Improving maternal mental health in South East Asia through assets based approaches.

Perinatal mental illness (mainly depression and anxiety during pregnancy and the first year after childbirth) is a major global health problem. Without the right kind of support and treatment, it can have long-term negative effects on the mother's and the child's health and wellbeing. Severe mental illness is one of the main causes of maternal deaths in the first year after childbirth and perinatal mental illness can negatively impact both the physical (low birth weight babies, reduced breast feeding, severe malnutrition and hampered growth), behavioural and social development of the infant, potentially creating a trans-generational cycle of poor mental and physical health. Perinatal mental illness disproportionately affects women who are already vulnerable, for example women exposed to violence, poor social support and low income. Although high quality information on LMICs is limited, it suggests that the occurrence of perinatal mental illness in LMIC may be three times higher than in high income countries. Therefore, effective and early treatment of perinatal mental illness is essential for the long-term welfare and wellbeing of populations in LMICs.
South East Asia comprises countries that are highly diverse in terms of ethnicity, language and culture and economic status, with several countries categorised as lower-middle and lowest income categories. In this region, perinatal mental illness is poorly understood and may be considered socially and culturally unacceptable with affected women and families experiencing stigma and blame. Further, there is inequity of access to skilled mental healthcare professionals, and lack of care guidance appropriate to perinatal mental health. This means that perinatal mental ill health is largely under recognised and under treated. We have established a South East Asian Perinatal Mental Health Research Network (SEAPMHRN) (currently involving members from Malaysia, Myanmar, Indonesia and Thailand) which includes researchers, clinicians, and a health Ministry in the region to develop a long-term research programme in perinatal mental health. This network has already conducted a 2-day workshop (Kuala Lumpur July 2019) to scope and establish research priorities as defined by the LMIC country participants. We aim to further expand and develop this network, bringing together multi-disciplinary experts (including NGOs and community workers) and lay people/women, to develop a context relevant research agenda for understanding and improving perinatal mental health. The research prioritisation workshop participants identified 3 key areas to address: understanding women's experiences of perinatal mental health problems, and preferences for care; improving screening and detection; and addressing the problem of low (perinatal) mental health literacy among professionals, and the public.
This proposal is for funding to cover the following related activities:
1. To support further networking meetings, encouraging expansion of the current network to include more links to policy makers, NGOs, patient and public involvement and community development organisations, and the continuing development of research priorities; setting up appropriate communication structures e.g. website and exchange visits; supporting grant writing groups which build local research capacity.
2. Conduct foundation research for each of the 3 priority areas identified: To test the methods for digitally capturing a range of women's experiences or perinatal mental illness from across participating countries; to conduct a literature review on the validity of existing translated screening tools for detecting perinatal mental health problems in SE Asian women; to assess and adapt (if possible) existing resources for future delivery of perinatal mental health awareness training in the region.

Perinatal mental illness can have negative, long-term impacts on the wellbeing and welfare of women, their children and families. It is associated with poor child development and in LMIC it results in higher rates of low birth weight, reduced breast feeding, severe malnutrition and hampered growth. South East Asia is a culturally and ethnically diverse region comprising several countries categorised as lower middle income or lowest income. There are severe problems of lack of access to trained mental health staff in many areas and issues of stigma and blame associated with mental ill health. We plan to expand our pan-South East Asia Perinatal Mental Health Research Network bringing together a multi- disciplinary group of experts from diverse fields of research, clinical practice, but especially third sector and representatives of women's groups.
Malaysia will be the network hub building on its recent economic and health improvement and existing collaborations in Indonesia, Thailand and Myanmar. Through exchange visits, workshop and website fora we will begin to address the research priorities already identified in an intensive 2-day workshop that involvedinvolving experts from the four (4) South East Asian countries. The research network, when fully developed, will have the capacity and expertise to undertake large-scale research for development and implementation of culturally appropriate screening tools and low cost community based interventions to improve perinatal mental health, undertaking qualitative research to determine the significance of social and environmental factors to maternal psychological distress among diverse communities.

This proposal is directly relevant to the ODA purpose of promoting welfare and wellbeing of individuals and vulnerable population groups in four LMIC countries that are ODA eligible (Malaysia, Indonesia, Thailand and Myanmar). The prevalence of perinatal mental ill health is significantly higher in LMICs compared to HIC with rates estimated to be three times as high. Perinatal mental illness has a significant and long term impact on mothers and families health and wellbeing and on the economic growth of societies in LMIC. Our overarching aim is to improve the mental health and wellbeing of mothers, infants and families in South East Asia, through improvement in detection, assessment and treatment of perinatal mental illness. This aim directly relates to the WHO Sustainable Development Goal 3: ensure healthy lives and promote wellbeing for all at all ages. This SD goal includes promotion of mental health and wellbeing and is also central to the MRC-NIHR Global Maternal and Neonatal Health Research Priorities.

We aim to achieve this by further developing a pan-South East Asia Perinatal Mental Health Research Network that will bring together a multi-disciplinary group of experts from diverse fields of research and clinical practice to co-produce a context relevant research agenda for understanding and improving perinatal mental health. The network will have the capacity and expertise to undertake large-scale research and interventions to improve perinatal mental health, and to develop a plan for research capacity building to ensure long term sustainability of the research programmes. Malaysia will be the network hub building on its substantial recent health and economic improvements and current collaborations in Thailand, Indonesia and Myanmar. Countries in South East Asia are characterised by geographical, cultural, ethnic, linguistic and economic diversity. There are wide variations in reported prevalence rates of perinatal health problems, with a dearth of robust data.

The expected short and intermediate outcomes for this project are: 1. a strong network of healthcare practitioners, NGOs, women with lived experience, academics and policy-makers in South East Asia with interest or expertise in maternal mental health; 2. a communication strategy and structures for the network, and to enhance project dissemination of project activities; 3. identification of research and training needs for the countries involved in the network; 4. identification of culturally appropriate screening tools, or of screening tool needs for the countries involved in the network; 5. feasibility test our methods of video recording womens' experiences of mental health problems during pregnancy and up to one year postnatally;5. Evaluate and adapt a best fit training intervention to improve mental health literacy of professionals and community workers; 6. establish priorities for long-term research within the network.

The development of our Network and its Stakeholder Alliances should raise awareness of perinatal mental health problems at all levels (women's organisations, NGO's, Ministries for Health, researchers and Practitioners). The research undertaken within this proposal will provide a foundation for future research in the region.

We anticipate that lessons learned from this research will benefit not only member countries of the network, but ultimately will have implications for the global management of maternal mental health.