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From the President: Emerging Issues

 An Increasing Awareness of Maternal Mental Health

MEglovitch.jpgBy Michelle Eglovitch, MPH
Program Associate, Women's & Infant Health, AMCHP

 

 C. McCoy.JPG

 

 Carolyn McCoy, MPH
Senior Policy Manager, Health Reform Implementation, AMCHP

The mental and emotional wellbeing of expectant and new mothers, troubling rates of maternal depression and anxiety, as well as their effect on mothers, families, and communities, is a growing national concern. Maternal mental health encompasses mental health disorders during and after pregnancy, including mood/depression and anxiety disorders (collectively referred to as Perinatal Mood and Anxiety Disorders, or PMAD). 15 to 20 percent of women will experience depression during or after pregnancy, and up to 15 percent of women will develop anxiety during pregnancy or after childbirth1. Untreated maternal depression and anxiety can have negative short-term consequences ranging from inability to self-care, to disruption of infant-child bonding2. Long-term consequences of untreated maternal depression and anxiety involve negative mental health outcomes for the mother, and also may put strain on the family unit2.

Nationwide, research on maternal mental health screening and subsequent outcomes is limited, potentially due to lack of a universal screening protocol and variances by facility in procedure. However, research shows that recognition and treatment rates for depression specifically are lower in pregnant and postpartum women (14 percent) than in the general population (26 percent) 3.  For those providers who are screening for postpartum depression, they may be doing so with a tool that is not validated or through informal assessments which are ineffective in identifying actual cases of depression4. Although rates of screening vary by facility and state, there is insufficient evidence that such screenings are universally translating into better patient outcomes5. Thus, not only is there missed opportunity in provider settings to screen for maternal mental health disorders, but lack of a universal knowledge base on what to do if a mother receives a positive screen.

Fortunately, renewed attention to maternal mental health has given way to several initiatives to address screening and treatment outcomes on the legislative, coverage, and care quality fronts. In July 2015, Representative Katherine Clark (D-MA) introduced the "Bringing Postpartum Depression Out of the Shadows Act." The bill seeks to improve access to maternal mental health services by creating a grant program to states for screening and treatment for maternal depression. Also in January 2016, the U.S. Preventive Services Task Force (USPSTF) released a revised recommendation for the screening of all adults, including pregnant and postpartum women. The USPSTF goes on to recommend that "Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up6." This guidance is especially important now that the health insurance plans sold through the health insurance Marketplace as part of the Affordable Care Act are required to cover all USPSTF preventive services with an A or B rating with no cost sharing. Depression screening for adults has always been covered without cost sharing by these plans, however, the revision of the guidance and specification that pregnant and postpartum women should be screened universally could lower barriers to screening for the patient and provider. Additionally, as of 2014, most individual and small group health insurance plans sold inside and outside of the Marketplace are required to cover mental health and substance use disorder services. Plans serving the Medicaid expansion populations must also cover mental health and substance abuse disorder services. For non-expansion Medicaid populations, all state Medicaid programs for adults provide some mental health services and some offer substance use disorder services to beneficiaries, and Children's Health Insurance Program (CHIP) beneficiaries receive a full service array.  

Young women of reproductive age have another avenue for coverage with the ACA's requirement for all non-grandfathered health plans — employer-sponsored, as well as individual policies purchased in or out of the Marketplace — to allow dependents to remain on their parent's plan until the age of 26. Coverage is available regardless of an adult dependent's employment or marital status. This provision holds potential for ensuring that young adult women have continued access to coverage and care.

Finally, in January 2016 the Council on Patient Safety in Women's Health Care – a multidisciplinary collaboration with representation from all major health professional organizations serving women – released a maternal mental health safety bundle. The bundle includes sets of three to four action items for four focus areas that apply to various health professionals and facilities serving women prenatally and postpartum, and is accompanied by a listing of resources and Web links. Amongst other important features, the bundle seeks to rectify barriers to screening and treatment.  For example, the bundle makes recommendations to facilitate relationships between healthcare providers to address lack of collaboration between different sources of maternal care.

Maternal depression and anxiety are significant medical issues for women, and may go unrecognized by patients, family members, caregivers, and healthcare providers. Recent initiatives to address maternal mental health are important not only because they shed national light on such an imperative public health issue, but also because they call for further improvements in policy and procedures to better serve mothers. AMCHP and partners are actively working to address this issue and connect its members with resources and tools. The Alliance for Innovation on Maternal Health (AIM) is the 'implementation arm' of the Council, and partners with states and major hospital systems to implement maternity safety bundles across birth facilities. AIM's goal is to prevent 1,000 maternal deaths and 100,000 cases of severe maternal morbidity nationally by 2018. AMCHP and six other organizations are core partners on the initiative. Further, numerous state Title V agencies selected National Performance Measure #1: percent of women with a past year preventive medical visit, as a priority area. In draft state action plans, states positioned this measure as an opportunity to enhance access to services and supports for women across the lifespan, including access to mental health services postpartum (as well as zooming in on intimate partner violence and substance use). AMCHP also supports states in health reform implementation and can offer best practices and guidance on how Title V agencies can get involved in ensuring women have access to necessary coverage to receive screening and treatment. If your state has a specific technical assistance need pertaining to maternal mental health, please contact Michelle Eglovitch, Program Associate for Women's and Infant Health, at meglovitch@amchp.org.

  1. The 2020 Mom Project. (2016). About Maternal Mental Health Disorders
  2. New York State Department of Health. (2005). Understanding Maternal Depression, A Fact Sheet for Care Providers
  3. Wisner, K. L., Sit, D. K., McShea, M. C., Rizzo, D. M., Zoretich, R. A., Hughes, C. L., & Confer, A. L. (2013). Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings. JAMA Psychiatry, 70(5): 490-498.
  4. Gjerdingen, D. K., & Yawn, B. P. (2007). Postpartum depression screening: importance, methods, barriers, and recommendations for practice. The Journal of the American Board of Family Medicine, 20(3), 280-288.
  5. Yawn, B. P., Olson, A. L., Bertram, S., Pace, W., Wollan, P., & Dietrich, A. J. (2012). Postpartum depression: screening, diagnosis, and management programs 2000 through 2010. Depression Research and Treatment, vol. 2012, Article ID 363964, 9 pages.
  6. US Preventive Services Task Force. (2016). Screening for Depression in Adults: Recommendation Statement. JAMA, 315(4):380-387.