Every year, half a million babies are born in California. Alarmingly, the most common complications of childbirth are the mother’s depression, anxiety, or other mental health disorders. The magnitude of suffering from maternal mental health disorders dwarfs hospital-acquired infections, sexually transmitted diseases, new breast cancer diagnoses, and many other conditions that attract greater media interest, public reporting, and performance incentives and penalties.
Maternal mental health issues arise in up to one in five pregnancies. In California, as many as one in four mothers (27%) have prenatal or postpartum depression (PDF), according to a survey by the California Department of Public Health. It’s worse for underserved populations affected by race, poverty, or other social factors that increase the frequency and severity of mental health conditions. Low-income mothers are 1.4 times more likely than wealthier moms to exhibit depressive symptoms before, during, or after pregnancy.
Left undetected and untreated, these conditions can lead to negative health outcomes for the mother, undermine the mother-child bond, and damage the child’s long-term physical, emotional, and developmental health. And the financial cost of untreated maternal mental health conditions can be significant because of effects such as greater use of emergency care services and higher rates of absenteeism at work.
While the disorders are highly treatable, few mothers are identified by screening or diagnosis, and among those who are recognized, only 15% receive treatment. And from a cost perspective (including lost income/productivity and negative outcomes for children), untreated maternal depression costs (PDF) an estimated at $22,500 per mother, which in California totals about $2.5 billion a year.
Maternal mental health conditions can occur anytime during or after pregnancy, with onset as late as the baby’s first birthday. We are not talking about either of the two ends of this spectrum — a transitory (e.g., two weeks) and less severe condition known as the “baby blues” or the rare but more extreme psychotic episodes that make national headlines. It is the much more common “middle zone” of suffering where one in five women find themselves and don’t receive the care they need.
California Task Force Addresses Maternal Mental Health
In California in 2014, the California Legislature passed a resolution calling for a multistakeholder group to study, identify, and recommend solutions to address these issues. The California Endowment and the California Health Care Foundation funded a diverse task force of public health experts, clinicians, consumers, policymakers, and representatives from health plans, purchasers, state agencies, and community-based organizations. The panel included project staff from 2020 Mom, a grassroots nonprofit working to close gaps in maternal mental health in California and nationally; Cynosure Health, a national health care improvement organization; and the Central Valley Health Policy Institute, which focuses on emerging health issues in Central California. Over an 18-month period, the task force explored the barriers, models, and potential solutions that affect a half-million California mothers and their babies each year. California accounts for one in eight births in the US.
Women with maternal mental health issues face herculean challenges to receiving adequate relief from their suffering. These include:
Lack of understanding by health care providers about how to follow up with symptomatic women
Fragmented care systems that foster inconsistent approaches to the problem by obstetricians, pediatricians, and primary care physicians
Inadequate screening, sometimes caused by the mother’s fear that her child will be taken away if the mother gives wrong answers
Poor access to appropriate treatment
Stigma that prevents new and expectant mothers from reaching out for help
Despite the availability of effective treatments, the health care system is tragically ill-equipped to identify and help the women who need them. The task force reviewed novel solutions that address social issues, family and generational expectations, travel limitations, and cultural sensitivities. Yet available services are often disconnected and uncoordinated across different care settings.
Two Ambitious Objectives
The task force set two bold aims for tackling this problem across vast expanses of California: By 2021, ensure that 80% of women are screened at least once during pregnancy and the postpartum period, and by 2025, increase that rate to 100%. The goals acknowledge the federal recommendations on screening and set the stage for effective treatment and symptom management. With these targets in mind, the task force developed recommendations to address barriers:
Select one of several maternal mental health screening measures developed by national organizations.
Promote a “no wrong door” approach to screening so it can be offered by health providers of all types.
Build capacity by expanding referral resources and telehealth consultation such as MCPAP for Moms, which operates in Massachusetts.
Persuade insurers to develop programs offering competent maternal mental health care, including arranging specialty care as required.
Take local action through community collaboratives that can help address social determinants.
Combat stigma with statewide and local public awareness campaigns spearheaded by the California Department of Public Health.
Maternal mental health conditions disrupt the lives of many more women, children, families, and communities than people realize. It’s likely that everyone knows many mothers — and their children — who experience unnecessary suffering from maternal mental health conditions that are treatable if we recognize and build systems to address them during the vulnerable perinatal period. Massachusetts, Maryland, and other states are doing just that. Will California step up, too?
Bruce Spurlock is president and CEO of Cynosure Health, a health care improvement organization whose vision is to eliminate suboptimal care and make safe, reliable, and affordable care a reality for every patient. Dr. Spurlock leads and advises large improvement collaboratives at the regional, state, and national level to accelerate adoption of evidence-based practices. He is a nationally known speaker on a broad range of health care topics including translating policy into practice, trends in health care, and effectively engaging stakeholders to drive improvement.
Joy Burkhard is the founder and executive director of 2020 Mom, and founder and chair of the National Coalition for Maternal Mental Health. Joy has worked for more than 20 years for a large health care insurer leading quality improvement and complex health policy implementation projects.