Developing a Perinatal Mental Health Indicator in England (PMHI)
Ron Gray (NPEU (Former member))
Emily Savage-McGlynn (NPEU (Former member))
Mental health and wellbeing
Department of Health
In January 2013, the Policy Research Unit in Maternal Health and Care (PRU-MHC) at the National Perinatal Epidemiology Unit (NPEU) was commissioned, as part of the 2011-2016 programme of work, to undertake the development of a perinatal mental health indicator for England.
The intention was that the indicator would be considered for inclusion in the Public Health Outcomes Framework (PHOF), the National Health Service Outcomes Framework (NHSOF), and potentially the Clinical Commissioning Group Outcomes Framework (CCGOF).
What is a perinatal mental health indicator?
A perinatal mental health indicator is a concise measure that describes as much about an aspect of the performance of maternity, postnatal care and perinatal mental health services in as few points as possible.
The perinatal period in these terms is considered as the period of time through pregnancy, childbirth, and up to one year postnatal.
This has been operationalised as 40 weeks before the date of birth, to 52 weeks after the date of birth.
The main purpose of an indicator is to assist with:
making comparisons between different trusts, commissioning authorities and local authorities
monitoring change in a service over time
with a view to identifying good practice and where service improvements are required.
The goal is to assess and monitor whether maternity and postnatal care services are identifying women with perinatal mental illness, offering appropriate and accessible services, and achieving outcomes acceptable to women and clinicians.
The role of the Policy Research Unit in Maternal Health and Care was to develop potential indicators and apply for their inclusion in the Outcome frameworks but as a research organisation the Policy Research Unit in Maternal Health and Care did not have a role in securing their inclusion.
Given the uncertainty on whether a particular indicator would or would not be adopted, the project team decided early on to develop a number of potential indicators rather than a single indicator for consideration.
Hence we often refer to an “indicator set” rather than a specific indicator.
Purpose of the indicator set
The overarching purpose of the indicator set is: to ensure that maternity and postnatal care services are identifying women with perinatal mental health problems, offering appropriate and accessible mental health services and achieving outcomes acceptable to women and clinicians which minimises potential harms to the woman, her family and the development of her child.
Potential Data Sources
Potential data sources were identified for use in the construction of the indicator:
Hospital admission records;
Admissions to specialist mother-baby units;
Health visiting data;
Scores on screening measures;
Referrals to counselling during perinatal period;
National Maternity Data Set (NMDS)
Child Health Data Set
IAPT (Improved Access to Psychological Therapies) Data Set
MHMDS (Mental Health Minimum Dataset)
HES (Hospital Episode Statistics)
However, early on in the project it became clear that a number of these data sources were not suitable for us in the indicator construction.
This was due primarily to the lack of data completion in routinely collected datasets and the specificity of data available.
In order to overcome the lack of data points in some of the target datasets, a data linkage was requested.
Maternity identifiers from the HES Dataset were linked with key data points in the IAPT and MHMDS datasets to provide us with the information required to develop some of the indicators.
We also considered, but quickly ruled out, data available from national surveys such as the CQC Maternity Surveys and data collected at a local level.
The former were ruled out because of the low response rate to postal questionnaires, and hence, the unrepresentative nature of the samples of respondents; the latter because the data would not necessarily be available on a national basis.
The indicators which the Policy Research Unit in Maternal Health and Care (in conjunction with the advisory group) suggested be taken forward are outlined in Table 1.
Table 1: Perinatal Mental Health Indicators for further consideration
Apex Indicator The questions for this indicator require translation into Snomed CT terminology before submission to NHS Digital for potential inclusion in the new Community dataset.
This requires permission from NHS England
While you were pregnant or since your baby was born, did you experience any problems with your emotional or mental health or have a period of feeling low?
What help did you get with this?
What further help would you have wanted?
Contact with mental health professional during perinatal period
Number of women seen during the perinatal period by a mental health professional (psychiatric services) per number of maternities with a birth in 2013/14, numbers and percentages, England, Clinical Commissioning Groups (CCGs)
Attended contact with IAPT during perinatal period
Number of maternities that had any attended contact with IAPT services during the perinatal period, as a proportion of all maternities with a birth in 2013/14, numbers and percentages, England, Clinical Commissioning Groups (CCGs), and Maternity Units.
Number of IAPT referrals showing reliable improvement as a proportion of all maternities with a birth in 2013/14 having completed a course of IAPT treatment, numbers and percentages, England, Clinical Commissioning Groups (CCGs), and Maternity Units
During the development of the indicators, an apex indicator comprising 3 sub-indicators was proposed (see Table 1)
It was proposed that these questions be asked of all mothers by the Health Visitor at the 9-12 month review.
An audit demonstrated the items were acceptable and useful to both mothers and health visitors.
Due to the qualitative and free-text wording of these items, we were advised that they were not appropriate for inclusion in the Community Dataset in their current format.
In order to be eligible for inclusion, the items need to be converted into a quantitative categorical format with terminology that is compatible with SNOMED CT.
This would need to be arranged by NHS England.
Indicator and Methodology Assurance Service (IMAS)
Draft IMAS application forms for each of the three proposed indicators have been completed and ate currently being refined.
The IMAS requires the identification of a sponsor for the indicators who will assist in moving the indicators through the approval process and who will then ensure that the indicator receives ongoing funding for maintenance in the respective Outcomes Frameworks.
This is where the work moves on from the Policy Research Unit in Maternal Health and Care to policy colleagues in the Department of Health and NHS England.
Four indicators were selected.
The Apex indicator will require new data collection and is thus several years away from implementation.
The other three indicators could in principle be created now and adoption depends on the wishes and needs of policy makers.