This is the third article in a three-part article series on perinatal mental health.

A new movie — A Mouthful of Air – was released in 800 theaters around the country on Friday, October 29.  SPOILER ALERT: The storyline is about maternal depression and suicide.

This is an excellent example of art meeting life.

Mental health conditions – primarily anxiety and depression – are the most common complications of pregnancy and childbirth, affecting 1 in 5 pregnant or postpartum parents.  Tragically, suicide and overdose are the leading causes of death for women in the first year following pregnancy.

Data about maternal suicide comes from Maternal Mortality Review Committees (MMRCs), which are multi-disciplinary committees that convene at the regional, state, or local level.  MMRCs are charged with comprehensively reviewing deaths of women during or within a year of pregnancy, and have access to a wide range of documents – health records, police reports, social service records – that enable reviewers to more fully understand the circumstances of each death.  MMRCs are the only review committees that examine deaths during the entire year postpartum and also include information about suicide and self-harm.

Maternal Mortality Review Committee Findings

A review of 14 state MMRCs from 2008 to 2017 showed that mental health conditions were the leading cause of death in 11 percent of cases, with 100 percent of these deaths deemed preventable.  The majority (63 percent) of pregnancy-related mental health deaths occurred in the late postpartum period, with the peak incidence of maternal suicide at 6-9 months postpartum. The majority of deaths by suicide occurred among white women (86 percent) who were covered by Medicaid during prenatal care or at time of delivery (63 percent).  One-third of these women had a previously documented suicide attempt, and over 50 percent had visited an emergency department within a month of their death.

Substance use plays an important role in maternal suicides: 40 percent of pregnancy-related mental health deaths were overdoses or poisonings. Over 20 percent of these overdoses were intentional and almost 60 percent were unintentional (the remaining were of unknown intent). 

Several states have also recently released reports from their MMRCs.  Colorado’s MMRC reported that 30 percent of postpartum deaths were due to suicide or overdose, and over 50 percent of those who died by suicide in the postpartum period had a documented psychiatric disorder. California’s MMRC showed that 75 percent of women who died by suicide made at least one visit to the emergency department and 40 percent made at least three visits.   Massachusetts’ MMRC focused on substance use, showing that deaths related to substance use increased from 8 percent to 40 percent from 2005 to 2014; 50 percent of women who died by suicide or overdose in the postpartum period had a documented mental health diagnosis; and 92 percent of these diagnoses were documented prior to delivery. 

How is it possible that in the country with the highest health care spending per capita, the most common complication of pregnancy is mental illness and the most common cause of death is suicide or overdose? 

More importantly, why aren’t all childbearing people routinely educated about and screened for mental health conditions? 

The answers are multifaceted. Medicaid covers almost 50 percent of births in the United States, but pregnancy-related Medicaid coverage typically ends at 60 days postpartum, potentially leaving new mothers uninsured at a medically-vulnerable time in their lives.  Extending Medicaid coverage could save lives: consider that the majority of women who died by suicide were covered by Medicaid during pregnancy or at time of delivery, and that the majority of maternal suicide deaths occur 6-9 months postpartum, well past the mandatory 60 days of Medicaid coverage.  Perhaps these mothers would still be alive if Medicaid continued their coverage for the full year postpartum, giving them access to health care providers when they needed it the most.

Even when pregnant and postpartum individuals have insurance coverage, barriers within the health system often prevent them from accessing the care that they need. New parents face barriers to accessing care, including shame and stigma, cost, time, transportation, and childcare. The field of maternal mental health is relatively new, with most policies and programs being enacted in the past two decades.  The U.S. health care system separates physical and mental health, whereas maternal mental health cuts across both, without a clear home.  Many frontline providers, such as obstetricians and pediatricians, cite lack of education, reimbursement, and resources as barriers to screening and treatment. 

As a result, efforts addressing maternal mental health rely largely on grassroots advocates, lone researchers, and overwhelmed practitioners, many of whom are fueled by their lived experience.  Postpartum Support International, for example, has a nationwide network of over 1,200 volunteers, the vast majority of whom experienced maternal mental health conditions and want to ensure others find help and support.

So what can be done?

First and foremost, universal guidelines for educating and screening parents during pregnancy and the first year postpartum must be established.  Childbearing people interact with healthcare providers almost two dozen times during pregnancy and the first year following delivery, with 15 regularly-scheduled obstetric visits and 8 well-baby pediatric appointments.   And although several medical governing bodies – including the United States Preventive Services Task Force – have recommended screening, each state, health system, practice, and provider can choose whether and when to screen, resulting in widespread and unacceptable disparities.

Second, all public and private insurance should provide reimbursements for screening and treating maternal mental health conditions.  Coverage for maternity care should be increased to reflect the cost of educating and screening patients and providing attendant treatment, resources, and referrals.  Mental healthcare reimbursement should be increased to market rates to expand the universe of mental health providers willing to accept insurance.  Midwifery care – along with doula, peer, and lactation support – should be adequately reimbursed.  

Finally, all current and future providers in fields that serve pregnant and postpartum patients must receive education and training to discuss, screen, assess, and treat mental health conditions with a specific focus on health disparities.  In particular, obstetric providers, as the de facto primary care providers for pregnant people, must be trained to take the lead in addressing maternal mental health by providing resources, educating and screening patients, and providing culturally-appropriate treatment and/or warm hand-offs to ensure continuity of care.

Robust and comprehensive maternal mental health care can help new mothers thrive during the important childbearing years, leading to optimal health outcomes for themselves, their babies and families, and society.