This article was originally published in our Fall 2020 print issue.
Despite common narratives, pregnancy is not always a joyful period for mothers, as new data shows that maternal mental health problems are quite prevalent; the California Health Care Foundation found that one in five Californian women suffer from depression, anxiety, or a combination of both while pregnant or after giving birth. Despite the prevalence of mental health issues in this population, due to cultural stigma and social pressures, few women seek treatment for their condition. According to a report released by the American Academy of Pediatrics, an estimated 50 percent of women who are depressed during and after pregnancy go undiagnosed and untreated, according to research cited in the report.
Dana Edgull, a manager in the Maternal Mental Health division of the Behavioral Health Services in Monterey County, often works with mothers who are anxious about seeking help for their mental health issues.
“After they have their baby, they think it’s supposed to be the happiest time of their lives, and many women feel guilty when they finally have to say, ‘I’m really not doing well’, ‘I’m really struggling’, or ‘I need some extra help right now,” she said.
Perinatal mood and anxiety disorders are the most common medical complication faced by mothers. These disorders occur in the perinatal period, which includes the time that a woman is pregnant, and the postpartum period, which is the first year after the baby has been born. They include prenatal and postpartum depression and/or anxiety disorders such as Generalized Anxiety Disorder, Panic Disorder, Obsessive-Compulsive Disorder, and Birth-related PTSD; in extreme cases, mothers may develop bipolar disorder or postpartum psychosis. While definitive causes of maternal mental health issues are still unknown, research has suggested that a combination of factors can affect the likelihood of developing a perinatal mental health disorder, such as previous experience of mental health problems, biological causes, lack of support, difficult childhood experiences, experience of abuse, low self-esteem, stressful living conditions, and major traumatic life events.
While maternal mental health issues cause negative health outcomes for mothers, they also can severely impede the development of the child. If maternal mental health conditions are undiagnosed and untreated, they can negatively affect the mother-child bond and the child’s long-term physical, socioemotional, and cognitive developmental health.
“If a mom is really depressed, she cannot be fully engaged in her relationship with her child, or respond to her child’s cues in a way that supports and meets their needs, and this can impact the baby’s brain development from a very early age,” Edgull said.
According to a study in JAMA Pediatrics, a mother’s depression and anxiety from conception through the first year of the baby’s life is associated with negative developmental outcomes through adolescence. The study found that a mother experiencing depression and anxiety before and after birth was linked with her child experiencing shortfalls in language, cognitive and motor development in infancy.
“Research is showing that when women experience heightened levels of stress during pregnancy, when their bodily systems are constantly inundated with high levels of cortisol, that affects their developing baby as well,” Edgull explained. “What we’re finding is that women who have heightened levels of stress during pregnancy, their children are later on being diagnosed with chronic conditions and hyperactivity disorders.”
Data collected by the California Department of Public Health (CDPH) that 21% of pregnant and postpartum women in California are affected by maternal mental health disorders, and the prevalence of these conditions is even higher within racial minority populations. People who are Black, Native, or from other communities of color are disproportionately likely to experience negative perinatal outcomes. According to the Center for Law and Social Policy (CLASP), nearly two in five women of color experience depression after giving birth, a rate that is nearly two times higher than new mothers overall. As well, data from the Maternal and Infant Health Assessment (MIHA) conducted by the California Department of Public Health (CDPH) shows that one in four African American and Latina mothers in California reports experiencing some level of depressive symptoms.
“One of the biggest risk factors for developing maternal mental health issues is poverty,” Edgull said. Data from the CDPH shows that nearly half of all mothers living in poverty have maternal mental health issues, and a study conducted by the Urban Institute found that one in nine poor infants lives with a mother experiencing severe depression and more than half live with a mother experiencing symptoms of depression. Though depression is highly treatable, many low income mothers do not seek treatment; the Urban Institute’s study also found that more than one-third of low income mothers with major depressive disorder get no treatment at all.
In addition to the trauma that untreated maternal mental health conditions can inflict on an individual, they also are often very costly. A 2019 economic analysis published in Mathematica examined the economic impact of these disorders; when following the mother-child pair from pregnancy through five years postpartum, the estimated cost is $14.2 billion for births in 2017, or an average of $32,000 for every mother-child pair affected but not treated. 53% of the total costs, or around $7.5 billion, occurred in the perinatal period.
Policy and system barriers have contributed to the incidence of untreated maternal mental health issues and its impacts on children’s emotional and social development; however, growing interest in maternal mental health has led many researchers and public health practitioners to design and implement a variety of interventions.
Within California, the Hospital Quality Institute is leading an initiative to help hospital perinatal staff understand, recognize, and effectively respond to mental health issues in the perinatal period. This initiative is aimed to complement the passing of Assembly Bill 3032; a bill that went into effect in January of 2020, AB 3032 requires education of perinatal employees about maternal mental health conditions and to inform postpartum women and families about signs and symptoms of maternal mental health disorders, local post-hospital treatment options, and community resources.
Edgull also emphasized the necessity of mental health screenings in the prevention and treatment process. “There needs to be more screening. Women should be screened during pregnancy and then for 12 months after birth on a regular basis,” she said.
To this end, another recent policy that aims to address the issue of maternal mental health in the state is Assembly Bill 2193, which requires all licensed health care practitioners who provide prenatal or postpartum care for a patient to screen or offer to screen mothers for maternal mental health conditions. Effective in July 2019, this bill additionally requires both private and public health plans and health insurers to create maternal mental health programs.
On a federal level, in 2016, the Bring Postpartum Depression Out of the Shadows Act was passed, which includes support for identification and treatment of maternal depression. The bill authorizes the Secretary of Health and Human Services to provide federal grants to states for the purpose of screening, assessing and treating PPD, and these grants allow states to create, improve or maintain programs around maternal mental health and help women who are pregnant or recently postpartum.
In regards to federal policy, Edgull highlighted the need for legislation that mandates nationwide paid parental leave.
“It’s ludicrous that on average, in the United States, a working woman gets 6 weeks off following a regular vaginal birth, and 8 weeks for a Cesarean section,” she said. “I would say that I would consider universal paid maternity leave policy to be a top priority for lawmakers.”
Unlike other developed countries, maternity leave coverage in the United States has been provided primarily through employer policies and is not required in many states. Research has shown that paid maternity leave promotes greater bonding between mothers and newborns, and improves health and behavioral outcomes in infants, such as earlier initiation and longer duration of breastfeeding. Moreover, a 2018 study published in Maternal and Child Health Journal found that longer maternity leave (greater than 12 weeks) and paid leave were associated with better mental health outcomes for mothers, especially among mothers returning to full-time work.
For many mothers dealing with mental illness, navigating the healthcare system is intimidating and it can be increasingly difficult when healthcare providers are disjointed in the provision of care. Edgull also explained that there needs to be a streamlined process for follow-up between healthcare providers who offer screenings and those who offer treatment, as the system can often be disjointed.
“There’s a phrase that we use in public health– ‘Don’t screen if you can’t intervene’. Often, unfortunately, that’s what happens, as mothers are screened for maternal mental health issues but have such infrequent visits that it can be hard to follow up,” she said.
To this end, a research group at the University of Washington is assessing the impact and cost-effectiveness of remote consultation between providers to create a cohesive pathway for the treatment of perinatal depression in community health centers and primary care practices. For this study, researchers are using a collaborative care model for depression, which consists of placing a multi-professional provider team at each clinic. A care manager and psychiatric consultant conduct a weekly review of patients with depression review patients with depression weekly with a psychiatric consultant to create treatment plans and support the primary-care and obstetric providers. By linking social workers, mental health professional, and obstetric physicians, mothers are provided with a set of cohesive recommendations for effective treatment of their conditions.
The prevalence of maternal mental health disorders is a pressing issue within public health, and healthcare practitioners across the country are implementing novel strategies to ameliorate negative health outcomes in this vulnerable population. Historically, maternal health has fallen to the wayside in terms of national health policy priorities, but as research has shown, investing in and protecting the health of mothers and their children has vast impacts on lifelong health outcomes. For this reason, lawmakers and healthcare providers should strive to address this issue through passing landmark legislation and providing early interventions to women and children who need them.