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Poor perinatal mental health (PMH) affects 13-30% of women globally, with higher rates in low- and middle-income countries. Biological, socioeconomic, and sociocultural factors, as well as gender inequalities, increase the risk of poor PMH, especially for marginalized groups like non-binary people, trans men, and women with disabilities. Poor PMH has severe consequences for both mothers and infants, including increased risk of maternal mortality, obstetric complications, self-harm, and adverse infant outcomes.

Addressing PMH is crucial for improving maternal and child health, reducing poverty, and strengthening societies. USAID is committed to optimizing PMH through evidence-based interventions, addressing systemic barriers, and fostering collaboration with diverse stakeholders. This collective effort can improve maternal and child health, reduce maternal mortality, and break the cycle of intergenerational trauma associated with poor mental health.

This concise review provides a quick overview of the manual titled, “Guide for Integration of Perinatal Mental Health in Maternal and Child Health Services.” The authors highlight the key features of the manual and its effectiveness in delivering on its intended purpose.

Highlights

• Breakdown of the layout of the manual and what each chapter includes
• Exploration of the strengths and limitations of the manual
• Suggestions for further inclusion

How to Use

Stakeholders should use this review to provide greater context when referencing the manual.

Summary

Mental health and psychosocial support (MHPSS) during the perinatal period is a global issue. This period is characterized by high risk of depression, anxiety, and somatic disorders – often referred to as common perinatal mental disorders (CPMDs) with one in six pregnant women and one in five postpartum women impacted by a mental health and psychosocial concern during pregnancy or in the first postnatal year.

Highlights

In humanitarian settings, these risks are often amplified by adversity and destabilizing factors including political instability, violence, loss, poverty, and migration. While MHPSS needs occur throughout the life course, the focus of this brief will be the perinatal period, as during this time, these illnesses can have severe, and even intergenerational effects, on maternal and newborn health (MNH) and development. The perinatal period is also a critical time when women are more frequently interfacing with health staff, allowing for more timely identification of mental health and psychosocial concerns and referral for appropriate support.

How to Use

Collaborating for Maternal Mental Wellbeing: Technical Brief on Perinatal Mental Health in Humanitarian Settings from the IAWG Maternal and Newborn Health Sub Working Group aims to provide an overview of MHPSS perinatal mental health in emergency response, present relevant resources, suggestions for improving collaboration and provision of perinatal mental health, examples of service delivery collaboration, and culminate with a call to action to progress momentum for peri­natal mental health.

This global perinatal mental health (PMH) Theory of Change offers a common framework that can guide global PMH thinking, investments, and programming to improve countries’ progress towards widely accessible, high-quality provision of PMH care services. The co-creation of these guiding documents was a critical step in fostering a global community working collaboratively towards a shared vision of better PMH globally.

Highlights

• The PMH theory of change (ToC) is anchored in the social ecological model with the individual woman at the center and the added impact of her family, community, the service delivery ecosystem, and society at large as further levels of influence.
• The PMH ToC offers illustrative evidence-based interventions at the individual, interpersonal relationships, community, service delivery ecosystem, and policy ecosystems levels, linked to outputs, and a shared impact goal of “Improved PMH and wellbeing through promotion, prevention, early identification, care, and treatment, resulting in better health outcomes for all women, children, and families.”
• The package also offers key considerations in planning PMH interventions, such as ensuring that PMH interventions or integrated into existing care platforms, and that key social determinants are fundamental and intersect with every aspect of the ToC.
• The package also includes a prioritized set of PMH implementation research questions to support alignment of PMH research agendas.

Common perinatal mental disorders are the most frequent complications of pregnancy, childbirth and the postpartum period, and the prevalence among women in low- and middle-income countries is the highest at nearly 20%. Women are the cornerstone of a healthy and prosperous society and until their mental health is taken as seriously as their physical wellbeing, we will not improve maternal mortality, morbidity and the ability of women to thrive. On the heels of several international efforts to put perinatal mental health on the global agenda, we propose seven urgent actions that the international community, governments, health systems, academia, civil society, and individuals should take to ensure that women everywhere have access to high-quality, respectful care for both their physical and mental wellbeing. Addressing perinatal mental health promotion, prevention, early intervention and treatment of common perinatal mental disorders must be a global priority.

On March 30, 2022, the World Health Organization released guidance on maternal and newborn care for a positive postnatal experience. A total of 63 recommendations on maternal care, newborn care, health systems, and health promotion address individual patient care and service delivery.

The new guidelines respond to global trends in maternal-newborn morbidity and mortality. As death rates drop globally, the new guidelines place great emphasis on thinking beyond survival, and continue to provide guidance on essential interventions to continue reductions in maternal and newborn mortality.

Here is what’s new:

• The importance of family-centered care | The new guidelines address the importance of the home and whole family in the health of the mother-baby dyad, including specific guidelines for the inclusion of men in care plans, the use of home-based medical records, and assessment of the home environment prior to discharge.
• Increased focus on maternal well-being | Moving beyond survival for the mother, the new guidelines address maternal mental health and comfort, including specific guidelines for pain control following delivery, and universal screening and intervention for depression and anxiety.
• Thinking beyond survival for the newborn | Interventions during the hours, days, and weeks following birth can have long-lasting impact on the health and well-being of children. The new guidelines specifically address responsive care, early infant development, safe sleep, and screening for hearing and eye abnormalities.
• Tackling health system and workforce challenges | The new guidelines recommend several strategies for increasing the size and quality of the healthcare workforce needed for a positive postnatal experience, including specific recommendations about mobilizing a greater diversity of health workers, establishing midwife-led continuity of care models, and using digital tools to improve birth registration and health behaviors in the home. The new guidelines also recommend integration of complementary maternal-newborn services when possible (maternal mental health and early infant development) and routine screening and prevention of infectious diseases (de-worming, TB, HIV screening).

A summary of USAID’s MOMENTUM Maternal Mental Health Technical Consultation and the way forward supporting the mental health of mothers in humanitarian and fragile settings.

This action plan was adopted in 2013 at the sixty-sixth World Health Assembly. In 2019, the plan was extended until 2030. It provides guidance for national action plans and addresses prevention and promotion strategies for all resource settings to promote mental health and well-being for all, prevent mental health conditions for those at-risk, provide care, enhance recovery, promote human rights, and reduce mortality, morbidity and disability for persons with mental disorders.

Objectives include:

1. More effective leadership and governance for mental health
2. The provision of comprehensive, integrated mental health and social care services in community-based settings
3. Implementation of strategies for promotion and prevention
4. Strengthened information systems, evidence, and research 

The “Giving Voice to the Silent Burden: Maternal Mental Health Technical Consultation”, conducted in September 2021 and hosted by USAID’s MOMENTUM Country and Global Leadership (MCGL), in collaboration with the World Health Organization and United Nations Population Fund, was a pivotal three-day convening that brought together members of the maternal, newborn, child health, nutrition, humanitarian and fragile settings, and mental health communities to collaborate and inform the path forward for maternal mental health to ensure that pregnant and postpartum women, and their families, receive the respectful and nurturing care they need and deserve. Key discussions included an overview of the global burden of CPMDs and current evidence on effective interventions, country experiences introducing and scaling up maternal mental health programs, integrating mental health care into existing service delivery platforms, strengthening provider capacity to deliver maternal mental health care, and the role of community, civil society, and faith organizations in supporting mental health.

Landscape Analysis Brief

This landscape analysis brief, published in October 2021 and developed by USAID’s MOMENTUM Country and Global Leadership (MCGL), describes the current state of perinatal mental health and the burden of common perinatal mental disorders for women, newborns, and families in low- and middle-income countries (LMICs). To date, mental health has lacked proper attention in the health sector in terms of funding and action. The perinatal period is associated with an elevated risk of mental health conditions – women with a history of a major postnatal depression had a 25% risk of a recurrence in a subsequent pregnancy,[4] and postnatal depression is a major risk factor for maternal death by suicide, accounting for 20% of mortality in the year after childbirth. [5] Perinatal mental health conditions have also been associated with adverse physical, emotional, and neurological development in newborns and children. [6] Studies from LMICs found that depressed mothers had a higher risk of preterm births and low-birthweight babies. [6] The presence of CPMDs in mothers also appears to increase the risk of stunting and wasting in children. [7] There also appears to be an association between CPMDs and the extent to which mothers seek immunization services or care for ill children. [8]

Key Findings

• Mental health remains underfunded and often ignored in the face of more visible physical health concerns. The global treatment gap for mental health disorders is estimated at nearly 90%.[1]
• CPMDs pose significant and lasting implications for women’s health and quality of life, and have been associated with adverse development in newborns and children.[2]
• Perinatal mental health needs to be better integrated across multiple health sectors and sectors outside of health, away from centralized institutions to the primary care and community level, and into health care provider education and practice.
• Future research should include findings from different contexts, avoid inappropriate generalization, generate more evidence for vulnerable populations, expand beyond postnatal depression, center on the expressed desires of women, and explore integrated approaches that improve both women’s and children’s health at scale.

The following sessions from the technical consultation highlighted select key and emerging evidence. Note that to view all consultation session recordings, including those listed here, you must register.

Highlighted Sessions

• Common Perinatal Mental Disorders: Current Evidence and Gaps. This panel discussion covered what evidence exists, and what we know works, from various perspectives, and identified areas for further research or implementation learning.

• We need to understand the many context-specific factors, including gender and family dynamics, social pressures, and localized knowledge and conceptualizations of mental health, that impact perinatal mental health.
• Measurement tools have been developed and validated in higher income settings, and the language used may not translate appropriately into other contexts.
• Targeted, low-intensity interventions delivered by non-specialists (supported by training and effective supportive supervisory systems) at the public health care level can reduce the treatment gap in LMICs.

• Evidence and Gaps for Women in Fragile and Crisis-Affected Contexts. In this session, speakers reviewed current evidence and reflected on gaps in approaches for addressing CPMDs in fragile and crisis-affected settings, including for displaced populations and those living in areas affected by conflict and complex emergencies. Participants and panelists explored how needs and service delivery platforms may vary across different types of settings and discussed priorities for strengthening maternal mental health programming.
  • Local terms for mental health conditions vary from country to country. We must understand local terms and engage local people to help, to provide effective treatment.
  • Sequential care, or treatment for one issue at a time, is problematic because many people are coping with multiple mental health-related issues. The Common Elements Treatment Approach treats conditions simultaneously and customizes the response by using different solutions for each condition a person may have.
  • Greater investment is needed in lay people who come from the communities they serve, and who are trained to respond to mental health issues, to sustain services.

• Overlapping Risks: Evidence and Gaps for Vulnerable Populations. This session reviewed the current state of evidence around perinatal mental health for vulnerable populations such as adolescents, women experiencing gender-based violence (GBV), minority populations and women living with HIV. Speakers discussed global initiatives, contextualized programming, and outstanding knowledge and program gaps. They drew lessons from diverse vulnerable populations and identified areas that must be addressed to better include and support these vulnerable women and girls.
  • Use youth as navigators and consider them key development partners to co-design mental health programs and contextualized approaches. Greater involvement of adolescents in program decision-making yields better results.
  • A research study in Ethiopia found significant marginalization exists among migrant workers, which have led to high levels of depression associated with violence and social isolation.
  • A research study on perinatal mental health in rural Rajasthan, found that women with co-morbidities, women experiencing IPV, and women from low-income families are vulnerable to poor well-being outcomes. In addition, there is a need for an integrated interventions that deal with mental health, GBV, and suicidal ideation.
  • There is a strong need to integrate men and boys, and the community, into mental health programs to ensure they are equal partners in improving women’s mental health.

• Interventions Addressing CPMDs through the Continuum of Perinatal Care: Evidence and Gaps. This session presented evidence from a variety of interventions in one South Asian, one Southeast Asian and two African countries, that address the needs of women during and after pregnancy. Speakers touched on when and how women were screened for CPMDs, linkages with appropriate care, post-intervention follow up, and intervention outcomes. Speakers discussed care provided at community and facility levels by trained community health workers, peer counselors, and nurses/midwives.
  • Mental health programs have historically been siloed and difficult to scale. Systems-wide change is needed.
  • Support systems are critical for maternal mental health interventions. Community health workers, midwives, and other healthcare workers need support systems to effectively task shift and scale programs for their own mental health.
  • Maternal mental health requires significant advocacy to reduce shame and stigma, for policy-change and scale-up, and for resource mobilization and financing.

Introduction Mistreatment of women during childbirth is increasingly recognised as a significant issue globally. Research and programmatic efforts targeting this phenomenon have been limited by a lack of validated measurement tools. This study aimed to develop a set of concise, valid and reliable multidimensional measures for mistreatment using labour observations applicable across multiple settings.

Methods Data from continuous labour observations of 1974 women in Nigeria (n=407), Ghana (n=912) and Guinea (n=655) were used from the cross-sectional WHO’s multicountry study ‘How women are treated during facility-based childbirth’ (2016–2018). Exploratory factor analysis was conducted to develop a scale measuring interpersonal abuse. Two indexes were developed through a modified Organisation for Economic Co-operation and Development approach for generating composite indexes. Measures were evaluated for performance, validity and internal reliability.

About the Series

The Self-Care Learning and Discovery Series, held June 24-August 27, 2021 was a highly interactive, virtual forum where participants exchanged and incubated ideas, experiences, and solutions on a variety of self-care topics. Hosted by White Ribbon Alliance (WRA) on behalf of the Self-Care Trailblazer Group (SCTG), the Self-Care Learning and Discovery Series presented new knowledge, elevated self-care solutions, forged connections across issues and geographies, and much more! The series was open to all interested self-care stakeholders, including advocates, health providers, government representatives, implementers, journalists, community leaders, academia, product developers, feminists, youth champions, and more. There was no fee to participate.  

Sessions

The Self-Care Learning and Discovery Series included 16 virtual sessions, organized by diverse partners from around the world, that explored a different self-care topic. Each session featured examples and discussions of self-care evidence, advocacy, and practice through interactive panels, participatory dialogues, and more. All sessions are available in English, French, and Spanish and include English closed captioning. 

Please continue to visit the Self-Care Learning and Discovery Series platform to access self-care session recordings and resources that can be easily downloaded and shared at no cost.