BY: JOY BURKHARD, MBA
When a mother suffers from a mental health disorder, the result has a resounding effect on her physical health and the health of her child. Maternal mental health disorders such as depression, bipolar disorder and anxiety, which can occur during pregnancy or up to a year postpartum, affect up to 1 in 5 women1 and can soar as high as 50 percent for women living in poverty.2, 3 These disorders often go undiagnosed and untreated, creating an alarming domino effect for mothers, their children and their families.
In 2009, The Harvard Center on the Developing Child found that the architecture of children's brains was flawed when their mothers had experienced maternal depression early in their children's lives.4 Equally as worrisome is the impact of untreated depression and anxiety during pregnancy, which has been found to increase risk of prematurity and low birth weight deliveries and high risk behaviors in mothers.5 Prematurity itself can also lead to long-term developmental challenges in children and increased costs to families, communities and society.6
As society becomes more stressed7 and the rates of young women with pre-existing depression and anxiety skyrocket,8 the national nonprofit organization 2020 Mom has focused on closing the gaps in maternal mental health care through education, advocacy and collaboration. The organization was formed in 2011 at the urging of the California State Legislature and receives its funding from grants and private donations. Since its inception, 2020 Mom has brought together multiple stakeholders from public and private settings to better understand needs in the field of maternal mental health and to push for policy change.
The number of change agents working to transform the field has been growing, and advocates can be found in obstetric provider offices, hospitals, child health advocacy organizations, public health settings and more. Several influential champions within the American Congress of Obstetrics and Gynecology, a professional organization of women's health care physicians, worked successfully to gain the organization's recommendation in May 2015 that "clinicians screen patients at least once during the perinatal period for depression and anxiety symptoms using a standardized, validated tool"9 and follow up with appropriate treatment when indicated.STATE, FEDERAL, LOCAL ADVOCACY
At the state level, stakeholders and policymakers are recognizing that the barriers to maternal mental health care as well as potential solutions are as complex as the range of the disorders themselves. Several states have formed multistakeholder task forces or blue-ribbon commissions to study why women are not being diagnosed and treated for maternal mental health disorders and to issue recommendations for change.
In California, 2020 Mom established the California Task Force on the Status of Maternal Mental Health Care and issued its report last year. The report identifies both system and provider barriers, along with the mothers' personal barriers to care, noting, "the same factors that place a woman at higher risk of developing a maternal mental health disorder, together with her symptoms, impair her ability to be diagnosed and seek treatment."10 Even if a mother is lucky enough to be screened for a maternal mental health disorder, is diagnosed, and receives a referral, she still may not receive care. Research suggests less than 15 percent of women who screen positive for maternal depression will receive treatment.
The report also details systemic barriers, including shortages of mental health providers, particularly psychiatrists confident and competent with complex prescription regimens through pregnancy and lactation; provider capacity to follow patients and manage care once a woman is identified as having a disorder; and the bifurcated mental health and medical care delivery payment models.
Because depression and anxiety are prevalent during pregnancy, the report notes obstetric providers such as OB/GYNs and nurse midwives should be the primary professionals for screening, identification and management of treatment. All other providers who interact with women, including pediatricians, should also be cognizant of these disorders and screen and refer back to the obstetric provider for treatment management. These recommendations require additional capacity and core competency.
Several states in addition to California also have taken action. Most notably, Massachusetts established a standing Maternal Mental Health Commission and passed legislation that established and supports a statewide telepsychiatry program to address the shortage of reproductive psychiatrists. Similar to California, Mental Health America of Maryland ran a task force in 2017 and issued its own state strategic plan. Also in 2017, Texas passed a law requiring depression screenings in pediatric settings for mothers whose children receive check-ups through Medicaid or the Children's Health Insurance Program.
At the federal level, the U.S. Congress passed a bill in 2016 that, if funded, will provide grants to states to address maternal mental health through programs like telepsychiatry that address access to care. 2020 Mom will continue to advocate for funding these grants and will support legislation addressing maternity and family leave policy and the reporting of maternal mortality rates and causes, including suicide.
Recognizing that solutions must be addressed at the federal, state and community level, 2020 Mom is piloting a project to equip local community leaders to develop their own community-based action plans, which may include building up treatment programs with local hospitals, as well as training OB/GYNs on how to screen, manage care and connect with a psychiatrist when needed.HOW INSTITUTIONS CAN HELP
2020 Mom is urging the National Committee for Quality Assurance (NCQA) to adopt a Healthcare Effectiveness Data and Information Set (HEDIS) measure to provide reporting by state on how often OB/GYNs are screening for maternal mental health disorders (a performance measure) and, ultimately, whether patient outcomes improve.
Employers are in a unique position as the primary purchasers/payers of health care to urge insurers (including those providing administrative services to self-insured employers) to offer an integrated medical-behavioral product through one company. Employers also can press insurers to build obstetric provider capacity by providing case management programs that lean on insurer nursing staff in following patients, assisting patients with finding in-network providers trained in maternal mental health, tracking medication use when prescribed, and more.
Since 99 percent of all births happen at hospitals, hospitals are in a position to build up treatment programs. Such programs can include provider- and peer-led support groups, outpatient day treatment programs and access to individual therapists and psychiatrists.
The movement to close gaps in maternal mental health care is gaining momentum around the country from a small rural community behavioral health agency in Colorado to the chambers of Congress. 2020 Mom is inspired and fueled by the commitment of all the individuals who have raised their voices and are taking action.
JOY BURKHARD is founder and executive director of 2020 Mom in Los Angeles.
- Norma I. Gavin et al., "Perinatal Depression: A Systematic Review of Prevalence and Incidence," Obstetrics and Gynecology 106, no. 5 (November 2005):1071-83.
- Christyn L. Dolbier et al., "Relationships of Race and Socioeconomic Status to Postpartum Depressive Symptoms in Rural African American and Non-Hispanic White Women," Maternal and Child Health Journal 17, no. 7 (September 2013):1277-87.
- Esther K. Chung et al., "Maternal Depressive Symptoms and Infant Health Practices among Low-Income Women," Pediatrics 113, no. 6 (June 2004):e523-29.
- Center on the Developing Child at Harvard University, Maternal Depression Can Undermine the Development of Young Children: Working Paper No. 8 (December 2009). http://developingchild.harvard.edu/wp-content/uploads/2009/05/Maternal-Depression-Can-Undermine-Development.pdf.
- Justin Chan et al., "Risks of Untreated Depression in Pregnancy," Canadian Family Physician 60, no. 3 (March 2014): 242-43. www.ncbi.nlm.nih.gov/pmc/articles/PMC3952758/.
- March of Dimes, "The Impact of Premature Birth on Society," March of Dimes website. www.marchofdimes.org/mission/the-economic-and-societal-costs.aspx.
- American Psychological Association, "APA Stress in Society Survey: US at 'Lowest Point We Can Remember'; Future of Nation Most Commonly Reported Source of Stress," news release, Nov. 1, 2017. www.apa.org/news/press/releases/stress/index.aspx.
- Ramin Mojtabai, Mark Olfson and Beth Han, "National Trends in the Prevalence and Treatment of Depression in Adolescents and Young Adults," Pediatrics published online, Nov. 24, 2016. http://pediatrics.aappublications.org/content/early/2016/11/10/peds.2016-1878.
- American College of Obstetricians and Gynecologists, "Screening for Perinatal Depression," Committee Opinion, no. 630, May 2015. www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Screening-for-Perinatal-Depression.
- California Task Force on the Status of Maternal Mental Health Care, Report, April 2017. www.2020mom.org/ca-task-force-recommendations.