Maternal Mental Health Core Indicator

Percentage of women with mental health concerns during pregnancy.

Method of Calculation

Percentage of women who experienced any mental health concern during pregnancy

Number of women who gave birth (live or still) who experienced any mental health concern* during pregnancy

100

Total number of women who gave birth (live or still)

*Includes pregnant females who experienced anxiety, depression, history of postpartum depression, addiction, bipolar, schizophre

100

Percentage of women who experienced depression during pregnancy

Number of women who gave birth (live or still) who experienced depression during pregnancy

100

Total number of women who gave birth (live or still)

100

Percentage of women who experienced anxiety during pregnancy

Number of women who gave birth (live or still) who experienced anxiety during pregnancy

100

Total number of women who gave birth (live or still)

100

Percentage of women who had a history of postpartum depression

Number of women who gave birth (live or still)* who have a history of postpartum depression

100

Total number of women who gave birth (live or still)* that have had a previous birth

*Exclude women that gave birth (live or still) that have a parity of 0

100

Recommended Subset Analysis Categories

Geographic Areas of Maternal Residence

Ontario
Public Health Unit
Dissemination Area

Data Sources

Numerator & Denominator	Alternative Data Source
BORN Information System Original Source: Better Outcomes Registry Network (BORN) Ontario Distributed by: Better Outcomes Registry Network (BORN) Ontario Suggested Citation: BORN Information System [years], Date Extracted: [date]	Healthy Babies Healthy Children Integrated Service for Children Information System (HBHC-ISCIS) Original Source: Healthy Babies Healthy Children Integrated Services for Children Information System (HBHC-ISCIS), Public Health Unit Distributed by: Public Health Unit Suggested Citation: ISCIS [years], Extracted: [date]

Data Elements in the BORN Information System (BIS)

Name and Description	Categories	Encounter	BORN ID
Mental Health Concerns Indicates the presence of a mental health concern in this pregnancy.	None Anxiety Depression History of postpartum depression, Addiction Bipolar Schizophrenia ther O	Labour Birth (Mother) Antenatal General Antenatal Specialty	M0048

QUESTION FOR THE SUBGROUP: Should this second table be listed under "Recommended Subset Analysis Categories" instead of here???

Dimension	Categories
Mental Health Concern	None Anxiety Depression History of Postpartum Depression Addiction Bipolar Schizophrenia Other Missing Data
Anxiety	Yes No Missing Data
Depression	Yes No Missing Data
History of Post Partum Depression	Yes No Missing Data
Parity	1 2 3-4 >=5 Missing Data
Newborn DOB Calendar	2013 2014 etc.

Analysis Checklist

Working with Mental Health Variables

In the Public Health Standard Reports, comparator data for Ontario or Peer Group is only available for six months prior to the date of extraction. Public Health Units are categorized into Peer Groups as per the 2011 classifications.
Niday Perinatal Data (i.e., data prior to April 1, 2012) is available from BORN upon request; however, the mental health variable was not defined the same way as the corresponding data element in the BIS and may not give consistent results over the two time periods.
Occurrences of different types of mental health concerns during pregnancy are not mutually exclusive; therefore, the total number of mental health concerns may be greater than the total number of women with one or more mental health concerns.
The denominator for the ‘History of post-partum depression’ indicator should be limited to those that have had a previous birth (parity > 0; (note that a limitation of using this denominator is that it excludes those that had a previous stillbirth or pregnancy loss)). This has been indicated in the instructions for the Public Health Standard Reports and Public Health Cube below.

If Using the Public Health Standard Reports

Please follow the general analysis checklist for the BORN Information System data source.
In the Public Health Standard Reports, comparator data for Ontario or Peer Group is only available for six months prior to the date of extraction. Public Health Units are categorized into Peer Groups as per the 2011 classifications.
For Maternal Mental Health:

Select the PHU-Pregnancy report under Clinical Reports
Specify the dates/years of analysis
Go to the link for ‘Frequency mental health concerns during pregnancy, by public health unit and province’
Calculate the percentages from the standard report or export the table to Excel

Note: the percentage of women that have a history of postpartum depression that is presented in the standard report uses a denominator that includes all women who have given birth (it is not just restricted to those that have had a previous birth). This should be adjusted for in your own calculations by using the number of women that have had a previous birth (found in the parity section of the standard report; parity > 0) as the denominator (note that a limitation of using this denominator is that it excludes those that had a previous stillbirth or pregnancy loss).

If using the Public Health Cube

Please follow the general analysis checklist for the BORN Information System data source.
For women who experienced any mental health concern during pregnancy, and for women who experienced anxiety and depression during pregnancy:

Select Dimension: "Mental Health Concern” (found under Dimension > Pregnancy > Maternal Health History > Mental Health Concern)
Select Measure: "# of Pregnancies – Women Who Gave Birth” (found under Measures > Pregnancy)
Specify Filters by right clicking on each of the following dimensions and selecting the following categories:

Newborn DOB Calendar (found under Newborn DOB > Newborn DOB Calendar) = Deselect 2012 (and others as appropriate for your analysis)

To calculate the total number of unique women with any mental health concern, take the total number of pregnancies and subtract those with "none” and "missing” (it is not recommended to use the number of women who answered "yes” to having a mental health concern because occurrences of different types of mental health concerns during pregnancy are not mutually exclusive; therefore, the total number of mental health concerns may be greater than the total number of women with one or more mental health concerns.
Calculate percentages within the Cube or export to Excel

For women who have a history of postpartum depression(experienced postpartum depression during a previous pregnancy):

Select Dimension: "Mental Health Concern” (found under Dimension > Pregnancy > Mental Health Concerns > History or Post Partum Depression)
Select Measure: "# of Pregnancies – Women Who Gave Birth” (found under Measures > Pregnancy)
Add filters to the tables and specify by right clicking on each of the following dimensions and selecting the following categories:

Newborn DOB Calendar (found under Newborn DOB > Newborn DOB Calendar) = Deselect 2012 (and others as appropriate for your analysis)
Parity (found under Dimensions > Pregnancy > Pregnancy History > Parity) = Parity 1, Parity 2, Parity 3-4, Parity ≥ 5

Calculate percentages within the Cube or export to Excel

If using HBHC-ISCIS as an Alternative Data Source

Percentage of HBHC Clients and/or parenting partners with a history of depression, anxiety or other mental illness.
The Healthy Babies Healthy Children (HBHC) screening tool was developed by the Ministry of Children and Youth Services and is a comprehensive tool for identifying families with potential risk of negative developmental outcomes for children. The screening tool asks a question regarding mental health which is collected in the Integrated Services for Children Information System (ISCIS).
NOTE: the ISCIS database only collects data on families that give consent for the HBHC program and thus does not represent all births within a geographical area. Also, the data collected in the HBHC system does not differentiate between which parenting partner had a history of mental illness, thus cannot specifically distinguish as ‘maternal’ mental health.

Indicator Comments

Influencing Factors and Benefits of Breastfeeding

Breastfeeding has a number of well-documented short and long-term health benefits for both babies and mothers (1,2). It is known to reduce the risk of sudden infant death syndrome and gastrointestinal, ear and respiratory infections throughout childhood (1). Breastfeeding infants is also associated with lower levels of diabetes and obesity later in life (3).
Exclusive breastfeeding of infants until 6 months of age is recommended by the World Health Organization (WHO) (4). Exclusive breastfeeding is defined as no other food or drink, not even water, except breast milk (including milk expressed or from a wet nurse) for 6 months of life, but allows the infant to receive oral rehydration solution, drops and syrups (vitamins, minerals and medicines).
In recent years, there has been increased public health attention directed towards increasing rates of exclusive breastfeeding as part of the WHO Baby-Friendly Initiative (5). As such, public health practitioners have a unique and important role in promoting and supporting breastfeeding.
There are many factors known to influence breastfeeding rates including: age, income, education, living with a partner, previous pregnancies, home delivery, attitudes and comfort with breastfeeding, hospital practices, social network and return to work / school (6). Data on these factors are also available in the BORN database, although there may be high rates of missing information.
Maternal mental health is an important indicator of health because maternal anxiety and depression and other mental health conditions can have negative effects on both the women’s health, as well as the wellbeing of her baby and family. Increased awareness of the issues can help ensure proper care and treatment which will help to minimize these effects (1-4). Furthermore, public health has been recently recognized as having the potential to play a uniquely effective role in reducing the negative impacts of perinatal mood disorders (4).
Maternal depression and anxiety is considered a risk factor for the socio-emotional and cognitive development of children. Research has also shown that maternal mental health problems in pregnancy and/or the postpartum period increase the likelihood that school age-children experience suboptimal global, behavioural, cognitive, and socio-emotional development (5). The partners of mothers who are depressed also experience more stress and depression (1,6).
Maternal mental health concerns may start during pregnancy or at any time up to one year after the birth of a child (7); as many as 19.2% of women experience a depressive episode during the first 3 months post-partum (8).
Every woman is vulnerable to mental health problems during pregnancy or postpartum, but there are certain factors such as poverty, single status, minority ethnicity, and a history of depression can increase the risk (9,10). LGBTQ women may also be predisposed to maternal mental health concerns due to issues related to difficulty conceiving, social support, the couple relationship, and legal and policy barriers (11, 12)
Risk factors for postpartum depression specifically include: a history of mood disorders, depression symptoms during the pregnancy and a family history of psychiatric disorders; younger maternal age, stress factors such as negative life events; poor marital relationships; having a special needs infant or medically fragile infant; lack of social support; tobacco use or drug abuse during pregnancy; and personal and family psychopathology (13,14) .
About half of all women with a previous history of depression will experience maternal depression, and 30% of women diagnosed with postpartum depression had their initial onset of depression during pregnancy (15).
It is natural for women postpartum to experience feelings of sadness and it occurs in approximately 50-80% of women. These feeling are sometimes referred to as "baby blues”. However, a woman is diagnosed with depression if she experiences these disturbing moods, feelings, and behaviors nearly every day for two weeks that significantly interfere with her ability to care for herself, her other children, her home, and her work (7,16).
A history of postpartum depression does not necessarily indicate a mental health concern during the current pregnancy. However, a previous experience with a perinatal mood or anxiety disorder such as post-partum depression increases one’s risk of experiencing it again; the risk for post-partum depression increases to 25%-30% with a prior history of postpartum depression (15,17). Therefore, this indicator includes a history of postpartum depression as a maternal mental health concern.
The terms ‘maternal mental health’ and ‘postpartum depression’ are used throughout this indicator document because that is how it is referenced in the data source (BORN); however, it is acknowledged that ‘perinatal mood disorder’ and ‘postpartum mood disorders’ are appropriate alternatives.
This indicator largely focuses on the mental health of the mother during and postpregnancy due to the availability of the data; however, the preconception period (before pregnancy) is also an important predictor of pregnancy complications and adverse birth outcomes. (12, 18).
Maternal mental health variables from BORN capture any maternal mental health concerns during pregnancy, including those pre-existing, diagnosed during pregnancy or active during pregnancy, both diagnosed or self-reported (19). Maternal mental health variables from BORN are self-reported and thus subject to under-reporting and social desirability bias.
It is important to understand the degree of missing data for mental health concern data from BORN for your health unit prior to reporting on it. The total missing for maternal mental health concerns for Ontario in 2013 was 5.2% in 2013 and 2.1% in 2014. By Public Health Unit, the total missing for mental health concerns ranged from 0.1% to 14.8% in 2013 and from 0.1% to 6.8% in 2014 (20).

Dimension Choices

The 'Infant Feeding at Entry to Public Health Service' indicator is measured using the dimension 'Feeding at hospital or MPG'. The ‘Feeding at hospital or MPG’ dimension was chosen as opposed to 'Feeding at discharge' due to inconsistencies in time of discharge between hospitals and Midwifery Practice Groups (MPGs). In hospitals, discharge can be within a few days after birth but in MPGs it is measured when the MPG discharges the infant from their care, which is usually 6 weeks after birth. This results in high levels of missing information for the 'Feeding at discharge' dimension among infants born in MPGs. As such, the use of the 'Feeding at hospital or MPG' approximates infant feeding at entry to public health service in the best possible current method, given the data quality issues of the variable 'Feeding at discharge'.
The 'Infant Feeding at Entry to Public Health Service' indicator uses the '# of births – Live' measure for the denominator data (as opposed to '# of births - discharged home or home births') to ensure consistency between populations drawn for the numerator and denominator. More specifically, infants who are discharged to the neonatal intensive care unit or to another hospital would be captured in the 'Feeding at hospital or MPG' but excluded from the '# of births - discharged home or home births'. However, the LDCP Infant Feeding Surveillance Pilot Study (7) and the BORN Standard Report available through the BIS use the '# of births - discharged home or home births' as the denominator for their infant feeding indicator. As of 2016, BORN is currently addressing this issue and changes may be made in future data collection.

Data Changes over Time

Data are available from April 1st, 2012 to present. BORN in their reports use a waiting period of 6 months to give hospitals and MPGs the opportunity to verify data before reporting. A recent report by Public Health Ontario found that the time to 99% completeness for BORN data ranges by public health unit and can be up to 15 months (8). For more information on the lag time by public health unit, please refer to Table 4 (page 20-21).
Prior to April 2014, the indicator for 'intention to exclusively breastfeed' did not distinguish between intention to exclusively breastfeed and intention to breastfeed in combination with breast milk substitute. If data from before April 2014 is being used, the indicator can be adapted to 'intention to breastfeed (exclusively or in combination)' by combining mothers who intended to exclusively or combination-feed in the more recent data.
As of Fall 2014, there were three level 3 NICUs that had not yet started submitting data to BORN (i.e. Mount Sinai, London Health Sciences, and Sunnybrook). As such, for some public health units, there are large proportion of missing information. This error is currently being worked on and data from January 2016 onwards are expected to be more complete.

Handling Missing Values and Small Cell Counts

For any indicator, if missing is less than 5%, individuals with missing values should be excluded. If missing is 5-30%, individuals with missing values should be included as their own category. If missing is more than 30%, the indicator should not be reported
Some cells may have very small counts, especially when obtaining data by dissemination area. Data can be rolled up into neighbourhood level or multiple years can be combined to address small cell counts that threaten confidentiality.

References

Cited References

Horta, B.L. et al. (2007) Evidence on the long-term effects of breastfeeding. Geneva: World Health Organization.
Office of the Surgeon General, Centers for Disease Control and Prevention & Office on Women's Health (2011). The Surgeon General's Call to Action to Support Breastfeeding. Rockville (MD): Office of the Surgeon General (US). Available from: http://www.ncbi.nlm.nih.gov/books/NBK52687/.
Owen, C. G., Martin, R. M., Whincup, P. H., Smith, G. D., & Cook, D. G. (2006). Does breastfeeding influence risk of type 2 diabetes in later life? A quantitative analysis of published evidence. The American Journal of Clinical Nutrition, 84(5), 1043-1054.
WHO. (2016). The WHO's infant feeding recommendation. The World Health Organization. Retrieved 26 January 2016, from http://www.who.int/nutrition/topics/infantfeeding_recommendation/en/.
Pound, C. M., Unger, S. L., Section, H. P., & Nutrition and Gastroenterology Committee. (2012). The Baby-Friendly Initiative: Protecting, promoting and supporting breastfeeding. Paediatrics & Child Health, 17(6), 317.

Ontario Public Health Association (2007). Breastfeeding Position Paper. Ontario: OPHA Breastfeeding Workgroup.
Haile R., Procter TD., Alton GD. et al. on behalf of LDCP Breastfeeding Surveillance Project Team. (2015). Infant Feeding Surveillance Pilot Study: Final Report and Recommendations. Woodstock, Ontario: LDCP Breastfeeding Surveillance Project Team.
Ontario Agency for Health Protection and Promotion (Public Health Ontario). (2016). BORN Information System: Data quality assessment for public health monitoring. Toronto: Queen's Printer for Ontario.

Acknowledgements

Lead Authors

Adrianne Folkema

Sandy Dupuis

Rachel Skellet

Jessica Deming

Denis Heng

Reviewers

Joanne Enders

Natalie Greenidge

Lori Snyder-MacGregor

Contributing Authors

Reproductive Health Sub-Group

Other Acknowledgements

Paula Morrison, BORN

Gillian Alton, BORN

Erin Graves, BORN

Revision History

This Core Indicator Product webpage is maintained by the Reproductive Health Subgroup.

Date	Review Type	Author	Changes	PDF
June 2016	New Indicator	Reproductive Health Sub-Group	New Indicator
May 4, 2019	Website Update: No Content Review	Caitlyn Paget, on behalf of the CIWG	No changes made to indicator definitions. Migrated to new website structure and format, including: Reorganized content to provide high-level information at a glance, and move in-depth analytic information into dedicated sections for users to access when needed. Renamed "Basic Categories" to "Recommended Subset Analysis Categories"; "Definitions" renamed to "Glossary". Replaced both "Cross-References to Other Indicators" and "OPHS" sections with "Related OPHS Topics" to crosslink with relevant Core Indicators webpages including OPHS program standard(s) and associated indicator(s). Added descriptive sub-headings to the Analysis Checklist and Indicator Comments sections. Removed "Corresponding Health Indicator(s) from Statistics Canada and CIHI" and "from Other Sources" sections. Updated Revision History table, and added PDF copy of previous version for reference.

APHEO's Core Indicators Project has been developed through collaboration across the field of public health in Ontario,

to provide standardized methodology for population health assessment, to measure complex concepts of individual and community health.

Please contact core.indicators@apheo.ca for further information.

Maternal Mental Health (DRAFT)

Maternal Mental Health Core Indicator

Related OPHS Topics

Method of Calculation

Recommended Subset Analysis Categories

Data Sources

Data Elements in the BORN Information System (BIS)

Analysis Checklist

Working with Mental Health Variables

If Using the Public Health Standard Reports

If using the Public Health Cube

If using HBHC-ISCIS as an Alternative Data Source

Indicator Comments

Influencing Factors and Benefits of Breastfeeding

Dimension Choices

Data Changes over Time

Handling Missing Values and Small Cell Counts

References

Cited References

Acknowledgements

Lead Authors

Reviewers

Contributing Authors

Other Acknowledgements

Revision History