Policy Opportunities To Improve Prevention, Diagnosis, And Treatment Of Perinatal Mental Health Conditions

Despite its high burden of morbidity, mortality, and economic cost, perinatal mental illness is poorly addressed by the US health care system. One in five pregnant or postpartum people has a diagnosed mood or anxiety disorder, which are the most common mental health conditions that occur during the perinatal period.¹ This period brings with it increased vulnerabilities for depression, pharmacotherapy discontinuation, addiction recurrence, and overdose death postpartum.^2–4 Many also suffer during this period from other mental health conditions that affect their well-being.

Perinatal mental illnesses contribute to adverse outcomes during pregnancy and postpartum, including pregnancy-related morbidity and mortality for the pregnant person. For example, perinatal anxiety in the last trimester of pregnancy can increase risk for preeclampsia, cesarean birth, and neonatal intensive care.^5,6

The burden of perinatal mental illness is not limited either to the pregnant person or to the time immediately surrounding pregnancy. Perinatal depression can lead to fetal growth restriction and postnatal cognitive and emotional complications, including infant attachment barriers and poor cognition.^7,8 Both at and well after childbirth, perinatal mental illness generally can lead to psychological and developmental disturbances in infants, children, and adolescents; preterm birth; and low birthweight.^7,9,10

Untreated perinatal mental health conditions that occur during pregnancy and the first five years of a child’s life carry a societal burden of $14 billion per year in the US.¹¹ This figure underestimates the actual cost because of the underreporting of these conditions and the exclusion of costs associated with caregivers and limiting the time horizon to five years.¹

Although mandatory perinatal mental health screenings have led to increased identification of mental health conditions, mental health services—including individual therapy, hospital care, outpatient treatment, and medication therapy—are used less by pregnant people than by nonpregnant people with mental health conditions.¹² For many, lack of adequate insurance coverage is a barrier to care seeking.

In this overview article we describe screening, treatment, and bias associated with mental health conditions; identify barriers to addressing them; and review policies designed to overcome challenges and support overall perinatal mental health.

Screening And Diagnosis

Early detection, prevention, and effective treatment could reduce the effects of perinatal mental illness on childbearing people, infants, and their families. Nonetheless, societal and health care system features present obstacles to the identification of people who are suffering from perinatal mental illness and those who are susceptible to it, leading to preventable morbidity and mortality. Persistent, cumulative deficits and barriers include lack of screening, limited clinician follow-up and coordinated care after screening, barriers to access to care, stigma, shame, judgment, and blame, all of which impede the pursuit of preventive or psychiatric services.

It was only in 2019 that the US Preventive Services Task Force issued its first guidelines regarding perinatal depression.¹³ The guidelines highlighted compelling evidence for counseling interventions but did not find sufficient evidence to support the use of psychotropic medications.¹⁴

The evidence supports focusing screening on people with well-established risk factors for developing perinatal mental health conditions, including those with a history of mental illness, a family history of perinatal mental illness, a history of interpersonal violence, a mistimed pregnancy, pregnancy complications, lack of social support, low socioeconomic status, and childbearing during adolescence. Therefore, the task force guidelines emphasize focusing on at-risk groups. However, given the long history in the US of underdiagnosis of perinatal mental health conditions, the evidence base for defining at-risk groups presents challenges, including systematic biases that are then replicated through the screening process. In addition, although depression is the dominant mental health condition that occurs during the perinatal period, it is not the only condition, and others—such as disordered eating or generalized anxiety disorder—could be overlooked when clinicians rely on these guidelines.¹⁵ Using evidence-based screening tools for other conditions in conjunction with depression screenings could support the comprehensive assessment of overall mental health and well-being during and after pregnancy.

Measurement

Measurement is the cornerstone of effective population health improvement. The Centers for Disease Control and Prevention does not track perinatal mortality associated with suicide and overdose, so estimates of psychiatric contributors to death among childbearing people remain artificially low.¹⁶

Relatively few quality measures focus on either mental health or perinatal health, and almost none address the intersection of the two. Of the thirty-three adult health care quality measures for Medicaid (the Adult Core Set) for 2021, none focus on perinatal mental health.¹⁷ Despite an increase in professional organizations recognizing the need to address perinatal mental health, national health care quality entities have developed, tested, validated, and endorsed few measures. Because quality measures drive clinicians’ behavior, the limited number of such measures provides little incentive for clinicians to identify and treat these problems.

Treatment

The health sector focuses almost no systematic attention on monitoring the quality of care associated with detecting and treating perinatal mental illness. Even when people receive a positive screening test or diagnosis, the landscape remains difficult. High rates of attrition persist when patients are referred outside of their preferred care system.¹⁸

Although promising collaborative care models that integrate mental health services into perinatal clinics exist, these effective options remain unavailable to most pregnant and postpartum people.^19,20 Availability is limited by the lack of billing codes for same-day or multiclinician visits and by structural barriers (for example, lack of co-located services) to care that involves multiple departmental units or clinician types.²¹

Bias

Racial and ethnic inequities persist in the identification of illness and its treatment. Black people with postpartum depression have lower odds of initiating treatment, following up with treatment, and refilling antidepressant medications than White people.²² In the absence of research documenting the causes of inequities, listening to the voices of Black communities to take into account their lived experiences becomes critically important. For instance, a statement on the National Health Law Program blog shares that Black pregnant people might not seek follow-up treatment as a consequence of “their experiences of structural racism, …the legacies of slavery that continue to reverberate in modern medical practice,” distrust of the medical system, stigma, and concern about being judged by clinicians.²³ Furthermore, lack of culturally responsive mental health awareness and expectations may contribute to clinicians’ underuse of effective preventive measures and treatments in this population.^24,25

Overcoming Barriers

Barriers to appropriate identification and treatment of perinatal mental illnesses include differential access to services based on the payer, fragmented and siloed care delivery systems, the lack of a workforce that is culturally and racially concordant with their patients, and the persistent effects of systemic racism and sexism.

Payer

Medicaid funds perinatal and maternal services for low-income people and covers 45 percent of births in the United States.²⁶ Relative to people with employer-sponsored insurance, people with Medicaid may find that they have limited coverage of wellness and preventive services and difficulty finding clinicians who accept Medicaid payment rates.^27,28 In addition, public insurance generally does not cover abortion and infertility treatment. Because “Black and Latinx women, as well as other birthing people of color, make up a disproportionate share of Medicaid enrollees,” particularly during pregnancy, payer differences create inequities.²⁸

In addition, although pregnancy qualifies a person who meets income standards for Medicaid, coverage may only be guaranteed for sixty days postpartum,²⁹ depending on policy choices made by the state.

Care Delivery Systems

In the absence of a national health system in the US, no entity owns the problem of addressing perinatal mental health needs.

In the absence of a national health system in the US, no entity owns the problem of addressing perinatal mental health needs. Clinical systems almost exclusively address physical health.³⁰ There are few quality metrics that provide guidance on screening, diagnosis, treatment, or referral related to perinatal mental health.²⁸ Access to perinatal mental health services is limited for rural and tribal communities as a result of the geographic distribution of providers, long distances that must be traveled for care, and a limited workforce that can provide culturally concordant care.³¹ Tying perinatal mental health services to existing clinical services might not be viewed as beneficial among populations that have been poorly treated by the health care system.³²

Workforce

The workforce cannot adequately support the perinatal mental health needs of those most affected by poor mental health. Racial and cultural concordance between clinicians and the populations they serve has been shown to improve pregnancy-related outcomes, such as improved experiences and satisfaction with care for pregnant people³³ and improved care for newborns and infants,³⁴ yet such clinicians remain limited in supply.^35,36 In addition, competency requirements for education and training regarding perinatal mental health are lacking.³⁷ Most perinatal health clinicians (for example, obstetricians, midwives, and family medicine physicians) receive minimal training in their educational programs and have few opportunities for continuing education regarding perinatal mental health. A broader range of clinicians and teams on the front lines—including community health workers, pediatric providers, and doulas—have shown promise for providing culturally relevant and racially congruent care.³⁸

Roles Of Racism And Sexism

Various aspects of the challenges related to meeting the mental health needs of birthing people can only be understood in the historical context of racism and sexism. Many public policies in the US regarding birth and parenting have racist roots that can be traced back to viewing Black women as property whose primary economic function was birthing for the financial benefit of the slaveholder.³⁹ From these roots have grown the racial politics of “welfare”—now known as the Temporary Assistance for Needy Families program—which has been the subject of political disparagement and led to intrusive policies designed to control Black women’s fertility and blame them for bearing the financial scars of racism.⁴⁰

These racist and sexist roots play out in the specific context of medicine as well, most notably in contributing to the inability of clinicians and health systems to fully acknowledge the range of experiences of birthing people and to the treatment of perinatal mental health exclusively within a negative context. The depersonalization that comes with this promotes a narrow focus on identification, diagnosis, and treatment of poor mental health, rather than a focus on individual need and promoting conditions that are conducive to wellness, resilience, and thriving that a more holistic, justice-centered approach could deliver.⁴¹

Policies To Improve Perinatal Mental Health

Policy changes must address underlying challenges that people face before, during, and after pregnancy.

Policy changes must address underlying challenges that people face before, during, and after pregnancy. We present six federal and state policy opportunities here.

Extend Medicaid Coverage

Approximately four in ten people with Medicaid coverage do not make a postpartum visit, forcing them to self-manage postpartum depression and breast-feeding challenges. Maternity coverage typically ends at sixty days postpartum, cutting people off from access to care during the critical twelve-month postpartum period.⁴² Policies limiting coverage to sixty days postpartum conflict with evidence-based recommendations from maternal health experts to replace the single six-week postpartum visit with ongoing support tailored to individual needs.⁴³

Extending Medicaid through at least twelve months with comprehensive perinatal care would ensure access to services—including prevention and treatment for postpartum depression and chronic conditions—that are essential for the well-being of people and their infants. Expanding Medicaid coverage under the Affordable Care Act, which achieved some of the coverage effects of a twelve-month postpartum extension, reduced preterm birth and low birthweight for Black infants.^44,45 If coverage were extended, approximately 28 percent of people who were uninsured during the first year postpartum would likely be newly eligible for Medicaid or the Children’s Health Insurance Program (CHIP).⁴⁵

The American College of Obstetricians and Gynecologists, the American Medical Association,^46,47 and more than 275 other leading medical organizations advocate for a full twelve months of postpartum coverage, commonly referred to as the “fourth trimester.” The Medicaid and CHIP Payment and Access Commission (MACPAC) sent Congress recommendations in early 2021 to extend Medicaid coverage to twelve months postpartum, fully paid for by the federal government to ensure state participation.⁴⁸

Section 9812 of the American Rescue Plan Act of 2021 establishes direct legal authority for states to provide continuous Medicaid coverage through twelve months postpartum. However, it does not provide a 100 percent federal matching rate, as recommended by MACPAC, and it authorizes these options for only a five-year period beginning April 1, 2022. These limitations make it likely that states—particularly those with the highest rates of maternal mortality and morbidity—will decline the option.

This would be unfortunate, as access to and coverage of health insurance throughout a person’s life course ensure adequate continuance of care before, during, and after pregnancy, recognizing that birth outcomes are interlinked with all phases of the life course. Moreover, people can and do become pregnant within the postpartum period. The cyclical nature of health and well-being requires a continuous approach to care to ensure ideal birth outcomes.⁴⁵ Physical and mental health conditions prevented or diagnosed and treated in advance of pregnancy translate into healthier pregnancies and better birth outcomes.⁴⁹ Providing coverage during the preconception period would extend the health benefits of Medicaid coverage through twelve months postpartum.

Encourage Co-Location Of Services

People generally receive postpartum care from clinicians in locations and health systems that are different from where their infants receive care. The postpartum person and infant may have different Medicaid health plans with different care networks. Co-locating care to support same-day, same-location appointments for the postpartum person and infant reduces barriers to accessing care. Co-location facilitates joint assessment and management of depression and overall health during the postpartum period. In a co-located facility, clinicians can screen the postpartum person and infant within one appointment. This is consistent with American Academy of Pediatrics guidelines, which recommend screening for maternal depression at well-baby visits by the pediatric clinician—one way of effectively co-locating services for parent and infant.⁵⁰

During the COVID-19 pandemic, innovative approaches to co-locating services and reducing access barriers were implemented by health systems to alleviate patients’ fears of coming into hospital facilities. One example is Boston Medical Center’s Curbside Care for Moms and Babies initiative, which brought two siloed clinical groups together to the home of the postpartum person and infant through mobile health visits in a retrofitted van, which shows that this goal can be achieved with minimal investment.⁵¹ As confidence in the safety of returning to provider offices for appointments increases, a framework incorporating the essential features and lessons learned from Boston’s mobile co-located services into physical building space for postpartum and newborn care can be applied.

Co-location of services for postpartum care covered by Medicaid requires reimbursement redesign for the parent’s coverage. Bundled payments for prenatal care, labor, delivery, and postpartum care are built on the assumption that the clinician will coordinate all needed services excluding newborn care. This common payment structure creates no incentives to co-locate postpartum and newborn care. Furthermore, some insurers carve out behavioral health services from the rest of coverage, creating yet another source of fragmentation that impedes care coordination.

New or alternative payment strategies should support the continuum of services that promote high-quality, evidence-based care that improves outcomes. For example, more widespread coverage of maternal depression screening during well-baby visits or within co-located delivery models, including care coordination and referrals for behavioral health, could facilitate use. Finally, enrolling the parent and infant into the same Medicaid health plan would reduce one barrier to co-located services.

Cover Varied Care Models

Community-based maternity care professionals provide valuable services including home visiting during and after pregnancy, labor support, and encouragement of autonomy and empowerment.⁵² This care model includes doula expertise, which amplifies community connections and prioritizes cultural congruency among community health workers.⁵³ During home visits, providers can assess for maternal depression and address interconnected parent and child needs.^54,55 Providing culturally congruent support in the home increases breast-feeding rates and patient satisfaction and reduces perinatal health disparities.^56,57 It can also reduce health care costs during the critical postpartum period. For example, the Duke Family Connects International program reported that for every $1 invested in home visiting, the program saved just over $3 in emergency department costs.⁵⁸

Adequate Medicaid reimbursement is critical for the sustainability of doulas, who often depend on donations and community grants.

However, most insurers do not cover the services of doulas or perinatal community health workers, limiting access to those who can afford to pay out of pocket. At this time, only three states provide Medicaid coverage for these services, but with the recent increase in attention to maternal mortality and morbidity, interest has been heightened for many states. However, as state Medicaid programs explore doula coverage, they face making decisions about certification requirements and reimbursement rates. Adequate Medicaid reimbursement is critical for the sustainability of doulas, who often depend on donations and community grants. Research should aim to identify adequate reimbursement rates that reflect the time, effort, and expertise of community-based maternal care professionals. In addition, research comparing the outcomes from services delivered by doulas with and without certification would help guide state Medicaid agencies’ doula coverage requirements.

Enhance Telehealth Policies

The COVID-19 pandemic has demonstrated that access to telehealth has offered a safer (for example, less exposure to the virus) and more convenient (for example, no travel) method for accessing health care services. In March 2020 the Centers for Medicare and Medicaid Services (CMS) created new flexibilities (for example, allowing Medicaid reimbursement for telehealth services) that adapted and expanded telehealth, including behavioral health services, thus opening up an opportunity for payers to maximize the potential benefits of telehealth services.⁵⁹ The time-limited pandemic policies allowed clinicians and Medicaid health plans to shift in-person care visits to telehealth, thereby supporting access.

Yet challenges persist related to the digital divide, including absence of technology-enabled devices, digital literacy, and reliable internet service.⁶⁰ People with low incomes are disproportionately affected by this divide.⁶¹ Addressing cellular and broadband deserts (an issue that extends beyond health policy but contributes to the social determinants of health) and workforce shortages requires attention, amid attempts to find opportunities to expand and maintain telehealth policies after the pandemic. In late 2021 it is not yet clear which policies federal and state governments will make permanent beyond the pandemic.

Enhance Data, Research, And Accountability

At this time, there are no mental health measures as part of CMS’s Core Set of Maternal and Perinatal Health Measures for Medicaid and CHIP, referred to as the Maternity Core Set.⁶² The development and use of perinatal mental health–specific measures has the potential to build the evidence base and support research that would fill critical gaps in knowledge. For example, better data would enable the health sector to further understand the prevalence of, disparities in, and challenges associated with perinatal mental health conditions; identify opportunities to create quality improvement initiatives; and foster accountability within the health care system. The consistent use of valid and reliable measures can support the collection and analysis of data across payers, clinicians, and health systems at both a micro and a macro level.

The National Committee for Quality Assurance is testing an adapted version of its existing depression care quality measures for pregnant and postpartum people and plans to submit the revised measure for potential use in the national Healthcare Effectiveness Data and Information Set as part of the Adult Core Set of quality measures for Medicaid. The adapted measures will assess screening, follow-up care, and treatment response or remission.^17,63 If these measures are included in the Adult Core Set, states will have an opportunity to collect them as part of their efforts to monitor the quality of their Medicaid programs. Furthermore, the measures can be used to inform the important work of perinatal quality collaboratives (state or multistate networks working to improve the quality of perinatal care) and Maternal Mortality Review Committees (state- or citywide committees to review deaths within one year postpartum). With increased financial support, such groups could include the measures to guide their work.

Enact Policies That Support Families

Untreated maternal depression among people with limited resources may continue the cycle of poverty for both parents and children.⁶⁴ Depression can lead to increased absenteeism, reduced productivity, job loss, and challenges returning to work. Among people with the lowest incomes, only 4 percent have access to paid parental leave, and approximately 31 percent have access to sick leave.⁶⁵ Without state-mandated or employer-sponsored paid leave, people rely on the federal Family and Medical Leave Act of 1993, which allows qualifying workers to receive up to twelve weeks of unpaid, job-protected leave with continuous health coverage.⁶⁵ However, although 60 percent of workers quality for the program,⁶⁵ most cannot afford to forgo their income.

Many people feel forced to return to work in the immediate postpartum period,⁶⁶ which is a critical time to support the physical and mental health of the postpartum person as well as for breast-feeding, bonding and attachment, adjustments to the demands of parenthood, and development of caregiving skills. Lack of paid family leave during this period negatively affects families’ physical and mental health and economic security.^67,68

The American Families Plan proposed by the administration of President Joe Biden in 2021 includes two provisions that offer important steps toward supporting families.⁶⁹ First, it would ensure that both low- and middle-income families spend no more than 7 percent of their income on child care. It also seeks to ensure the receipt of high-quality care and support children with disabilities by ensuring small class sizes and culturally and linguistically responsive environments. Second, it would create a national paid family and medical leave program, ensuring twelve weeks of paid leave of up to $4,000 per month with a minimum of two-thirds of average weekly wages replaced.

Conclusion

The scale of human suffering and economic cost associated with perinatal mental health conditions cries out for a response.

The scale of human suffering and economic cost associated with perinatal mental health conditions cries out for a response. Fortunately, policy options are available to address various barriers that still stand in the way of the identification and treatment of these conditions and the achievement of high-quality outcomes. Policy makers should strongly consider these policy options as they seek to improve the US health care system and maternal and child health.

ACKNOWLEDGMENTS

Kara Zivin received support from National Institute of Mental Health Grant No. R01 MH120124. The authors thank Noelle Serino for her assistance with copy editing. Jennifer Moore is the spouse of the Health Affairs editor-in-chief, Alan Weil, who had no editorial role in the decision to publish this article.

NOTES

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