US healthcare struggles to tackle maternal behavioral health crisis

Mental health conditions contribute to nearly one in four pregnancy-related deaths in the US, but the national healthcare system isn’t equipped to tackle the scope of the crisis.

Pregnancy is a vulnerable period for birthing people that can either prompt new or exacerbate existing mental health problems. Postpartum depression is a widespread issue, while the risks of drug overdose and suicide increase within a year of a pregnancy. Yet struggling patients frequently face payment issues, long wait times, stigma, and other barriers when they seek help—something few do in the first place.

These roadblocks are the product of the country’s fragmented healthcare system, according to maternal health providers and advocates. The hurdles reflect the broader strain on behavioral health resources, particularly in the wake of the Covid-19 pandemic. The problem is so severe that in 2022, the American Hospital Association called on health systems to take steps to improve maternal mental health.

As it stands, perinatal people with behavioral health issues are caught in a troublesome catch-22, said Sue Gullo, who directs healthcare improvement company Premier Inc’s women and infants unit. Mental health clinicians aren’t experts in pregnancy care, while ob-gyns and other pregnancy providers aren’t equipped to manage severe mental health issues.

“There’s all these complexities that don’t create a safety net for these moms,” Gullo said.

Many patients fall through the cracks

The American College of Obstetricians and Gynecologists recommends all perinatal people get screened for mental health conditions, but data on health plan quality indicates providers aren’t meeting standards. On average, just 8.8% of privately insured pregnant women were screened for depression in 2021, compared with 15.7% among those with Medicaid coverage.

Even so, the perinatal period offers an opportunity for providers to connect patients to mental health services, given that they’re more likely to come in for pregnancy-related care, Gullo said.

Pediatricians can screen a new parent for depression during their baby’s checkups, Gullo said. On the other hand, family physicians, who offer both primary and obstetric care and tend to have long relationships with patients, might have more opportunities to spot concerning signals sooner, said Tochi Iroku-Malize, a New York-based doctor and president of the American Academy of Family Physicians. Symptoms to look for could include trouble bonding with the baby, severe anxiety over parenthood, or regular thoughts of death or suicide.

To integrate behavioral health services into primary care, clinicians need more training and payers should incentivize care coordination between specialties because “both sides can’t necessarily get reimbursed for the same service, even though you do need to collaborate to make this work,” Iroku-Malize said.

Joy Burkhard, founder and executive director of 2020 Mom, a maternal mental health advocacy group, said crackdowns on mental health parity laws—which require insurers to cover behavioral health services at the same level as physical health concerns—could also help improve access to maternal mental health care.

“Doctors can’t do this work alone,” Burkhard said. “Payers and hospitals are in a unique position to do something.”

Closing the gaps

Nontraditional players like Maven Clinic, a pregnancy-centric telehealth firm that contracts with employers to provide services to employees, are also trying to close the chasm. Neel Shah, an ob-gyn and Maven’s chief medical officer, said that more than 30% of Maven’s patients said they receive support for depression or anxiety, and that most patients wait less than two hours for care.

Shah is overseeing Maven’s expansion into the Medicaid population, beginning with a pilot in Arkansas in 2022. He said he’s trying to ensure that patients who struggle to access services in the traditional healthcare system aren’t left further behind in the telehealth space.

“We take care of a pretty diverse cross-section of America,” Shah said, adding that “an app isn’t going to fix healthcare, but what we can do is turn the devices that people carry into a portal for human service.”

Medicaid plays a key role in shaping maternal health outcomes, and states can now extend postpartum Medicaid coverage up to a year after childbirth—ideally allowing new parents to stay connected to care, including mental health support.

Meanwhile, the federal government launched a maternal mental health hotline last spring that offers counseling and community referrals to pregnant people and new parents in distress.

The hotline fielded more than 5,200 calls and texts between the May launch and October, with anxiety and depression being the top concerns and most calls coming from postpartum parents, according to the federal Health Resources and Services Administration, which runs the hotline.

The hotline “eliminates the need, necessarily, to go to a provider as the door to get into care,” said Michael Warren, who heads HRSA’s Maternal and Child Health Bureau. HRSA is now ramping up outreach efforts for the hotline, though Warren said it has limited capacity for follow-up.

Despite increased awareness around the maternal mental health crisis in recent years—and efforts by some health systems to address patient needs—major barriers to care remain, both in and out of the doctor’s office.

“The systemic gaps are many,” Burkhard said. “This is why we still haven’t solved this problem.”