Introduction

Perinatal mental health (PMH) disorders are among the most common morbidities of the perinatal period [1, 2]. The perinatal period represents a unique time in a woman’s life when there are significant physical and social changes [3]. During this time, women are at higher risk of new onset of mental health disorders, or recurrence of pre-existing mental health conditions [4, 5]. PMH disorders are associated with morbidity and mortality [4]. In women, they are associated with increased obstetric complications, reduced quality of life, substance use, and suicide [6–8]. They increase the likelihood of women experiencing poverty, physical health complications and intimate partner violence [8]. Further to this, PMH disorders can increase the risk of preterm birth, and poor fetal and infant growth and may impact the mother-infant bond [9, 10]. In children, caregiver PMH disorders can lead to poor neurodevelopmental outcomes and an increased risk of mental health disorders in adolescence [11, 12]. At the societal level, PMH disorders add a significant social and economic burden [4]. Globally, it is estimated that the prevalence of PMH disorders is 10–20% [10, 13], however, the majority of research has been performed in high-income countries [HIC], and rates are thought to be increased in low- and middle-income countries (LMIC) [11, 14].

The past two decades have seen a growing focus on the importance of PMH, however there are currently no global indicators that can measure the status or progress towards universal access to high-quality PMH care [10, 15, 16]. The prevention, identification, and treatment of women with PMH disorders is now included in multiple World Health Organization [WHO] guidelines for maternal and child health [16–18]. The Sustainable Development Goals also include the promotion of maternal mental health [19]. However, there is significant variation in policy, guidelines, service availability, screening tools, and implementation approaches worldwide [4, 9].

Indicators are instruments with the objectives of improving population health and reducing inequalities, and are a vital means of informing decision-making [20]. A monitoring framework with key indicators would enable consistent measurement of the status of PMH globally. It would inform actions aimed at improving the prevention, care, and treatment of PMH disorders, and facilitate monitoring and evaluation of progress towards specified targets. Therefore, the aim of this review is to identify existing PMH indicators published in the literature and create a core set of indicators to inform future development of a monitoring framework which can be used to measure PMH globally.

Methods

A protocol including the scope and aims of this research as well as all subsequent findings was reviewed and refined in consultation with: WHO Department of Maternal, Newborn, Child, Adolescent Health and Ageing; WHO Mother and Newborn Information Tracking Outcomes and Results (MoNITOR) group; WHO Department of Mental Health and Substance Use; and members from the USAID MOMENTUM Country and Global Leadership PMH Community of Practice (S1 Appendix). Findings were reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist (S1 Table) [21].

Data extraction and analysis

Indicators were extracted individually from each resource. All available indicator data such as: indicator name, definition, numerator, denominator, and data source were compiled (S3 Table). Indicators with similar definitions were grouped together. Where it was determined that the indicators measured the same outcome, we proposed an indicator definition by combining them. (Table 1). The indicators in this core list were then mapped to the relevant level in the PMH ToC. The quality of each indicator was outside the scope of this review and hence was not assessed.

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Table 1. Core list of indicators mapped against PMH ToC.

https://doi.org/10.1371/journal.pone.0317998.t001

Results

A total of 5808 resources from three databases were retrieved (Fig 1). An additional 12 resources from other sources including government websites and international agency websites were also retrieved. After duplicates were removed 4082 records were screened at the title/abstract stage and 109 at full text. Overall, 2 studies could not be retrieved and 91 were excluded at full text screening, resulting in 18 resources for inclusion.

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Fig 1. PRISMA flow diagram.

https://doi.org/10.1371/journal.pone.0317998.g001

From the 18 resources which were included, 25 indicators which measured PMH were extracted (S3 Table). Of these, 15 studies came from the database search of peer reviewed material with 17 indicators extracted. The grey literature search of webpages found the additional three resources, with eight indicators extracted. These sources were all from governmental websites (United Kingdom (UK) (n = 6), Australia (n = 1) and the United States of America (U.S.) (n = 1)]. There were no indicators found relating to PMH through searching the webpages of WHO, OECD, MICS or DHS [15, 26–28]. Of the 18 resources, 16 were from HICs (USA, UK, Australia, Ireland, Netherlands and Belgium]) and two were from LMICs (Mexico and Kenya).

The process of compiling indicators resulted in nine core indicators (Table 1). The proposed indicators were mapped to the PMH ToC, with six relating to individual measures of PMH, and three relating to measures of the PMH service delivery ecosystem.

Discussion

The aim this scoping review was to identify existing perinatal mental health indicators and propose a core set which could be used at a global level. We found 25 indicators for PMH aligned with the PMH ToC, which were condensed to form a core set of nine indicators. This set of indicators can contribute to the development of a monitoring framework which if implemented can measure countries’ progress towards widely accessible, high-quality provision of PMH care services.

We used the PMH ToC as the conceptual framework. Of the five domains of the ToC, we found PMH specific indicators for only two—individual and service delivery ecosystem. Broadly speaking, the included indicators in the individual domain aim to measure the prevalence of PMH disorders, while those identified in the service delivery ecosystem domain aim to measure service provision and quality. We were unable to identify any PMH specific indicators across the other three domains. Hence, many areas recognised as central to improving PMH may be without existing indicators. These, for example, include things such as understanding socio-cultural norms [9], community engagement with PMH promotion [10], the availability of treatment options; counselling and psychotherapy, accessibility of psychotropic medications and availability of inpatient care if required [4, 47], and policies that address PMH [48].

Of the 25 indicators identified for PMH, only two were from papers from an LMIC [Kenya and Mexico], with the rest from high-income countries. Therefore, the majority of the indicators may not be applicable to LMICs. This has also been highlighted in the pilot study by Al-Shammari et al. [35] in Kenya which used the International Consortium of Health Outcomes Measurement developed in the UK, which includes an indicator for postpartum depression. They found significant gaps in the mental health knowledge of their healthcare staff, which required specific training to implement the resource. They also found no women reporting a prior diagnosis of a PMH disorder despite many reporting symptoms [35]. This highlights the importance of global indicators being universally valid.

The WHO recommends that PMH care be integrated into existing maternal and child health services [18]. Whilst this is an important step in improving accessibility of PMH care, additional steps are necessary in advancing towards the goal of universal high-quality PMH care for all perinatal women. A cornerstone of indicator implementation involves the ability of health systems and data collection platforms to monitor progress. Currently, however, there are significant limitations to implementing a core set of PMH indicators as required data is not routinely captured in many countries around the world. A further important step is the alignment of all relevant guidelines to include PMH, this would include updating the WHO recommendations on antenatal care for a positive pregnancy experience to include PMH.

This scoping review has several limitations. The indicator data available was heterogenous and often incomplete. For example, many resources had indicators with incomplete definitions, or excluded the numerator, denominator, or possible data source. The definitions of each indicator also varied across sources, with differing use of terminologies when describing mental health disorders. An inability to populate all indicators and generalisation of some definitions to form a universal set of indicators may limit the feasibility of implementation. The scope of this research also excluded risk factors and social determinants for PMH, which may have addressed gaps in measurement for the other PMH ToC domains. The grey search of existing indicator databases and webpages was in English only, which could have led to an exclusion of indicators from LMICs. However, a lack of PMH indictors in both LMICs and HICs was well-recognised by experts consulted during this review, highlighting the urgent need for further research in this area. We also imposed a time limit on the papers selected (from January 2000). We felt that the last 24 years was an adequate time frame to include contemporary studies, but it is possible that we omitted studies published before this time.

Conclusion

The identified PMH indicators in this review provide an account of the current landscape of PMH measurement globally and is the first step in the development of a monitoring framework by the WHO to be used by countries to monitor progress and make programme adjustments. Future research would include the development of new indicators which address the gaps in the PMH ToC interpersonal relationship, community, and policy landscape domains. The development and adaptation of indicators in LMICs would also be vital for future implementation in these settings. Important next steps in this work include further consultation with stakeholders to prioritise and operationalise a core set of agreed indicators, and technical assessment of data sources to determine the feasibility of implementing the indicator set.

This review forms part of the foundational work for the development of a global monitoring framework which will monitor progress towards the provision of universal high quality PMH care. This has implications at a country and global level for the measurement and monitoring of PMH, an important component of the Sustainable Development Goals.

Supporting information

Acknowledgments

We would like to thank the following groups for their feedback and input during the consultation process of this review:

WHO Department of Maternal, Newborn, Child, Adolescent Health and Ageing.

WHO Mother and Newborn Information Tracking Outcomes and Results group.

WHO Department of Mental Health and Substance Use.

USAID MOMENTUM Perinatal Mental Health Community of Practice members.