No maternal health without mental health: suggested indicators to monitor perinatal mental health globally

OFFICIAL 1 No maternal health without mental health: suggested 2 indicators to monitor perinatal mental health globally 3 4 Francesca Palestra1*, #a, Allisyn C. Moran 1, #a, Neerja Chowdhary 2, #a, Tatiana Taylor Salisbury 3, Tarun 5 Dua 2&,#a, Shanon McNab 4&, Elly Layton5&, Elissa C Kennedy5&, Caroline SE Homer5&, Jane Fisher 6&, 6 Simone Honickman 7&, Zelee Hill8&. 7 8 1. Department of Maternal Newborn Child and Adolescent Health and Ageing (MCA), World 9 Health Organization (WHO), Geneva, Switzerland 10 2. Department of Mental Health, Brain Health and Substance Use (MSD), World Health 11 Organization (WHO), Geneva, Switzerland 12 3. Centre for Global Mental Health, King's College London, London, United Kingdom 13 14 4. MOMENTUM Country and Global Leadership, Jhpiego, Washington, District of Columbia, 15 United States of America 16 5. Burnet Institute, Australia 17 6. Public Health and Preventive Medicine, Monash University, Melbourne Australia 18 19 7. Department of psychiatry and mental health, University of Cape Town, Cape Town, South Africa 20 8. Institute for Global Health, University College London, London, United Kingdom 21 22 #a current address: Avenue Appia, Geneva Switzerland 23 *Corresponding author: Francesca Palestra, [email protected] 24 FP is the senior author who wrote and conceived the paper 25 AM, NC and TTS are joint senior authors and supported in the process and development of the paper 26 & contributed equally to this work. for use under a CC0 license. This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted October 6, 2024. ; https://doi.org/10.1101/2024.10.04.24314919doi: medRxiv preprint NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice. OFFICIAL 27 Abstract 28 Perinatal mental health refers to the psychological wellbeing of women during pregnancy and up to one 29 year postpartum. Perinatal mental health conditions as depression significantly affect maternal, newborn 30 health, and child development worldwide. However, the absence of standardized indicators limits 31 effective monitoring and evaluation. This paper introduces a framework with indicators for global 32 perinatal mental health monitoring. 33 The framework development involved a scoping review, expert consultations, and stakeholder surveys. A 34 global expert group, guided by evidence and the World Health Organization (WHO), identified an initial 35 set of indicators. Two rounds of online surveys were conducted, allowing stakeholders to rank these 36 indicators and suggest additional ones. Indicators were chosen based on their validity, reliability, 37 relevance, feasibility, and potential impact for advocacy purposes on perinatal mental health. The WHO 38 expert working group finalized the set of indicators. 39 Six perinatal mental health indicators were identified for future testing. These include three primary 40 indicators: policy presence, screening coverage, and prevalence of perinatal mental health conditions. 41 Three secondary indicators cover mental health expenditure, healthcare professional training, and 42 provision of care. 43 Challenges to implementing standardized monitoring include resource limitations and data collection 44 methods. Strengthening health workers and facility capacity to measure, report, and interpret perinatal 45 mental health data, including the use of screening tools, is crucial. The integration of these indicators into 46 existing systems, such as health information management systems (HIMS) and national surveys, will be 47 key. 48 Monitoring perinatal mental health is essential for improving maternal and newborn outcomes. The 49 proposed framework offers a means to enhance global monitoring and guide policy interventions. Global 50 stakeholders are encouraged to integrate perinatal mental health into their policy, program, and 51 monitoring agendas. 52 53 Key words 54 Perinatal mental health, maternal health, newborn health, depression, mental health conditions, health 55 monitoring, indicators 56 for use under a CC0 license. This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted October 6, 2024. ; https://doi.org/10.1101/2024.10.04.24314919doi: medRxiv preprint OFFICIAL 57 Introduction 58 Perinatal mental health (PMH) is one of the most neglected issues in maternal health [1]. PMH refers to 59 the psychological wellbeing of individuals during pregnancy and up to one year postpartum [2]. This is 60 not to be confused with the perinatal period of a newborn which is seven days after birth [3]. 61 A variety of mental health conditions may be experienced during the perinatal period, including but not 62 limited to depression, anxiety, psychoses and alcohol and substance use [4, 5]. Perinatal mental health 63 conditions pose a significant burden globally, affecting millions of women each year. Globally it is 64 estimated that 10-20 % of pregnant women and those who just have given birth experience depression and 65 rates are highest in low- and middle-income countries [8, 9], Different cultural practices, poverty, biological 66 and social factors have been associated with influencing women’s vulnerability to perinatal mental health 67 conditions [10]. 68 Poor PMH not only has adverse effects on the woman's quality of life but also impacts the health 69 outcomes of newborns and children [11]. For example, perinatal depression has been linked to suicide and 70 adverse birth outcomes, such as preterm birth and low birth weight, as well as long-term developmental 71 and behavioral issues in children [12, 13]. Perinatal mental health is therefore crucial for the wellbeing of 72 women and their babies. 73 Despite the prevalence and impact of perinatal mental health conditions, there is a lack of standardized 74 indicators for global monitoring. No perinatal mental health indicators are currently tracked routinely 75 across countries in health information management systems (HIMS) or through standardized national 76 health surveys as Demographic and Health Surveys (DHS) or Multiple Indicator Cluster Surveys MICS). 77 Existing indicators, mainly from high-income countries, vary widely between countries and regions, 78 making it challenging to compare data and assess the effectiveness of interventions [14, 15, 16]. 79 Moreover, many indicators focus predominantly on the diagnosis and treatment of perinatal mental health 80 conditions (mainly postpartum depression) rather than on the services provided and the access of women 81 to those services, ensuring preventive measures and appropriate referral. There is also a need for more for use under a CC0 license. This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted October 6, 2024. ; https://doi.org/10.1101/2024.10.04.24314919doi: medRxiv preprint OFFICIAL 82 comprehensive and integrated approaches to perinatal mental health monitoring that address the 83 complexity of healthcare systems and policies across countries ensuring integration across levels of care 84 and within maternal, newborn and child health services [17]. Standardized indicators are essential for 85 assessing the burden of perinatal mental health conditions globally and should show progress to address 86 perinatal mental health issues, as well as guide policy and resource allocation. 87 88 Overview of the Global PMH Theory of Change and scoping review on PMH 89 indicators 90 A Global PMH Theory of Change (ToC) was published in 2022 [18] providing a strategic roadmap for 91 developing standardized indicators for perinatal mental health monitoring. It outlines the underlying 92 assumptions and pathways through which the proposed indicators are expected to bring about positive 93 changes in the monitoring and management of perinatal mental health conditions. By identifying key 94 inputs, activities, outputs, outcomes, and impacts, the ToC serves as a guide for understanding how the 95 proposed indicators can contribute to improved maternal and newborn health outcomes. The ToC is based 96 on a social ecological model where its domains are in order: individual, interpersonal relationship, 97 community, service delivery ecosystem and policy landscape. 98 Further a scoping review conducted in 2023 aimed to identify existing perinatal mental health indicators 99 used in monitoring systems worldwide [17]. The search in the scoping review was conducted in accordance 100 with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping 101 Reviews. After consultation with WHO it was decided to exclude indicators related to risk factors for PMH 102 or did not measure PMH directly. Additional indicators which measured mental health but were not specific 103 to the perinatal period were excluded, as these are well described in WHO Mental Health Atlas [19]. Results 104 were compiled and mapped to the relevant level in the Global PMH ToC. The review considered the 105 indicators which: (1) aligned with the Global PMH ToC and landscape analysis definition of perinatal for use under a CC0 license. This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted October 6, 2024. ; https://doi.org/10.1101/2024.10.04.24314919doi: medRxiv preprint OFFICIAL 106 mental health (during pregnancy and up to one year after childbirth); (2) had a definition, including how it 107 could be measured; and (3) was published from 1 January 2000 to 6 September 2023. 108 Nine indicators were identified which addressed individual (six indicators) and service-level (three 109 indicators) characteristics (Table 1). In order to be reflective of global differences in the feasibility and 110 availability of data to determine if indicators are met, stakeholder engagement in determining a final set 111 of indicators is needed. 112 Table 1. List of PMH indicators identified in the scoping review Theory of change domain Indicator Individual 1. Proportion of women with postpartum depression Individual 2. Proportion of women with depression in perinatal period Individual 3. Proportion of women with postpartum psychosis Individual 4. Proportion of women with adjustment and distress in perinatal period Individual 5. Proportion of women with PTSD in perinatal period Individual 6. Proportion of women with mental health conditions in perinatal period Service delivery ecosystem 7. Proportion of women screened for mental health conditions in perinatal period Service delivery ecosystem 8. Proportion of women with access to mental health services during the perinatal period for use under a CC0 license. This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted October 6, 2024. ; https://doi.org/10.1101/2024.10.04.24314919doi: medRxiv preprint OFFICIAL Service delivery ecosystem 9. Proportion of healthcare providers trained to provide mental healthcare in perinatal period 113 114 115 The purpose of this paper is to present the process for developing a set of primary and secondary 116 indicators for countries in monitor PMH, discuss challenges in implementation of screening methods and 117 training providers, and provide policy recommendations for integrating perinatal mental health indicators 118 into existing monitoring frameworks. 119 Methods 120 The development of a set of indicators for perinatal mental health involved a multi-stage process to ensure 121 robustness and inclusivity of all World Health Organization (WHO) regions. This was a four-phase 122 process (Table 2) guided by a WHO working group of experts and included online surveys based on the 123 identified indicators of the scoping review and in consultation with the WHO Mother and Newborn 124 Information for Tracking Outcomes and Results (MoNITOR) advisory group. This process brought to the 125 finalization of global indicators on PMH with primary and secondary indicators for further reflection and 126 adjustment. 127 Table 2. Phases to develop global PMH indicators Phase 1 Establishment of WHO experts group on PMH monitoring and discussion on identified indicators of the scoping review Phase 2 First survey with WHO experts group on PMH monitoring Phase 3: Second survey with WHO experts group on PMH monitoring and additional suggested stakeholders from global, regional and country level Phase 4: Consultation with WHO experts group on PMH monitoring and the WHO MoNITOR advisory group and development of global PMH indicators 128 for use under a CC0 license. This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted October 6, 2024. ; https://doi.org/10.1101/2024.10.04.24314919doi: medRxiv preprint OFFICIAL 129 130 In phase one, a WHO working group of experts, comprised of 21 experts in perinatal mental health and 131 monitoring and evaluation, from diverse regional backgrounds, was convened to provide guidance on 132 indicator selection. The role of the WHO working group included providing feedback on the scoping 133 review, on the list of proposed indicators and relevance in relation to the ToC; feedback and review on the 134 findings from surveys, and of the proposed indicators, including feasibility of implementation. 135 In phases two and three, two rounds of surveys were conducted through an anonymized online form, 136 among an international group of stakeholders, including healthcare professionals, researchers, 137 policymakers, and representatives from civil society organizations. In phase two with the first survey, 138 respondents were asked to select the top three PMH indicators for global monitoring from the list of nine 139 indicators identified through the previous scoping review [17] and to propose any additional indicators 140 used at the country-level which may be useful for global monitoring. During phase three the second 141 survey included a wider group of stakeholders invited to order the list of indicators, selected from the 142 previous survey, from the most to the least important indicator; and to propose additional ones if relevant. 143 After each round of survey, the WHO working group of experts had online consultations to provide 144 feedback on the findings. The specific questions of the two surveys are reported in S1 First and second 145 surveys. 146 147 The first survey was completed by 21 members of the WHO working group, resulting in a total of 17 148 answers out of 21 participants. The second survey was completed by 35 stakeholders part of a broader 149 group of experts involved more generally in maternal, newborn, child and adolescent health program 150 implementation, mental health programme and monitoring and evaluation from global, regional and 151 country levels. These stakeholders were identified through WHO regional offices and by the members of 152 the WHO expert committee. The second survey requested participants to In the second survey the first 153 question collected a total of 17 answers, while the second questions collected 8 answers. for use under a CC0 license. This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted October 6, 2024. ; https://doi.org/10.1101/2024.10.04.24314919doi: medRxiv preprint OFFICIAL 154 Phase four included consultation with the WHO experts group on PMH monitoring and the WHO 155 MoNITOR advisory group and development of global PMH indicators. Firstly, the feedback obtained 156 from these surveys was analysed and a list of proposed indicators was developed to ensure their relevance 157 and applicability across different settings. Later on, the WHO Mother and Newborn Information for 158 Tracking Outcomes and Results (MoNITOR) advisory group and the WHO experts group on PMH 159 monitoring, shared overall guidance and inputs on the results collected from the two surveys, which 160 further informed the development process. 161 Inclusion and exclusion criteria were established to ensure the selection of indicators that met predefined 162 quality standards and objectives. Indicators were included if they demonstrated validity, reliability, 163 feasibility and potential impact for advocacy purposes. They also needed to be relevant to the assessment 164 of perinatal mental health conditions and be able to measure progress towards improving maternal and 165 newborn health outcomes for global monitoring purposes. Indicators were excluded if they lacked 166 empirical evidence, were risk-related to develop PMH conditions or were overly complex or resource- 167 intensive or were specific to a particular context and not generalizable to a broader population. 168 169 This work is based on the review of the literature and expert opinion, including WHO’s technical 170 advisory groups on monitoring and measurement, and it is not original research. Therefore, we did not 171 seek approval from the WHO ERC for ethical clearance. 172 We obtained written consent from members of the WHO expert group, following WHO protocols for 173 expert group participation, which include declarations of interest and confidentiality agreements. The 174 consent forms are securely stored on WHO servers, protected by a password. The WHO expert group has 175 been involved in this activity on the prioritization of the PMH indicators from the 8th of December 2023 176 until the 25th of April 2024. 177 178 Results for use under a CC0 license. This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted October 6, 2024. ; https://doi.org/10.1101/2024.10.04.24314919doi: medRxiv preprint OFFICIAL 179 A summary of all steps in the selection of the indicators and results on the identification and prioritization 180 of indicators can be found in S2 Table. 181 Results from phase two (first survey) 182 A total of 17 out of 21 WHO Working Group members selected the top three PMH indicators for global 183 monitoring choosing from the nine indicators identified through the previous scoping review [17] (Table 184 3). 185 Table 3. The PMH indicators for global monitoring in order of relevance by stakeholders from the 186 first survey Theory of change domain Indicator Score Service delivery ecosystem 7. Proportion of women screened for mental health conditions in perinatal period 12 (70%) Service delivery ecosystem 8. Proportion of women with access to mental health services during the perinatal period 12 (70%) Service delivery ecosystem 9. Proportion of healthcare providers trained to provide mental healthcare in perinatal period 11 (64%) 187 188 Additionally, three more indicators have been suggested to be important for inclusion (although not 189 classified as top three) which are at individual level: 2. “Proportion of women with depression in perinatal 190 period”; 6. “Proportion of women with mental health conditions in perinatal period” and 1. “Proportion of 191 women with postpartum depression”. 192 Nine respondents proposed additional indicators used at the country-level potentially useful for global 193 monitoring: 194  Postnatal care (PNC) disaggregated for women and baby for use under a CC0 license. This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted October 6, 2024. ; https://doi.org/10.1101/2024.10.04.24314919doi: medRxiv preprint OFFICIAL 195  Early Childhood Development Index (ECDI) 196  System readiness indicators: 1. Presence of content on screening and counseling for maternal 197 mental health in relevant pre-service curricula (MCH nurses; Community Health Workers etc.); 2. 198 Antenatal care (ANC) and postnatal care (PNC) consultation /home visit guidelines including 199 PMH screening, counseling & follow up 200  Availability of PMH policy or included in national mental health policy 201  PMH included in WHO country annual work plan 202  PMH included in national health policy and other documents 203  Proportion of health budget (mental health budget) allocated to maternal mental health (I have not 204 used, but would be a useful indicator of high-level commitment at governance level) 205 206 Results from phase three (second survey) 207 The survey requested 35 participants to put in order from the most important to the least the priority PMH 208 indicators for global monitoring identified in the previous survey by the WHO working group of experts 209 and to propose any additional indicator. 210 17 stakeholders completed the survey and the most voted indicators have been listed in order of priority: 211 1. Proportion of women with access to mental health services during the perinatal period; 212 2. Proportion of women screened for mental health conditions in perinatal period 213 3. Proportion of healthcare providers trained to provide mental healthcare in perinatal period; 214 4. Proportion of women with mental health conditions in perinatal period; 215 5. Proportion of women with depression in perinatal period 216 6. Proportion of women with postpartum depression 217 Additionally, eight respondents suggested the inclusion of additional indicators such as: 218  Proportion of women with perinatal mental condition linked to psychosocial support OR mental 219 health services for use under a CC0 license. This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted October 6, 2024. ; https://doi.org/10.1101/2024.10.04.24314919doi: medRxiv preprint OFFICIAL 220  Proportion of health budget allocated to perinatal mental health 221  The proportion of women attending a first referral appointment for treatment of a mental health 222 condition 223  Women with anxiety during perinatal period and additional risk-related indicators for PMH 224 225 Results from phase four 226 Results consultations with WHO expert committee 227 Following analysis of both surveys results, the key recommendations by the WHO expert committee were 228 on the identification and prioritisation of indicators and on feasibility and implementation. These two 229 aspects will be described separately. 230 Identification and prioritisation of indicators 231 There was consensus from the WHO expert group to include the list of indicators below based on 232 prioritisation from stakeholders and likely feasibility: 233  To include indicators number 1. “Proportion of women with postpartum depression” and 2. 234 “Proportion of women with depression in perinatal period” , which are important although may 235 be difficult to measure initially. 236  To include indicator 6. “Proportion of women with mental health conditions in perinatal period”, 237 and to better describe the common mental health conditions in the metadata. 238  The committee also discussed the inclusion of indicator 7. “Proportion of women screened for 239 mental health conditions in perinatal period” versus the possible inclusion of an indicator which 240 measured the number of consultations on PMH through ANC and PNC services. It was decided to 241 include indicator 7 since will already provide more specific information with the use of validated 242 screening tools. Further, the WHO recommendations on maternal and newborn care for a positive 243 postnatal experience currently include PMH services for PNC [20] but not for ANC [21], 244 therefore different countries could have a different approach in providing PMH services. for use under a CC0 license. This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted October 6, 2024. ; https://doi.org/10.1101/2024.10.04.24314919doi: medRxiv preprint OFFICIAL 245  To include indicator 9. “Proportion of healthcare providers trained to provide mental healthcare in 246 perinatal period”. 247 Then a list the indicators that were excluded (and rationale): 248  To exclude indicator 8. “Proportion of women with access to mental health services during the 249 perinatal period”. This indicator was excluded because of the unclear definition of “access”, and 250 reliable measurement at a national level was considered less feasible. 251  To exclude an indicator which measures anxiety during pregnancy although this can contribute to 252 postpartum depression. The expert group acknowledged anxiety as an important issue in PMH 253 and a precursor to and as a risk factor for depression. Since we were specifically excluding 254 indicators of risk factors, this indicator has been excluded. 255 256 Additional new indicators that were added: 257  The WHO expert committee recognized the importance of having two indicators for advocacy 258 purposes on budget allocation and on existing national policies for PMH. If countries are unable 259 to identify the budget specifically for PMH, the budget allocated to mental health may be reported 260 instead 261  To group some indicators as health system indicators: budget, trained staff, etc... Suggested 262 grouping indicators by primary indicators to monitor from the start and additional secondary 263 indicators to monitor within a later timeframe. 264 Feasibility and implementation 265  To include the data source for each indicator to assist with prioritization. It was agreed to focus 266 on a few indicators, define their purpose, and use them to advocate for services. It was recognised 267 that PMH services may not be well defined, or even existent in many countries. for use under a CC0 license. This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted October 6, 2024. ; https://doi.org/10.1101/2024.10.04.24314919doi: medRxiv preprint OFFICIAL 268  To include recommendations consistently on screening tools to use for data collection, and where 269 to locate resources and services at national level. Although screening is not universal, each 270 country should have adopted a specific tool at national level. 271 272 Results from consultation with WHO MoNITOR advisory group 273 The consultation with WHO MoNITOR advisory group was focused on the feasibility and 274 implementation of the global PMH indicators. They identified the need to refine the indicators related to 275 perinatal mental health services, as well as the training and competencies required by healthcare providers 276 in order to offer mental healthcare services during the perinatal period. It was also deemed essential to 277 identify the specific mental health conditions that need to be measured and provide clear definitions for 278 these conditions. Additionally, there should be a specification of the screening tools approved by WHO, 279 along with the appropriate timeframe for their use. Clarification is needed on how and where to measure 280 these indicators, along with considerations for ethical practices in the measurement process. The inclusion 281 of referral processes and psychosocial support within the mental health services needs to be detailed. It is 282 important to harmonize WHO guidelines by including perinatal mental health recommendations in 283 guidelines on childbirth and antenatal care. 284 Given the variety of information to be collected and possible weaknesses in routine data collection 285 systems, indicators could be collected by different sources. Some of the indicators could be integrated 286 into HIMS or collected through national reporting (e.g. for indicators concerning existence of a national 287 PMH policy, government expenditure, health providers trained), while others may be more reliably 288 collected through national surveys like DHS or MICS or mental heath surveys (e.g. indicators on 289 population prevalence of perinatal depression). 290 There should be a clear outline of the key elements required in a national plan for perinatal mental health, 291 such as the tools to use, the planning period, training, and the types of services available. The risk of 292 underreporting must be acknowledged. The indicator on the proportion of women with postpartum for use under a CC0 license. This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted October 6, 2024. ; https://doi.org/10.1101/2024.10.04.24314919doi: medRxiv preprint OFFICIAL 293 depression should be retained, as postpartum conditions are among the most frequently diagnosed. 294 Finally, there should be specific screening for perinatal mental health conditions for women staying in the 295 hospital for their small and sick newborns in NICUs. 296 297 Indicators for perinatal mental health monitoring 298 Based on the consultations a list of primary indicators and a list of secondary indicators was created based 299 on capacity or quality data available (Table 4 and Table 5). Metadata providing more detailed 300 descriptions of each indicator is available in S3 File. 301 Table 4. Primary indicators for global monitoring Monitoring domain Indicator Numerator Denominator Current preferred data source Other data sources Output Proportion of countries with national policy /plan for perinatal mental health in SRMNCAH or in the mental health policy/strategy Number of countries with national policy for perinatal mental health in SRMNCAH policy/strategy or in the mental health policy/strategy Total number of countries Policy review or WHO Policy survey Proportion of women screened for mental health conditions in perinatal period 1 Number of women who were screened for mental health conditions in in perinatal period 1 Total number of women who gave birth within a given time period Household surveys RHISOutcome Proportion of women with depression in perinatal period1 Number of women identified with depression2 in the perinatal period1 Total number of women who gave birth within a given time period Household survey RHIS 302 for use under a CC0 license. This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted October 6, 2024. ; https://doi.org/10.1101/2024.10.04.24314919doi: medRxiv preprint OFFICIAL 303 Table 5. Secondary indicators for global monitoring Monitoring domain Indicator Numerator Denominator Current preferred data source Other data sources Proportion of government allocated expenditure to perinatal mental health Total government allocated expenditure to perinatal mental health Total government allocated expenditure on health3 Output Proportion of in-service health care providers trained to provide mental healthcare services4 in perinatal period Number of in-service health care providers trained to provide mental healthcare services in perinatal period Total number of in-service health care providers providing services in perinatal period Health facility assessment NHAs Outcome Proportion of women with perinatal mental health condition linked to psychosocial support OR mental health services Number of women with perinatal mental health condition linked to psychosocial support OR mental health services Total number of women with perinatal mental health condition Household survey RHIS 304 305 1 Perinatal period: during pregnancy and up to 1 year after pregnancy 306 2 Depression following consultation and use of available screening tool 307 3 Relatively crude indicator 308 4 Mental Healthcare services include a variety of interventions, and it is not limited to screening of mental health conditions. 309 Please refer to the WHO Guide for integration of perinatal mental health in maternal and child health services. Geneva: World 310 Health Organization; 2022. 311 312 The primary indicators proposed for perinatal mental health monitoring represent measures aimed at 313 capturing key aspects of maternal psychological wellbeing during pregnancy and up to one year for use under a CC0 license. This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted October 6, 2024. ; https://doi.org/10.1101/2024.10.04.24314919doi: medRxiv preprint OFFICIAL 314 postpartum. These indicators have been carefully selected based on their significance in assessing the 315 population prevalence, policy and health system plans related to perinatal mental health conditions. They 316 serve as foundational metrics for monitoring PMH conditions and policies aimed at improving maternal 317 and newborn health outcomes. Primary indicators include measures in individual and healthcare system 318 domains, such as the prevalence of antenatal and postnatal depression, rates of screening coverage for 319 perinatal mental health conditions in the perinatal period, and the proportion of countries with national 320 policy or plan for perinatal mental health. 321 322 In addition to the primary indicators, secondary indicators are proposed to guide future efforts and 323 advancements in perinatal mental health monitoring within a later timeframe. These secondary indicators 324 represent desired outcomes and areas for improvement that may require additional research, resources, 325 and policy initiatives to achieve. They encompass measures aimed at enhancing the comprehensiveness, 326 accuracy, and equity of perinatal mental health monitoring, as well as addressing emerging challenges and 327 priorities in the field. Secondary indicators include individual, health service delivery and healthcare 328 system domains, assessing the proportion of women receiving timely and appropriate treatment for 329 perinatal mental health conditions, the proportion of in-service health care providers trained to provide 330 mental healthcare services, and the budget expenditure allocated to improve this population issue. 331 By setting ambitious yet achievable goals for the future, secondary indicators pave the way for continued 332 progress and innovation in perinatal mental health monitoring and ultimately contribute to better 333 outcomes for women and newborns worldwide. 334 Discussion 335 The proposed global PMH indicators has significant implications for global monitoring efforts at global 336 and national levels. By establishing a standardized set of metrics, countries can systematically track and 337 compare the prevalence and outcomes of perinatal mental health conditions across regions and over time. 338 This allows for more accurate assessment of the burden of perinatal mental health disorders and for use under a CC0 license. This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted October 6, 2024. ; https://doi.org/10.1101/2024.10.04.24314919doi: medRxiv preprint OFFICIAL 339 identification of populations at greatest risk. Additionally, standardized indicators facilitate the evaluation 340 of interventions and policies aimed at improving maternal and newborn health outcomes, enabling 341 countries to identify effective strategies and allocate resources more efficiently. Moreover, by raising 342 awareness and prioritizing perinatal mental health on the global agenda, the proposed indicators can 343 catalyze action and advocacy to address this critical public health issue. The WHO expert committee’s 344 advised to choose indicators to reflect key dimensions of perinatal mental health including prevalence, 345 screening, policy and health system plans related to perinatal mental health. Priority was given to 346 indicators that were evidence-based, feasible to measure, and relevant to global monitoring efforts. 347 Consideration was also given to indicators that could be easily integrated into existing health information 348 systems and data collection tools as the ones used by hospital and households’ surveys to facilitate 349 implementation and sustainability. 350 351 Challenges in implementing standardized monitoring systems 352 The need to strengthen coordination and technical leadership to harmonize recommendations for 353 improved measurement and monitoring of data related to maternal and newborn heath has been 354 highlighted in previous publications [17, 18] and by the WHO MoNITOR Advisory group [22]. Despite 355 the potential benefits, implementing standardized monitoring systems for maternal and newborn health 356 and in this case for perinatal mental health specifically, poses several challenges. These include resource 357 constraints, particularly in low- and middle-income countries, where healthcare infrastructure, funding, 358 coverage and poor accessibility of PMH services may limit data collection. The integration of PMH into 359 maternal and newborn health services including validated screening and diagnostic tools would be 360 essential in the implementation of a monitoring system [23]. 361 There are also technical challenges related to data collection, reporting mechanisms, the quality of data, 362 and interoperability of health information systems which hamper disparities in monitoring efforts between 363 high-income and low-income countries [24]. The national routine health information system is essential for use under a CC0 license. This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted October 6, 2024. ; https://doi.org/10.1101/2024.10.04.24314919doi: medRxiv preprint OFFICIAL 364 for decision-making, providing regular data on delivery and utilization of services and can be used for 365 program planning and track progress towards national and subnational targets [25]. In an effort to include 366 new indicators as the ones proposed in this paper, it is important to consider the use of household and 367 health facility survey. Household surveys are the primary source of coverage data for LMICs [26], 368 however not all interventions suggested by this framework can feasibly be tracked using this method. 369 Linking household and facility surveys would improve the coverage measurement, linking care-seeking 370 data from household surveys with service provision data from health facility assessments provides a 371 unique opportunity to produce measures of population coverage that account for service quality [27]. 372 These indicators offer the opportunity to be integrated into the next version of DHS or MICS. 373 Additionally, cultural and contextual factors may influence the acceptability and uptake of standardized 374 monitoring protocols, requiring tailored approaches to implementation. Addressing these gaps is essential 375 for improving the accuracy, comprehensiveness, and equity of perinatal mental health monitoring 376 worldwide and requires sustained commitment from governments, healthcare providers, and international 377 partners, as well as investment in capacity building and health system strengthening. Starting with 378 primary indicators to then expand to secondary indicators would enable each national system to build 379 capacity and advocate for an improved monitoring system in this area. 380 381 Opportunities for collaboration and capacity building for healthcare 382 workers 383 Collaboration and capacity building are essential for the successful implementation of standardized 384 monitoring systems for perinatal mental health. Multisectoral collaboration involving government 385 agencies, healthcare providers, academia, civil society organizations, and international partners can 386 leverage expertise and resources to support monitoring efforts [28]. Capacity building initiatives, 387 including task sharing and group problem solving therapy can empower health workers and users with the 388 knowledge and skills needed to respond, screen, diagnose, treat or refer to another specialist, perinatal for use under a CC0 license. This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted October 6, 2024. ; https://doi.org/10.1101/2024.10.04.24314919doi: medRxiv preprint OFFICIAL 389 mental health conditions effectively [29, 30]. This includes training on culturally sensitive approaches to 390 care, evidence-based interventions, and integration of mental health services into routine antenatal and 391 postnatal care [23]. By fostering collaboration and investing in capacity building, countries can strengthen 392 their healthcare systems and improve outcomes for women and newborns. 393 394 Policy recommendations for integrating perinatal mental health 395 indicators into existing monitoring frameworks 396 Integrating perinatal mental health indicators into existing monitoring frameworks requires policy 397 support and coordination at the national and international levels. Policymakers should integrate primary 398 and secondary PMH indicators into existing health information systems and monitoring frameworks for 399 maternal and newborn health, ensuring data on maternal psychological wellbeing are routinely collected 400 and reported. Additionally, policies should prioritize funding for mental health services and workforce 401 development, ensuring that healthcare providers have the resources and support needed to address 402 perinatal mental health effectively [31]. Finally, policies should promote collaboration across sectors and 403 encourage the adoption of evidence-based practices to improve perinatal mental health outcomes. By 404 incorporating perinatal mental health indicators into existing monitoring frameworks. Countries can 405 enhance their capacity to address this critical public health issue and achieve better outcomes for women 406 and newborns. 407 The proposed global indicators for perinatal mental health encompass a range of measures aimed at 408 capturing key aspects of maternal psychological wellbeing during pregnancy and the postpartum period. 409 By tracking these indicators, we can better understand the burden of perinatal mental health conditions, 410 identify gaps in care, and assess the effectiveness of interventions. Ultimately, these indicators have the 411 potential to improve maternal and newborn health outcomes by informing policy and practice and guiding 412 resource allocation to areas of greatest need. Additionally, pilot testing of these global PMH indicators to 413 finalize a PMH monitoring framework in different settings is needed to help identify any practical for use under a CC0 license. This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted October 6, 2024. ; https://doi.org/10.1101/2024.10.04.24314919doi: medRxiv preprint OFFICIAL 414 challenges or limitations, conduct data validation, and allow for further refinement and optimization 415 before full-scale implementation. 416 Conclusion 417 Given the significant impact of perinatal mental health on maternal and newborn health outcomes, there is 418 an urgent need for global stakeholders to prioritize the provision and monitoring of perinatal mental 419 health care. This includes governments, international organizations, healthcare providers, researchers, and 420 civil society organizations. Global stakeholders are called upon to pilot the global PMH indicators into 421 existing monitoring frameworks and programs, allocating resources for mental health services, and 422 promoting collaboration and capacity building among healthcare workers. By working together to address 423 perinatal mental health, we can ensure that all women receive the support and care they need to thrive 424 during pregnancy and the postnatal period, ultimately leading to better outcomes for both women and 425 newborns. 426 427 Acknowledgements 428 We acknowledge the kind contribution of each member of the WHO expert group on PMH monitoring 429 and the WHO MoNITOR advisory group. 430 431 References 432 1. The Lancet. Perinatal depression: a neglected aspect of maternal health. Lancet. 2023;402(10403):667 433 2. World Organization WH. 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