys.\n146\n147 The first survey was completed by 21 members of the WHO working group, resulting in a total of 17 \n148 answers out of 21 participants.  The second survey was completed by 35 stakeholders part of a broader \n149 group of experts involved more generally in maternal, newborn, child and adolescent health program \n150 implementation, mental health programme and monitoring and evaluation from global, regional and \n151 country levels. These stakeholders were identified through WHO regional offices and by the members of \n152 the WHO expert committee. The second survey requested participants to In the second survey the first \n153 question collected a total of 17 answers, while the second questions collected 8 answers. \nfor use under a CC0 license. \nThis article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available \n(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. \nThe copyright holder for this preprintthis version posted October 6, 2024. ; https://doi.org/10.1101/2024.10.04.24314919doi: medRxiv preprint \n\nOFFICIAL\n154 Phase four included consultation with the WHO experts group on PMH monitoring and the WHO \n155 MoNITOR advisory group and development of global PMH indicators.  Firstly, the feedback obtained \n156 from these surveys was analysed and a list of proposed indicators was developed to ensure their relevance \n157 and applicability across different settings. Later on, the WHO Mother and Newborn Information for \n158 Tracking Outcomes and Results (MoNITOR) advisory group and the WHO experts group on PMH \n159 monitoring, shared overall guidance and inputs on the results collected from the two surveys, which \n160 further informed the development process.\n161 Inclusion and exclusion criteria were established to ensure the selection of indicators that met predefined \n162 quality standards and objectives. Indicators were included if they demonstrated validity, reliability, \n163 feasibility and potential impact for advocacy purposes. They also needed to be relevant to the assessment \n164 of perinatal mental health conditions and be able to measure progress towards improving maternal and \n165 newborn health outcomes for global monitoring purposes. Indicators were excluded if they lacked \n166 empirical evidence, were risk-related to develop PMH conditions or were overly complex or resource-\n167 intensive or were specific to a particular context and not generalizable to a broader population.  \n168\n169 This work is based on the review of the literature and expert opinion, including WHO’s technical \n170 advisory groups on monitoring and measurement, and it is not original research. Therefore, we did not \n171 seek approval from the WHO ERC for ethical clearance.  \n172 We obtained written consent from members of the WHO expert group, following WHO protocols for \n173 expert group participation, which include declarations of interest and confidentiality agreements. The \n174 consent forms are securely stored on WHO servers, protected by a password. The WHO expert group has \n175 been involved in this activity on the prioritization of the PMH indicators from the 8th of December 2023 \n176 until the 25th of April 2024.\n177\n178 Results\nfor use under a CC0 license. \nThis article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available \n(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. \nThe copyright holder for this preprintthis version posted October 6, 2024. ; https://doi.org/10.1101/2024.10.04.24314919doi: medRxiv preprint \n\nOFFICIAL\n179 A summary of all steps in the selection of the indicators and results on the identification and prioritization \n180 of indicators can be found in S2 Table.\n181 Results from phase two (first survey)\n182 A total of 17 out of 21 WHO Working Group members selected the top three PMH indicators for global \n183 monitoring choosing from the nine indicators identified through the previous scoping review [17] (Table \n184 3).  \n185 Table 3. The PMH indicators for global monitoring in order of relevance by stakeholders from the \n186 first survey\nTheory of change \ndomain\nIndicator  Score\nService delivery \necosystem \n7. Proportion of women screened for mental health \nconditions in perinatal period \n12 (70%)\nService delivery \necosystem \n8. Proportion of women with access to mental health \nservices during the perinatal period \n12 (70%)\nService delivery \necosystem \n9. Proportion of healthcare providers trained to provide \nmental healthcare in perinatal period\n11 (64%)\n187\n188 Additionally, three more indicators have been suggested to be important for inclusion (although not \n189 classified as top three) which are at individual level: 2. “Proportion of women with depression in perinatal \n190 period”; 6. “Proportion of women with mental health conditions in perinatal period” and 1. “Proportion of \n191 women with postpartum depression”.\n192 Nine respondents proposed additional indicators used at the country-level potentially useful for global \n193 monitoring:\n194  Postnatal care (PNC) disaggregated for women and baby\nfor use under a CC0 license. \nThis article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available \n(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. \nThe copyright holder for this preprintthis version posted October 6, 2024. ; https://doi.org/10.1101/2024.10.04.24314919doi: medRxiv preprint \n\nOFFICIAL\n195  Early Childhood Development Index (ECDI)\n196  System readiness indicators: 1. Presence of content on screening and counseling for maternal \n197 mental health in relevant pre-service curricula (MCH nurses; Community Health Workers etc.); 2. \n198 Antenatal care (ANC) and postnatal care (PNC) consultation /home visit guidelines including \n199 PMH screening, counseling & follow up\n200  Availability of PMH policy or included in national mental health policy \n201  PMH included in WHO country annual work plan \n202  PMH included in national health policy and other documents\n203  Proportion of health budget (mental health budget) allocated to maternal mental health (I have not \n204 used, but would be a useful indicator of high-level commitment at governance level)\n205\n206 Results from phase three (second survey)\n207 The survey requested 35 participants to put in order from the most important to the least the priority PMH \n208 indicators for global monitoring identified in the previous survey by the WHO working group of experts \n209 and to propose any additional indicator.\n210 17 stakeholders completed the survey and the most voted indicators have been listed in order of priority:\n211 1. Proportion of women with access to mental health services during the perinatal period;\n212 2. Proportion of women screened for mental health conditions in perinatal period\n213 3. Proportion of healthcare providers trained to provide mental healthcare in perinatal period;\n214 4. Proportion of women with mental health conditions in perinatal period;\n215 5. Proportion of women with depression in perinatal period\n216 6. Proportion of women with postpartum depression\n217 Additionally, eight respondents suggested the inclusion of additional indicators such as:\n218  Proportion of women with perinatal mental condition linked to psychosocial support OR mental \n219 health services\nfor use under a CC0 license. \nThis article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available \n(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. \nThe copyright holder for this preprintthis version posted October 6, 2024. ; https://doi.org/10.1101/2024.10.04.24314919doi: medRxiv preprint \n\nOFFICIAL\n220  Proportion of health budget allocated to perinatal mental health\n221  The proportion of women attending a first referral appointment for treatment of a mental health \n222 condition\n223  Women with anxiety during perinatal period and additional risk-related indicators for PMH\n224\n225 Results from phase four \n226 Results consultations with WHO expert committee\n227 Following analysis of both surveys results, the key recommendations by the WHO expert committee were \n228 on the identification and prioritisation of indicators and on feasibility and implementation. These two \n229 aspects will be described separately. \n230 Identification and prioritisation of indicators\n231 There was consensus from the WHO expert group to include the list of indicators below based on \n232 prioritisation from stakeholders and likely feasibility: \n233  To include indicators number 1. “Proportion of women with postpartum depression” and 2. \n234 “Proportion of women with depression in perinatal period” , which are important although may \n235 be difficult to measure initially.\n236  To include indicator 6. “Proportion of women with mental health conditions in perinatal period”, \n237 and to better describe the common mental health conditions in the metadata.\n238  The committee also discussed the inclusion of indicator 7. “Proportion of women screened for \n239 mental health conditions in perinatal period” versus the possible inclusion of an indicator which \n240 measured the number of consultations on PMH through ANC and PNC services. It was decided to \n241 include indicator 7 since will already provide more specific information with the use of validated \n242 screening tools. Further, the WHO recommendations on maternal and newborn care for a positive \n243 postnatal experience currently include PMH services for PNC [20] but not for ANC [21], \n244 therefore different countries could have a different approach in providing PMH services.  \nfor use under a CC0 license. \nThis article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available \n(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. \nThe copyright holder for this preprintthis version posted October 6, 2024. ; https://doi.org/10.1101/2024.10.04.24314919doi: medRxiv preprint \n\nOFFICIAL\n245  To include indicator 9. “Proportion of healthcare providers trained to provide mental healthcare in \n246 perinatal period”. \n247 Then a list the indicators that were excluded (and rationale):\n248  To exclude indicator 8. “Proportion of women with access to mental health services during the \n249 perinatal period”. This indicator was excluded because of the unclear definition of “access”, and \n250 reliable measurement at a national level was considered less feasible.\n251  To exclude an indicator which measures anxiety during pregnancy although this can contribute to \n252 postpartum depression. The expert group acknowledged anxiety as an important issue in PMH \n253 and a precursor to and as a risk factor for depression. Since we were specifically excluding \n254 indicators of risk factors, this indicator has been excluded.\n255\n256 Additional new indicators that were added: \n257  The WHO expert committee recognized the importance of having two indicators for advocacy \n258 purposes on budget allocation and on existing national policies for PMH. If countries are unable \n259 to identify the budget specifically for PMH, the budget allocated to mental health may be reported \n260 instead\n261  To group some indicators as health system indicators: budget, trained staff, etc... Suggested \n262 grouping indicators by primary indicators to monitor from the start and additional secondary \n263 indicators to monitor within a later timeframe.\n264 Feasibility and implementation\n265  To include the data source for each indicator to assist with prioritization. It was agreed to focus \n266 on a few indicators, define their purpose, and use them to advocate for services. It was recognised \n267 that PMH services may not be well defined, or even existent in many countries. \nfor use under a CC0 license. \nThis article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available \n(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. \nThe copyright holder for this preprintthis version posted October 6, 2024. ; https://doi.org/10.1101/2024.10.04.24314919doi: medRxiv preprint \n\nOFFICIAL\n268  To include recommendations consistently on screening tools to use for data collection, and where \n269 to locate resources and services at national level. Although screening is not universal, each \n270 country should have adopted a specific tool at national level.\n271\n272 Results from consultation with WHO MoNITOR advisory group\n273 The consultation with WHO MoNITOR advisory group was focused on the feasibility and \n274 implementation of the global PMH indicators. They identified the need to refine the indicators related to \n275 perinatal mental health services, as well as the training and competencies required by healthcare providers \n276 in order to offer mental healthcare services during the perinatal period. It was also deemed essential to \n277 identify the specific mental health conditions that need to be measured and provide clear definitions for \n278 these conditions. Additionally, there should be a specification of the screening tools approved by WHO, \n279 along with the appropriate timeframe for their use. Clarification is needed on how and where to measure \n280 these indicators, along with considerations for ethical practices in the measurement process. The inclusion \n281 of referral processes and psychosocial support within the mental health services needs to be detailed. It is \n282 important to harmonize WHO guidelines by including perinatal mental health recommendations in \n283 guidelines on childbirth and antenatal care. \n284 Given the variety of information to be collected and possible weaknesses in routine data collection \n285 systems, indicators could be collected by different sources. Some of the indicators could be integrated \n286 into HIMS or collected through national reporting (e.g. for indicators concerning existence of a national \n287 PMH policy, government expenditure, health providers trained), while others may be more reliably \n288 collected through national surveys like DHS or MICS or mental heath surveys (e.g. indicators on \n289 population prevalence of perinatal depression).\n290 There should be a clear outline of the key elements required in a national plan for perinatal mental health, \n291 such as the tools to use, the planning period, training, and the types of services available. The risk of \n292 underreporting must be acknowledged. The indicator on the proportion of women with postpartum \nfor use under a CC0 license. \nThis article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available \n(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. \nThe copyright holder for this preprintthis version posted October 6, 2024. ; https://doi.org/10.1101/2024.10.04.24314919doi: medRxiv preprint \n\nOFFICIAL\n293 depression should be retained, as postpartum conditions are among the most frequently diagnosed. \n294 Finally, there should be specific screening for perinatal mental health conditions for women staying in the \n295 hospital for their small and sick newborns in NICUs.\n296\n297 Indicators for perinatal mental health monitoring \n298 Based on the consultations a list of primary indicators and a list of secondary indicators was created based \n299 on capacity or quality data available (Table 4 and Table 5). Metadata providing more detailed \n300 descriptions of each indicator is available in S3 File. \n301 Table 4. Primary indicators for global monitoring\nMonitoring \ndomain\nIndicator Numerator Denominator Current \npreferred \ndata source\nOther \ndata \nsources\nOutput Proportion of \ncountries with \nnational policy /plan \nfor perinatal mental \nhealth in \nSRMNCAH  or in \nthe mental health \npolicy/strategy \nNumber of \ncountries with \nnational \npolicy for \nperinatal \nmental health \nin \nSRMNCAH \npolicy/strategy \nor  in the \nmental health \npolicy/strategy\nTotal number \nof countries \nPolicy review \nor WHO \nPolicy survey\nProportion of \nwomen screened for \nmental health \nconditions in \nperinatal period 1\nNumber of \nwomen who \nwere screened \nfor mental \nhealth \nconditions in \nin perinatal \nperiod 1\nTotal number \nof women \nwho gave \nbirth within a \ngiven time \nperiod \nHousehold \nsurveys \nRHISOutcome\nProportion of \nwomen with \ndepression in \nperinatal period1\nNumber of \nwomen \nidentified with \ndepression2 in \nthe perinatal \nperiod1 \nTotal number \nof women \nwho gave \nbirth within a \ngiven time \nperiod \nHousehold \nsurvey \nRHIS\n302\nfor use under a CC0 license. \nThis article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available \n(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. \nThe copyright holder for this preprintthis version posted October 6, 2024. ; https://doi.org/10.1101/2024.10.04.24314919doi: medRxiv preprint \n\nOFFICIAL\n303 Table 5. Secondary indicators for global monitoring\nMonitoring \ndomain\nIndicator Numerator Denominator Current \npreferred \ndata source\nOther \ndata \nsources\nProportion of government \nallocated expenditure to \nperinatal mental health\nTotal \ngovernment \nallocated \nexpenditure \nto perinatal \nmental \nhealth \nTotal \ngovernment \nallocated \nexpenditure \non health3\nOutput\nProportion of in-service \nhealth care providers \ntrained to provide mental \nhealthcare services4 in \nperinatal period\nNumber of \nin-service \nhealth care \nproviders \ntrained to \nprovide \nmental \nhealthcare \nservices in \nperinatal \nperiod\nTotal number \nof in-service \nhealth care \nproviders \nproviding \nservices in \nperinatal \nperiod\nHealth facility \nassessment\nNHAs\nOutcome Proportion of women with \nperinatal mental health \ncondition linked to \npsychosocial support OR \nmental health services\nNumber of \nwomen with \nperinatal \nmental \nhealth \ncondition \nlinked to \npsychosocial \nsupport OR \nmental \nhealth \nservices\nTotal number \nof women \nwith perinatal \nmental health \ncondition\nHousehold \nsurvey\nRHIS\n304\n305 1 Perinatal period: during pregnancy and up to 1 year after pregnancy\n306 2 Depression following consultation and use of available screening tool  \n307 3 Relatively crude indicator\n308 4 Mental Healthcare services include a variety of interventions, and it is not limited to screening of mental health conditions. \n309 Please refer to the WHO Guide for integration of perinatal mental health in maternal and child health services. Geneva: World \n310 Health Organization; 2022.\n311\n312 The primary indicators proposed for perinatal mental health monitoring represent measures aimed at \n313 capturing key aspects of maternal psychological wellbeing during pregnancy and up to one year \nfor use under a CC0 license. \nThis article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available \n(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. \nThe copyright holder for this preprintthis version posted October 6, 2024. ; https://doi.org/10.1101/2024.10.04.24314919doi: medRxiv preprint \n\nOFFICIAL\n314 postpartum. These indicators have been carefully selected based on their significance in assessing the \n315 population prevalence, policy and health system plans related to perinatal mental health conditions. They \n316 serve as foundational metrics for monitoring PMH conditions and policies aimed at improving maternal \n317 and newborn health outcomes. Primary indicators include measures in individual and healthcare system \n318 domains, such as the prevalence of antenatal and postnatal depression, rates of screening coverage for \n319 perinatal mental health conditions in the perinatal period, and the proportion of countries with national \n320 policy or plan for perinatal mental health. \n321\n322 In addition to the primary indicators, secondary indicators are proposed to guide future efforts and \n323 advancements in perinatal mental health monitoring within a later timeframe. These secondary indicators \n324 represent desired outcomes and areas for improvement that may require additional research, resources, \n325 and policy initiatives to achieve. They encompass measures aimed at enhancing the comprehensiveness, \n326 accuracy, and equity of perinatal mental health monitoring, as well as addressing emerging challenges and \n327 priorities in the field. Secondary indicators include individual, health service delivery and healthcare \n328 system domains, assessing the proportion of women receiving timely and appropriate treatment for \n329 perinatal mental health conditions, the proportion of in-service health care providers trained to provide \n330 mental healthcare services, and the budget expenditure allocated to improve this population issue.\n331 By setting ambitious yet achievable goals for the future, secondary indicators pave the way for continued \n332 progress and innovation in perinatal mental health monitoring and ultimately contribute to better \n333 outcomes for women and newborns worldwide.\n334 Discussion \n335 The proposed global PMH indicators has significant implications for global monitoring efforts at global \n336 and national levels. By establishing a standardized set of metrics, countries can systematically track and \n337 compare the prevalence and outcomes of perinatal mental health conditions across regions and over time. \n338 This allows for more accurate assessment of the burden of perinatal mental health disorders and \nfor use under a CC0 license. \nThis article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available \n(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. \nThe copyright holder for this preprintthis version posted October 6, 2024. ; https://doi.org/10.1101/2024.10.04.24314919doi: medRxiv preprint \n\nOFFICIAL\n339 identification of populations at greatest risk. Additionally, standardized indicators facilitate the evaluation \n340 of interventions and policies aimed at improving maternal and newborn health outcomes, enabling \n341 countries to identify effective strategies and allocate resources more efficiently. Moreover, by raising \n342 awareness and prioritizing perinatal mental health on the global agenda, the proposed indicators can \n343 catalyze action and advocacy to address this critical public health issue. The WHO expert committee’s \n344 advised to choose indicators to reflect key dimensions of perinatal mental health including prevalence, \n345 screening, policy and health system plans related to perinatal mental health. Priority was given to \n346 indicators that were evidence-based, feasible to measure, and relevant to global monitoring efforts. \n347 Consideration was also given to indicators that could be easily integrated into existing health information \n348 systems and data collection tools as the ones used by hospital and households’ surveys to facilitate \n349 implementation and sustainability. \n350\n351 Challenges in implementing standardized monitoring systems\n352 The need to strengthen coordination and technical leadership to harmonize recommendations for \n353 improved measurement and monitoring of data related to maternal and newborn heath has been \n354 highlighted in previous publications [17, 18] and by the WHO MoNITOR Advisory group [22]. Despite \n355 the potential benefits, implementing standardized monitoring systems for maternal and newborn health \n356 and in this case for perinatal mental health specifically, poses several challenges. These include resource \n357 constraints, particularly in low- and middle-income countries, where healthcare infrastructure, funding, \n358 coverage and poor accessibility of PMH services may limit data collection. The integration of PMH into \n359 maternal and newborn health services including validated screening and diagnostic tools would be \n360 essential in the implementation of a monitoring system [23].\n361 There are also technical challenges related to data collection, reporting mechanisms, the quality of data, \n362 and interoperability of health information systems which hamper disparities in monitoring efforts between \n363 high-income and low-income countries [24]. The national routine health information system is essential \nfor use under a CC0 license. \nThis article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available \n(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. \nThe copyright holder for this preprintthis version posted October 6, 2024. ; https://doi.org/10.1101/2024.10.04.24314919doi: medRxiv preprint \n\nOFFICIAL\n364 for decision-making, providing regular data on delivery and utilization of services and can be used for \n365 program planning and track progress towards national and subnational targets [25]. In an effort to include \n366 new indicators as the ones proposed in this paper, it is important to consider the use of household and \n367 health facility survey. Household surveys are the primary source of coverage data for LMICs [26], \n368 however not all interventions suggested by this framework can feasibly be tracked using this method. \n369 Linking household and facility surveys would improve the coverage measurement, linking care-seeking \n370 data from household surveys with service provision data from health facility assessments provides a \n371 unique opportunity to produce measures of population coverage that account for service quality [27]. \n372 These indicators offer the opportunity to be integrated into the next version of DHS or MICS. \n373 Additionally, cultural and contextual factors may influence the acceptability and uptake of standardized \n374 monitoring protocols, requiring tailored approaches to implementation. Addressing these gaps is essential \n375 for improving the accuracy, comprehensiveness, and equity of perinatal mental health monitoring \n376 worldwide and requires sustained commitment from governments, healthcare providers, and international \n377 partners, as well as investment in capacity building and health system strengthening. Starting with \n378 primary indicators to then expand to secondary indicators would enable each national system to build \n379 capacity and advocate for an improved monitoring system in this area. \n380\n381 Opportunities for collaboration and capacity building for healthcare \n382 workers\n383 Collaboration and capacity building are essential for the successful implementation of standardized \n384 monitoring systems for perinatal mental health. Multisectoral collaboration involving government \n385 agencies, healthcare providers, academia, civil society organizations, and international partners can \n386 leverage expertise and resources to support monitoring efforts [28]. Capacity building initiatives, \n387 including task sharing and group problem solving therapy can empower health workers and users with the \n388 knowledge and skills needed to respond, screen, diagnose, treat or refer to another specialist, perinatal \nfor use under a CC0 license. \nThis article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available \n(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. \nThe copyright holder for this preprintthis version posted October 6, 2024. ; https://doi.org/10.1101/2024.10.04.24314919doi: medRxiv preprint \n\nOFFICIAL\n389 mental health conditions effectively [29, 30]. This includes training on culturally sensitive approaches to \n390 care, evidence-based interventions, and integration of mental health services into routine antenatal and \n391 postnatal care [23]. By fostering collaboration and investing in capacity building, countries can strengthen \n392 their healthcare systems and improve outcomes for women and newborns.\n393\n394 Policy recommendations for integrating perinatal mental health \n395 indicators into existing monitoring frameworks\n396  Integrating perinatal mental health indicators into existing monitoring frameworks requires policy \n397 support and coordination at the national and international levels. Policymakers should integrate primary \n398 and secondary PMH indicators into existing health information systems and monitoring frameworks for \n399 maternal and newborn health, ensuring data on maternal psychological wellbeing are routinely collected \n400 and reported. Additionally, policies should prioritize funding for mental health services and workforce \n401 development, ensuring that healthcare providers have the resources and support needed to address \n402 perinatal mental health effectively [31]. Finally, policies should promote collaboration across sectors and \n403 encourage the adoption of evidence-based practices to improve perinatal mental health outcomes. By \n404 incorporating perinatal mental health indicators into existing monitoring frameworks. Countries can \n405 enhance their capacity to address this critical public health issue and achieve better outcomes for women \n406 and newborns.\n407 The proposed global indicators for perinatal mental health encompass a range of measures aimed at \n408 capturing key aspects of maternal psychological wellbeing during pregnancy and the postpartum period. \n409 By tracking these indicators, we can better understand the burden of perinatal mental health conditions, \n410 identify gaps in care, and assess the effectiveness of interventions. Ultimately, these indicators have the \n411 potential to improve maternal and newborn health outcomes by informing policy and practice and guiding \n412 resource allocation to areas of greatest need. Additionally, pilot testing of these global PMH indicators to \n413 finalize a PMH monitoring framework in different settings is needed to help identify any practical \nfor use under a CC0 license. \nThis article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available \n(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. \nThe copyright holder for this preprintthis version posted October 6, 2024. ; https://doi.org/10.1101/2024.10.04.24314919doi: medRxiv preprint \n\nOFFICIAL\n414 challenges or limitations, conduct data validation, and allow for further refinement and optimization \n415 before full-scale implementation. \n416 Conclusion\n417 Given the significant impact of perinatal mental health on maternal and newborn health outcomes, there is \n418 an urgent need for global stakeholders to prioritize the provision and monitoring of perinatal mental \n419 health care. This includes governments, international organizations, healthcare providers, researchers, and \n420 civil society organizations. Global stakeholders are called upon to pilot the global PMH indicators into \n421 existing monitoring frameworks and programs, allocating resources for mental health services, and \n422 promoting collaboration and capacity building among healthcare workers. By working together to address \n423 perinatal mental health, we can ensure that all women receive the support and care they need to thrive \n424 during pregnancy and the postnatal period, ultimately leading to better outcomes for both women and \n425 newborns.\n426\n427 Acknowledgements\n428 We acknowledge the kind contribution of each member of the WHO expert group on PMH monitoring \n429 and the WHO MoNITOR advisory group. \n430\n431 References\n432 1. The Lancet. Perinatal depression: a neglected aspect of maternal health. Lancet. 2023;402(10403):667\n433 2. World Organization WH. WHO guide for integration of perinatal mental health in maternal and child health services. \n434 Geneva; 2022.\n435 3. WHO. ICD 11 Reference Guide. 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It is not subject to copyright under 17 USC 105 and is also made available \n(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. \nThe copyright holder for this preprintthis version posted October 6, 2024. ; https://doi.org/10.1101/2024.10.04.24314919doi: medRxiv preprint \n\nOFFICIAL\n503 31. Schiller CE, Cohen MJ, O'Hara MW. Perinatal mental health around the world: priorities for research and service \n504 development in the USA. BJPsych Int. 2020 Nov;17(4):87-91. doi: 10.1192/bji.2020.15. PMID: 33196694; PMCID: \n505 PMC7609989.\n506\n507\n508\n509\n510\n511\nfor use under a CC0 license. \nThis article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available \n(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. \nThe copyright holder for this preprintthis version posted October 6, 2024. ; https://doi.org/10.1101/2024.10.04.24314919doi: medRxiv preprint","source_license":"Public-Domain","license_restricted":false}